Exercise for falls prevention:
evidence update and
implementation challenges
Professor Cathie Sherrington
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Affiliated with the University of Sydney
Overview
Impact of exercise on falls
Uptake of exercise
Population health benefits of fall prevention
Resources to help you make a difference
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Understanding falls
Interaction between physiology, behaviour
and environment
People with better physical function fall in
more challenging environments/ activities
People with impaired physical function fall in
less challenging environments/ activities
Exercise impacts on many fall risk factors
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44 RCTs, 9603 participants
17% fewer falls in exercise than control
participants
- pooled rate ratio 0.83, 95% CI 0.75–0.91
- I2 62%
830 citations
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J Am Geriatr Soc 56:2234–2243, 2008.
54 RCTs
20% fewer falls in exercise than control
participants
- pooled rate ratio 0.80, 95% CI 0.73 to 0.88
- I2=50%
280 citations 5
NSW Public Health Bulletin. 22
(3-4);78-83 2011
Systematic review update 2016
Submission to British Journal of Sports
Medicine
90 trials, 101 comparisons
20,138 participants
Separate analyses by setting
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Systematic review update 2016: community setting
20% fewer falls in exercise than control participants
- pooled rate ratio 0.80, 95% CI 0.74 to 0.86
- I2 49%
- 70 comparisons
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Systematic review update 2016: community setting meta-regression
Greater effects from exercise programs that challenged
balance and involved 3+ hours exercise per week
- 72% heterogeneity explained
- both features led to a 39% reduction in falls
pooled rate ratio 0.61, 95% CI 0.52 to 0.71
No difference in effects
- trial quality, trial size
- participant age, general versus selected population,
fall rate in controls
- strength training, walking
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Community- all studies part 1
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Community- all studies part 2
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Community- high balance
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Community- 3+ hours
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Community- high balance, 3+ hours
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Otago exercise programme
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Otago exercise programme
FAME
group once a week in local venues for 24 weeks
trained postural stability instructors
included exercises to be carried out at home,
unsupervised, twice weekly
exercises similar to Otago with progression of
resistance bands and hand holds, plus more
dynamic balance work and floor work
provided information about local exercise
opportunities at the end of the intervention period
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Systematic review update 2016: community-dwelling clinical groups
Exercise had a fall prevention effect in people with
- Parkinson’s disease (pooled rate ratio 0.47,
95% CI 0.30 to 0.73, I2 65%, 6 comparisons)
- cognitive impairment (pooled rate ratio 0.55,
95% CI 0.37 to 0.83, I2 21%, 3 comparisons)
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Parkinson’s disease
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Cognitive impairment
Systematic review update 2016
No evidence of effect from exercise as a single
intervention
- residential care settings
- stroke survivors
- people with severe visual impairment
- people recently discharged from hospital
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Residential aged care
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Stroke
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Vision loss
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Recent hospital stay
Updated recommendations
1. Exercise programs should aim to provide a high challenge to
balance by safely:
a) reducing the base of support (e.g. standing with two legs
close together, standing with one foot directly in front of the
other, standing on one leg);
b) moving the centre of gravity and controlling body position
while standing (e.g. reaching, transferring weight from one leg
to another, stepping up onto a higher surface); and
c) standing without using the arms for support, or if this is not
possible then aim to reduce reliance on the arms (e.g. hold onto
a surface with one hand, or one finger)
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Updated recommendations
2. 3+ hours of exercise each week.
3. Ongoing participation in exercise
4. Targeted at the general community as well as
community dwellers with an increased risk of falls.
5. Group or home-based setting.
6. Walking training may be included in addition to
balance training but high risk individuals should not
be prescribed brisk walking programs.
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Updated recommendations
7. Strength training may be included in addition to
balance training.
8. Exercise providers should make referrals for
other risk factors to be addressed (eg vision)
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Updated recommendations
9. Exercise as a single intervention may not
prevent falls in stroke survivors, people with
severe visual problems, or people recently
discharged from hospital but may prevent falls in
people with Parkinson’s disease and cognitive
impairment. Exercise should be delivered to these
groups by providers with particular expertise.
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Systematic review identified 132 studies from
11,841 screened
Thematic synthesis of study findings
5987 participants aged 60 to 89 years in 24
countries
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Themes identified
social influences (interaction with peers, social awkwardness,
encouragement from others, professional instruction)
physical limitations (pain or discomfort, concerns about falling,
comorbidities)
competing priorities
access difficulties (environmental barriers, affordability)
personal benefits of physical activity (strength, balance and
flexibility, self-confidence, independence, improved health and
mental well-being)
motivation and beliefs (apathy, irrelevance and inefficacy,
maintaining habits)
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220 participants with past fall or mobility
disability chose the best and the worst features
of 10 hypothetical exercise programs
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Best worst results: out of pocket cost of $100 had the lowest utility
Higher utility
exercise at home
no need to use transport,
improvement of 60% in the ability to do daily tasks at
home,
exercise free of charge
decreasing the chances of falling to 0%.
Lower utility
X Travel time 30- 60 minutes
X out of pocket cost of $50.
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Markov model costs and benefits of widespread
rollout of a fall prevention program
incremental cost-effectiveness ratio (ICER) of
$A28,931 per QALY gained assuming program
cost of $700 per person and at a fall prevention
risk ratio of 0.75
cost-effective at a threshold value of $A50,000
per QALY gained
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physical activity is a behaviour embedded in
everyday life
population-wide levels of participation in physical
activity are hard to change
lack of ‘‘ownership’’ of the problem: requires
integrated action and partnerships beyond the
health sector
Insufficient use of advocacy and communications
to make the case strongly and convincingly 39
Starting earlier?
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What can I do?
Use any interaction with middle aged or older
people as an opportunity to prescribe/
encourage ongoing appropriate exercise
Raise awareness of the problem of falls and the
benefits of exercise among patients, health
professionals and the community
Advocate for suitable programs to be run by a
range of organisations
Advocate for greater funding of evidence-based
interventions
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Thanks to
• NHMRC funding for salary
and projects
• Co-investigators
• Staff and students
• Study participants
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