Exercise for falls prevention:

evidence update and

implementation challenges

Professor Cathie Sherrington

csherrington@george.org.au

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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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