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Meta-Analysis
. 2014 Nov 28;2014(11):CD009848.
doi: 10.1002/14651858.CD009848.pub2.

Exercise for reducing fear of falling in older people living in the community

Denise Kendrick  1 , Arun Kumar, Hannah Carpenter, G A Rixt Zijlstra, Dawn A Skelton, Juliette R Cook, Zoe Stevens, Carolyn M Belcher, Deborah Haworth, Sheena J Gawler, Heather Gage, Tahir Masud, Ann Bowling, Mirilee Pearl, Richard W Morris, Steve Iliffe, Kim Delbaere
Affiliations
Meta-Analysis

Exercise for reducing fear of falling in older people living in the community

Denise Kendrick et al. Cochrane Database Syst Rev. .

Abstract

Background: Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned, structured, repetitive and purposive physical activity aimed at improving physical fitness) may reduce fear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls.

Objectives: To assess the effects (benefits, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Week 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 to July 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Organization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts.

Selection criteria: We included randomised and quasi-randomised trials that recruited community-dwelling people (where the majority were aged 65 and over) and were not restricted to specific medical conditions (e.g. stroke, hip fracture). We included trials that evaluated exercise interventions compared with no intervention or a non-exercise intervention (e.g. social visits), and that measured fear of falling. Exercise interventions were varied; for example, they could be 'prescriptions' or recommendations, group-based or individual, supervised or unsupervised.

Data collection and analysis: Pairs of review authors independently assessed studies for inclusion, assessed the risk of bias in the studies and extracted data. We combined effect sizes across studies using the fixed-effect model, with the random-effect model used where significant statistical heterogeneity was present. We estimated risk ratios (RR) for dichotomous outcomes and incidence rate ratios (IRR) for rate outcomes. We estimated mean differences (MD) where studies used the same continuous measures and standardised mean differences (SMD) where different measures or different formats of the same measure were used. Where possible, we performed various, usually prespecified, sensitivity and subgroup analyses.

Main results: We included 30 studies, which evaluated 3D exercise (Tai Chi and yoga), balance training or strength and resistance training. Two of these were cluster-randomised trials, two were cross-over trials and one was quasi-randomised. The studies included a total of 2878 participants with a mean age ranging from 68 to 85 years. Most studies included more women than men, with four studies recruiting women only. Twelve studies recruited participants at increased risk of falls; three of these recruited participants who also had fear of falling.Poor reporting of the allocation methods in the trials made it difficult to assess the risk of selection bias in most studies. All of the studies were at high risk of performance and detection biases as there was no blinding of participants and outcome assessors and the outcomes were self reported. Twelve studies were at high risk of attrition bias. Using GRADE criteria, we judged the quality of evidence to be 'low' for fear of falling immediately post intervention and 'very low' for fear of falling at short or long-term follow-up and all other outcomes.Exercise interventions were associated with a small to moderate reduction in fear of falling immediately post intervention (SMD 0.37 favouring exercise, 95% confidence interval (CI) 0.18 to 0.56; 24 studies; 1692 participants, low quality evidence). Pooled effect sizes did not differ significantly between the different scales used to measure fear of falling. Although none of the sensitivity analyses changed the direction of effect, the greatest reduction in the size of the effect was on removal of an extreme outlier study with 73 participants (SMD 0.24 favouring exercise, 95% CI 0.12 to 0.36). None of our subgroup analyses provided robust evidence of differences in effect in terms of either the study primary aim (reduction of fear of falling or other aim), the study population (recruitment on the basis of increased falls risk or not), the characteristics of the study exercise intervention or the study control intervention (no treatment or alternative intervention). However, there was some weak evidence of a smaller effect, which included no reduction, of exercise when compared with an alternative control.There was very low quality evidence that exercise interventions may be associated with a small reduction in fear of falling up to six months post intervention (SMD 0.17, 95% CI -0.05 to 0.38; four studies, 356 participants) and more than six months post intervention (SMD 0.20, 95% CI -0.01 to 0.41; three studies, 386 participants).Very low quality evidence suggests exercise interventions in these studies that also reported on fear of falling reduced the risk of falling measured either as participants incurring at least one fall during follow-up or the number of falls during follow-up. Very low quality evidence from four studies indicated that exercise interventions did not appear to reduce symptoms of depression or increase physical activity. The only study reporting the effects of exercise interventions on anxiety found no difference between groups. No studies reported the effects of exercise interventions on activity avoidance or costs. It is important to remember that our included studies do not represent the totality of the evidence of the effect of exercise interventions on falls, depression, anxiety or physical activity as our review only includes studies that reported fear of falling.

Authors' conclusions: Exercise interventions in community-dwelling older people probably reduce fear of falling to a limited extent immediately after the intervention, without increasing the risk or frequency of falls. There is insufficient evidence to determine whether exercise interventions reduce fear of falling beyond the end of the intervention or their effect on other outcomes. Although further evidence from well-designed randomised trials is required, priority should be given to establishing a core set of outcomes that includes fear of falling for all trials examining the effects of exercise interventions in older people living in the community.

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Conflict of interest statement

Several co‐authors of this review are involved in the NIHR HTA‐funded PROACT65+ study (Iliffe 2010a). The study is a multicentre cluster‐randomised trial comparing a community group exercise programme with home‐based exercise with usual care to increase physical activity for people aged 65 and over in primary care. The trial may be included in future versions of the review.

Denise Kendrick: coinvestigator on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Arun Kumar: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Hannah Carpenter: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) G A Rixt Zijlstra: none known Dawn A Skelton: coinvestigator on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a). Director of Later Life Training, a not‐for‐profit training organisation that provides evidence‐based training for physiotherapists and exercise instructors working with frailer older people Juliette R Cook: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Zoe Stevens: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Carolyn M Belcher: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Deborah Haworth: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Sheena J Gawler: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Heather Gage: coinvestigator on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Tahir Masud: coinvestigator on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Ann Bowling: coinvestigator on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Mirilee Pearl: researcher on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a). Teacher of Tai Chi and exercise for older people, and Director of Fitness for a Certain Age. Richard W Morris: senior statistician on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Steve Iliffe: principal investigator on NIHR HTA‐funded PROACT65+ study (Iliffe 2010a) Kim Delbaere: none known

Figures

1
1
Study flow diagram
2
2
'Risk of bias' summary: authors' judgements about each risk of bias item for each included study
3
3
'Risk of bias' graph: authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Forest plot: Exercise versus control: primary outcome ‐ fear of falling, post intervention
5
5
Exercise versus control: primary outcome ‐ fear of falling, post intervention (see Figure 4 for forest plot)
1.1
1.1. Analysis
Comparison 1 Exercise versus control: primary outcome ‐ fear of falling, post intervention, Outcome 1 Fear of falling as measured by single‐item question, falls efficacy, balance confidence and concern about falling, post intervention.
1.2
1.2. Analysis
Comparison 1 Exercise versus control: primary outcome ‐ fear of falling, post intervention, Outcome 2 Fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, short term follow‐up (< 6 months).
1.3
1.3. Analysis
Comparison 1 Exercise versus control: primary outcome ‐ fear of falling, post intervention, Outcome 3 Fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, long term follow‐up (6 months and more).
2.1
2.1. Analysis
Comparison 2 Exercise versus control: subgroup analysis for fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, post intervention, Outcome 1 Type of exercise (as classified using ProFaNE taxonomy).
2.2
2.2. Analysis
Comparison 2 Exercise versus control: subgroup analysis for fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, post intervention, Outcome 2 Type of control group.
2.3
2.3. Analysis
Comparison 2 Exercise versus control: subgroup analysis for fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, post intervention, Outcome 3 Recruited participants at increased risk of falls.
2.4
2.4. Analysis
Comparison 2 Exercise versus control: subgroup analysis for fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, post intervention, Outcome 4 Type of exercise (individual versus group).
2.5
2.5. Analysis
Comparison 2 Exercise versus control: subgroup analysis for fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, post intervention, Outcome 5 Frequency of exercise.
2.6
2.6. Analysis
Comparison 2 Exercise versus control: subgroup analysis for fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, post intervention, Outcome 6 Duration of exercise.
2.7
2.7. Analysis
Comparison 2 Exercise versus control: subgroup analysis for fear of falling as measured by single‐item questions, falls efficacy, balance confidence and concern about falling, post intervention, Outcome 7 Primary aim of the study.
3.1
3.1. Analysis
Comparison 3 Exercise versus control: secondary outcomes, Outcome 1 Occurrence of at least one fall.
3.2
3.2. Analysis
Comparison 3 Exercise versus control: secondary outcomes, Outcome 2 Falls rate.
3.3
3.3. Analysis
Comparison 3 Exercise versus control: secondary outcomes, Outcome 3 Depression score, post intervention.
3.4
3.4. Analysis
Comparison 3 Exercise versus control: secondary outcomes, Outcome 4 Depression score, short‐term follow‐up (< 6 months).
3.5
3.5. Analysis
Comparison 3 Exercise versus control: secondary outcomes, Outcome 5 Physical activity as measured using PASE (Physical Activity Scale for the Elderly).
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    1. Faes M, Reelick M, Melis R, Borm G, Esselink RG. Multifactorial fall prevention for pairs of frail community‐dwelling older fallers and their informal caregivers: a dead end for complex interventions in the frailest fallers. Journal of the American Medical Directors Association 2011;12(6):451‐8. - PubMed
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Foley 2009 {published data only}
    1. Foley A, Hillier S, Barnard R. Evaluation of a geriatric day rehabilitation centre: subjective and objective outcomes in community‐dwelling older adults. Australian Journal of Primary Health 2009;15(2):117‐22.
Gillespie 2012 {published data only}
    1. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. [DOI: 10.1002/14651858.CD007146.pub3] - DOI - PMC - PubMed
Gitlin 2006 {published data only}
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Greendale 2009 {published data only}
    1. Greendale GA, Huang M, Karlamangla AS, Seeger L, Crawford S. Yoga decreases kyphosis in senior women and men with adult‐onset hyperkyphosis: results of a randomized controlled trial. Journal of the American Geriatrics Society 2009;57(9):1569‐79. - PMC - PubMed
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    1. Hakim RM, Newton RA, Segal J, DuCette JP. A group intervention to reduce fall risk factors in community‐dwelling older adults. Physical & Occupational Therapy in Geriatrics 2010;22(1):1‐20.
Hakim 2004 {published data only}
    1. Balzano JM, Burke JL, Hoy TW, Roberts EM, Hakim R. A comparative study of balance measures among elderly persons participating in Tai Chi or structured exercise programs. Journal of Geriatric Physical Therapy 2002;25(3):44‐5.
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Hakim 2010 {published data only}
    1. Cissel E, Cours J, Teel S, Hakim R. A cross‐sectional study of balance‐related measures with older adults who participate in Tai Chi, Yoga, or no exercise. Journal of Geriatric Physical Therapy 2005;28(3):119‐20.
    1. Hakim RM, Kotroba E, Cours J, Teel S, Leininger PM. A cross‐sectional study of balance‐related measures with older adults who participated in Tai Chi, yoga, or no exercise. Physical & Occupational Therapy in Geriatrics 2010;28(1):63‐74.
Harling 2008 {published data only}
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Harmer 2008 {published data only}
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Inokuchi 2007 {published data only}
    1. Inokuchi S, Matsusaka N, Hayashi T, Shindo H. Feasibility and effectiveness of a nurse‐led community exercise programme for prevention of falls among frail elderly people: a multi‐centre controlled trial. Journal of Rehabilitation Medicine 2007;39(6):479‐85. - PubMed
ISRCTN05350123 {published data only}
    1. ISRCTN05350123. The effects of computer game dancing on foot placement accuracy and gaze behavior in older adults: a randomized control trial. http://www.controlled‐trials.com/ISRCTN05350123 (accessed 1 August 2013).
ISRCTN05545178 {published data only}
    1. ISRCTN05545178. The use of a virtual reality video dance game for the training of motor control in elderly: a two‐groups pre‐test post‐test controlled experimental design. http://www.controlled‐trials.com/ISRCTN05545178 (accessed 1 August 2013).
ISRCTN21695765 {published data only}
    1. ISRCTN21695765. Cost‐effectiveness of a proprioceptive exercise program in institutionalised elderly with fear of falling: randomised controlled trial. http://www.controlled‐trials.com/ISRCTN21695765 (accessed 1 August 2013).
ISRCTN48015966 {published data only}
    1. ISRCTN48015966. The Chaos Clinic for prevention of falls and related injuries: a randomised, controlled trial. http://www.controlled‐trials.com/ISRCTN48015966 (accessed 1 August 2013).
ISRCTN67535605 {published data only}
    1. ISRCTN67535605. A randomised controlled trial to compare falls prevention rehabilitation for people who fall and call an emergency ambulance but who are not transported to hospital. http://www.controlled‐trials.com/ISRCTN67535605. UK, (accessed 1 August 2013).
ISRCTN75134517 {published data only}
    1. ISRCTN75134517. The effects of physical exercise training in combination with cognitive training on dual task costs of walking in elderly: a two‐groups pre‐test post‐test randomized controlled trial. http://www.controlled‐trials.com/ISRCTN75134517 (accessed 1 August 2013).
ISRCTN89512790 {published data only}
    1. ISRCTN89512790. Randomised controlled trial to test the effects of, respectively, health coaching and an integrative district nurse approach for preventing falls in elderly people living in the community. ISRCTN89512790 (accessed 1 August 2013).
Iwamoto 2009 {published data only}
    1. Iwamoto J, Suzuki H, Tanaka K, Kumakubo T, Hirabayashi H, Miyazaki Y, et al. Preventative effect of exercise against falls in the elderly: A randomized controlled trial. Osteoporosis International 2009;20(7):1233‐40. - PubMed
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    1. Kim H, Yoshida H, Suzuki T. The effects of multidimensional exercise on functional decline, urinary incontinence, and fear of falling in community‐dwelling elderly women with multiple symptoms of geriatric syndrome: a randomized controlled and 6‐month follow‐up trial. Archives of Gerontology & Geriatrics 2011;52(1):99‐105. - PubMed
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NCT00140322 {published data only}
    1. NCT00140322. Dane County Safety Assessment (SAFE) research study. http://clinicaltrials.gov/show/NCT00140322 (accessed 1 August 2013).
NCT00217360 {published data only}
    1. NCT00217360. RCT to reduce further falls and injuries for older fallers presenting to an emergency department. http://clinicaltrials.gov/show/NCT00217360 (accessed 1 August 2013).
NCT00323596 {published data only}
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NCT00483275 {published data only}
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NCT00805220 {published data only}
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NCT00986466 {published data only}
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NCT01006967 {published data only}
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NCT01313481 {published data only}
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NCT01523600 {published data only}
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