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Falls among older people are an international public health issue that requires significant attention from authorities. Around a third of people aged 65 and over experience at least one fall each year.1 Falls can lead to serious consequences, such as fractures, hospital admissions, mobility-related disability, loss of confidence and reduction in community participation. Importantly, costs related to falls are dramatically increasing worldwide.2
The previous (2009) version of this Cochrane systematic review of randomised trials3 provided evidence that the rate of falls in older people can be reduced with preventive interventions, such as exercise programmes, cataract surgery and psychoactive medication withdrawal.
This updated systematic review by Gillespie et al4 aimed to assess the effects of interventions designed to prevent falls in older people living in the community. Different types of interventions were included, such as exercises, educational programmes, medication and surgery. The focus of this PEDro summary is on the trials evaluating exercise interventions compared to control interventions (ie, usual care and placebo intervention).
Searches and inclusion criteria
This review followed the methodology advocated by the Cochrane Collaboration. Electronic databases (the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL) and online trial registers were searched. Ongoing and unpublished trials were identified by contacting researchers in the field. Randomised and quasi-randomised (eg, allocation by alternation) trials were eligible for this review. There was no language restriction.
Trials which investigated exercise interventions were grouped by exercise modality into six categories using the Prevention of Falls Network Europe taxonomy:5 gait/balance/functional training; strength/resistance training; flexibility; three dimension (Tai Chi, dance, etc); general physical activity; endurance and other. Trials which investigated more than one category of exercise were grouped as exercise containing multiple components.
Main outcome measures
The main outcome measures were rate of falls and number of fallers. The rate of falls is defined as the total number of falls per unit of person time that falls were monitored (eg, falls per person year). The rate ratio compares the rate of falls in intervention and control groups during each trial. For number of fallers, a risk ratio compares the number of people in intervention and control groups who fell once or more (fallers) during the follow-up period.
Rate ratios, risk ratio (RR) and their 95% CIs were calculated for individual trials. For trials that monitored falls for longer than 1 year, the results reported at 1 year, if available, were used to calculate treatment effects. Where appropriate, data were pooled. A preplanned subgroup analyses comparing participants at higher risk of falling (history of falling or one or more risk factors for falls at enrolment) versus lower risk (not selected on falls risk at enrolment) were conducted to explore potential sources of heterogeneity. Funnel plots were used to explore the possibility of publication bias.
This updated review contains 159 trials with 79 193 participants conducted in 21 different countries. High proportions (70%) of the included participants were women. Fifty-one new trials were added to this updated version. Twenty-eight ongoing, or completed but unpublished, trials were identified.
Fifty-nine trials with 13 264 randomised participants compared the effect of exercise on falls with the impact of control interventions. Exercise intervention was delivered in a group setting in 47 trials and at home in 12 trials. Funnel plot asymmetry was minimal. Results are summarised in table 1.
Multiple-component group exercise, multiple-component home-based exercise and Tai Chi reduced both rate of falls and risk of falling. Four trials in which the exercise intervention included just gait, balance or functional training achieved a statistically significant reduction in rate of falls but not risk of falling. One small pilot trial testing balance and strength training embedded in daily life activities also reduced rate of fall but not risk of falling. A larger trial of the same intervention has now been published and also found the intervention to reduce the rate of falls.6
Multiple-component group exercise was found to reduce the rate of falls in subgroups of participants at higher and lower risk of falling (p for comparison between effect sizes in high-risk and low-risk participants=0.86). For Tai Chi, a greater reduction in the risk of falling (p for comparison=0.02) and rate of falls was evident in the lower-risk subgroup. The subgroup analyses based on falls risk at enrolment are also presented in table 1.
The pooled effect of six trials including 810 participants showed that exercise is effective to reduce the risk of fracture (RR 0.34, 95% CI 0.18 to 0.63).
Falls trials use slightly different definitions of falls and methods to measure falls which can potentially modify trial results. Consensual recommendations include daily recording of falls with monthly or more frequent follow-up conducted by researchers blind to group allocation. However, 45% (72 of 159) of the included trials did not follow the consensual recommendations, which might have led to an under-reporting or over-reporting of falls. To facilitate the comparison of future studies’ findings, authors suggest the adoption of consensual recommendations in trials investigating fall prevention strategies.
Falls are currently a self-reported outcome so it is not possible to mask study participants to group allocation. This may bias trial findings. In future, technology may enable automated fall monitoring that will eliminate this concern.
This review provides some evidence that fall-prevention-intervention can also prevent fractures. Trials of exercise interventions that are large enough to detect effects on fractures in their own right are yet to be conducted. Future falls trials should routinely report fracture outcomes.
This well-conducted updated review provides robust evidence that exercise interventions can prevent falls in older people living in the community. Group-based and home-based exercise programmes are effective strategies to reduce the rate of falls and the risk of falling in older people living in the community. Multiple-component exercise reduces the rate of falls in people at both high and low risk of falling. Tai Chi reduces the risk of falling and appears to be more effective in people who are at low risk of falling.
▸ Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146.
Contributors MRF selected the systematic review and wrote the first draft of the manuscript. MRF, LSMP and PHF contributed to interpretation of the data, revision of drafts and approved the final manuscript.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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