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Care of the older person Systematic review and meta-analysis

Exercise-based fall prevention programmes decrease fall-related injuries 10.1136/eb-2013-101703

Findings The exercise-based fall prevention programmes included in the analysis generally decreased injurious falls in each of the four defined categories. The rate ratios for ‘all injurious falls’, ‘falls resulting in fractures’, ‘falls resulting in medical care’ and ‘falls resulting in serious injury’ were 0.63, 0.39, 0.70 and 0.57, respectively. The effect related to fractures was similar to previous studies (relative risk=0.34),1 but the overlap of included studies was substantial. The authors noted and addressed issues related to the heterogeneity of studies that contributed to the analysis of all injurious falls and, possibly, severe injurious falls.

Mark D Grabiner Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA Correspondence to: Dr Mark D Grabiner, Department of Kinesiology and Nutrition, University of Illinois at Chicago, 1919 W. Taylor Street, Room 648, Chicago, IL 60614, USA; [email protected]

Commentary on: El-Khoury F, Cassou B, Charles MA, et al. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f6234.

Implications for practice and research ▪ Participation in exercise programmes improves physical function and reduces falls in older adults. ▪ Reducing the number of falls in older adults reduces the number of fall-related injuries. ▪ Increasing the effectiveness of exercise-based fall prevention programmes should seek to define the mechanisms by which exercise derives its effectiveness.

Context Exercise demonstrably and robustly decreases falls in older adults, generally by about 30%. The systematic review and meta-analysis by El-Khoury and colleagues punctuates the previously published result that exercise significantly reduces fall-related fractures in older adults1 and additionally points to a similar effect on serious types of injuries requiring medical attention. Collectively, the results support a cause–effect arithmetic; by preventing falls in older adults, fall-related injuries and secondary effects such as medical costs to care for the injuries can also be reduced.

Commentary Generally, this paper makes a meaningful and intuitive contribution to the literature by demonstrating that older adults who participate in exercise programmes suffer fewer fall-related serious injuries. Indeed, the 95% confidence bands for the rate ratios include the values for the extent to which exercise decreases falls. It follows that the injury-related human costs to quality of life as well as to the healthcare system are similarly beneficially influenced. Regarding the studies selected for inclusion, there are various factors whose importance readers must gauge for themselves. On average, 80.1% of participants were woman. As women fall more often than men, this raises the question of the extent to which the findings can be generalised to men. The exercise exposures used in the included studies are quite variable, ranging from 5.5 weeks to 18 months and the extent to which the exercises were ‘challenging’ was expressed only in terms of what may be considered ‘balance’. Because the rate at which the population of older adults is growing, falls and fall-related injuries will continue to represent a significant and complex problem with social, medical and economic facets. El-Khoury and colleagues indirectly raise a number of broad questions, deriving answers to which, although of great importance going forward, present substantial challenges. First and foremost, how can the beneficial effects of exercise be amplified? Areas to which other questions relate include, but are not limited to: the specific categories of falls that are prevented by exercise; the specific kinds of serious injuries that are prevented and, conversely, not being prevented by exercise; and the subpopulations of older adults who derive the largest benefit from exercise—and under what conditions—with respect to falls and fall-related injuries. Competing interests None.

Methods This systematic review and meta-analysis addressed the effect of exercise-based fall prevention programmes on injurious falls in older adults. This is a clinically valuable question for which the evidence is limited. The search strategy, which ultimately yielded 17 trials with 4307 participants, was appropriate, as were data abstraction, evaluation and reporting of the data. The authors combined two previously reported approaches2 3 to create four (necessarily) somewhat overlapping classifications of injury. The heterogeneity of the included studies, based on the reported I2, may have been a concern for three of these classifications.

References 1. 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. 2. Campbell AJ, Robertson MC, Gardner MM, et al. Randomized controlled trial of a general practice program of home based exercise to prevent falls in elderly women. BMJ 1997;315:1065–9. 3. Schwenk M, Lauenroth A, Stock C, et al. Definitions and methods of measuring and reporting on injurious falls in randomized controlled fall prevention trials: a systematic review. BMC Med Res Methodol 2012;12:501–14.

Evid Based Nurs October 2014 | volume 17 | number 4 |


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Exercise-based fall prevention programmes decrease fall-related injuries Mark D Grabiner Evid Based Nurs 2014 17: 125 originally published online February 11, 2014

doi: 10.1136/eb-2013-101703 Updated information and services can be found at:

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