As contract physical therapists employed by an independent living center, we were recently approached by an administrator who was concerned about the increase in the number of falls within the facility. During the past 4 months, several residents had sustained serious injuries as a result of falling; 2 of them had to be transferred to skilled nursing facilities. The administrator had read an article in a popular newsstand magazine that claimed that exercise had the potential to reduce falls in elderly people. He asked us if there was any merit to this claim and whether it would be in the best interest of the facility to offer such a program to its residents. To best answer his questions, we decided to search the literature to see if there was any scientific evidence to support the idea that exercise could reduce the incidence of falls in elderly people. We also were interested in finding out what type of program was most effective, because this information would be useful in planning for space, equipment, and personnel.
Initial database used for search: MEDLINE
The MEDLINE database, created by the US National Library of Medicine, is the leading source for bibliographic references and abstracts from the biomedical literature. We decided to use this database to initiate our search because it gave us access to citations from more than 4,000 biomedical journals published worldwide as well as links to a number of full-text articles online. Although many vendors offer access to MEDLINE, we found PubMed, the free Internet version offered by the National Library of Medicine, to be the most effective way of accessing this database. We conducted our search using PubMed. This search was done on February 22, 2002.
Initial keywords: falls, exercise
We started our search by performing 2 queries, one for the keyword falls and one for the keyword exercise. In order to minimize bias in our search, we did not use keywords that focused on a particular outcome (ie, falls and reduction). We felt using the terms falls and exercise would encompass all studies, regardless of outcome. These searches resulted in 14,784 citations for falls and 104,516 citations for exercise. We decided to combine the 2 searches using the Boolean operator “AND” to focus our search on citations that contained both terms. In PubMed, Boolean operators such as “AND,” “OR,” and “NOT” must be typed in upper case. In order to combine our first 2 search results, we typed #1 AND #2 in the query box, which corresponded to the first 2 search statement numbers in our search history (see “Tips for Using the History Feature in PubMed”). The number of citations containing both keywords was reduced to 559 articles. Because 559 citations was still an overwhelming number of references to consider, we decided to place some limits on our search in order to eliminate less relevant articles from our list.
Limits: English, Human, Aged: 65+ years, 10 years, Randomized controlled trial
To set the appropriate limits, we clicked on the Limits option on the Features bar directly beneath the query box. A screen offering a number of different options to limit our search appeared (Fig. 1). We first decided to focus on articles that were written in the English language by clicking on the Languages dropdown list and selecting the option English. To further narrow our search, we also decided to look only at the articles describing studies that were done on human subjects by selecting Human from the Human or Animal dropdown list. We also looked only at the studies that considered a population with an age range similar to that of the patients in our independent living center by selecting Aged: 65+ years from the Ages dropdown list. Finally, in order to consider the latest findings and the highest level of evidence available on this topic, we limited our search to the randomized controlled trials published in the past 10 years by selecting 10 years from the Entrez Date list, which would pull up citations based on the date they were entered into PubMed, and Randomized Controlled Trial from the Publication Types list.
Imposing these limits narrowed down the number of citations from 559 to 50 articles. After a quick review of the titles, we were able to eliminate articles that focused on other interventions to reduce falls, such as consultation services, home evaluations, and psychotropic medication withdrawal. We found that only 14 articles were directly related to the effects of exercise on falls in older adults (Fig. 2), and we were able to keep track of the relevant articles by checking the box next to each citation and hitting the Display button underneath the Features bar after we completed our review of the citation list. Next, we decided to further evaluate the relevance of the remaining 14 articles by reading their abstracts. Of these 14 articles, 7 showed that exercise had a positive effect on risk of falls in elderly people, 6 showed that exercise had no effect on risk of falls in elderly people, and 1 did not have an accompanying abstract. To make matters more complicated, each of the 7 studies that showed that exercise had a positive effect on fall risk used varying exercise protocols. Given the conflicting evidence, it was clear to us that we needed additional information. For example, were some of these 14 randomized controlled trials more credible than others? Were some flawed from a scientific standpoint? Why did some studies show a positive effect and others no effect?
Because we did not feel we had the knowledge to adequately critique the scientific merit of these trials, we decided to see if a systematic review had been performed in this area. As defined by Sackett et al, a systematic review is “a summary of the medical literature that uses explicit methods to perform a thorough literature search and critical appraisal of individual studies and that uses appropriate statistical techniques to combine these valid studies.”1(p250) Although systematic reviews are not immune to reviewer bias and contradictory conclusions, we believed that, if a systematic review in this area did exist, it would help us answer our question.
Second database used for search: Cochrane Database of Systematic Reviews
The Cochrane Database of Systematic Reviews (CDSR) was created by the Cochrane Collaboration, an international network of review groups directed to prepare, maintain, and disseminate systematic reviews concerning health care issues. The goal of the Cochrane Collaboration is to assemble the highest-quality evidence by reviewing the relevant research in order to offer conclusions on the effects of health care. The CDSR is updated regularly as new research is published, and it is revised if errors are identified. If studies do not meet the requirements of the Collaborative Review Groups, they are disregarded. Once a review is published, it remains in the CDSR and is continuously modified on the basis of new evidence.
The CDSR can be accessed through the Internet at www.cochranelibrary.com. Although access to the abstracts is free, a subscription to the CDSR is required in order to gain access to the full-text articles. Nonregistered users can obtain a full copy of a review via mail or fax for a fee ($15 US). Copies of the articles also may be obtained through organizations that are registered users, such as university libraries and teaching hospitals. We accessed this database using Ovid Online* through a local university library. This search was performed on March 20, 2002.
Keywords: falls AND exercise
After logging onto Ovid, we started our search by clicking on EBM† Reviews-Cochrane Database of Systematic Reviews from the list of databases. Once the main search page appeared, we typed falls AND exercise in the query box. In Ovid, the query box is located under the Icon bar, a row of small icons offering access to the advanced features of Ovid. Like PubMed, Boolean terms must be capitalized. The result of this query was 17 systematic reviews.
Selection of articles for review:
After reading the titles, we found only one review that was directly related to the prevention of falls in elderly people. We then decided to read the abstract for more information.
Gillespie, LD; Gillespie, WJ; Robertson, MC; Lamb, SE; Cumming, RG; Rowe, BH. Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews. Issue 1, 2002.
BACKGROUND: Approximately 30 percent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention. OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group specialised register (January 2001), Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2001), MEDLINE (1966 to February 2001), EMBASE (1988 to 2001 Week 14), CINAHL (1982 to March 2001), The National Research Register, Issue 1, 2001, Current Controlled Trials (accessed 25 May 2001), and reference lists of articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate.
Interventions likely to be beneficial:
A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98).
A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73).
Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (1 trial, 530 participants, RR 0.64, 95% CI 0.49 to 0.84).
A reduction in falls was seen both inside and outside the home. Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95% CI 0.16 to 0.74).
Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes, both for unselected community dwelling older people (data pooled from 3 trials, 1973 participants, pooled RR 0.73, 95%CI 0.63 to 0.86), and for older people with a history of falling, or selected because of known risk factors (data pooled from 2 trials, 713 participants, pooled RR 0.79, 95%CI 0.67 to 0.94).
Interventions of unknown effectiveness:
Group-delivered exercise interventions (9 trials, 2177 participants).
Nutritional supplementation (1 trial, 50 participants).
Vitamin D supplementation, with or without calcium (3 trials, 679 participants).
Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants).
Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants).
Fall prevention programmes in institutional settings.
Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants).
Home hazard modification for older people without a history of falling (1 trial, 530 participants).
Hormone replacement therapy (1 trial, 116 participants).
Interventions unlikely to be beneficial:
Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).
CONCLUSIONS: Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modeling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.
[© 2001 Update Software Ltd/Cochrane Collaboration. Abstract reprinted from The Cochrane Library with permission of Update Software Ltd.]
Of the trials included in this systematic review, 13 dealt with the effects of exercise in reducing fall risk in elderly people. Of those 13 trials, 4 used interventions that were deemed “likely to be beneficial,” whereas 9 of the trials used interventions that were “of unknown effectiveness.” Of the 4 trials that used interventions “likely to be beneficial,” 3 used exercise programs that were individually prescribed, whereas the fourth trial evaluated the effects of a Tai Chi exercise intervention. Interestingly, of the 9 trials that were found to demonstrate “unknown effectiveness,” all used group-delivered exercise interventions. Because it was apparent that there was at least some evidence to support the concept that exercise could reduce falls in elderly people, we decided to obtain the full-text version of this systematic review by clicking on the Topic Review option next to the citation in the results list. We proceeded to read the review, but the details of the exercise protocols that were determined to be successful were not described. However, because the citations for the original articles were included in the text, we were able to refer to the original source to attain the details of these studies. We decided to focus our attention on the articles that dealt with individualized exercise programs because the outcomes for these trials were more compelling. We obtained these articles from the local university library and began to review their contents. The abstracts from these studies as they appear in MEDLINE are presented below, as is a brief discussion of each article.
Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Falls prevention over 2 years: a randomized controlled trial in women 80 years and older. Age and Ageing 1999;28:513–518.
[Editor's Note: Physical Therapy was unable to secure permission to reprint this abstract online. For access to the abstract on the Age and Ageing Web site, click here.]
This randomized controlled trial found that a personalized home balance and exercise training program significantly reduced the risk of falls in elderly people. The efficacy of this program was maintained over a 2-year period; however, the benefit was sustained only as long as the subjects adhered to the exercise program. The conclusions offered by this article seemed appropriate to answer our initial question regarding the efficacy of exercise in reducing falls in elderly people. Unfortunately, the article provided limited information regarding the details of the exercise program used, and readers were referred to another study by the same authors for the complete protocol (Campbell et al, 1997; see below). The 2 factors that were deemed essential to the success of this exercise regimen were: (1) all of the exercises were individually prescribed by a physical therapist and (2) the physical therapist remained in telephone contact with the subjects for the purposes of giving advice as well as maintaining their motivation.
Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997;315:1065–1069.
[Editor's Note: Physical Therapy was unable to secure permission to reprint this abstract online. For access to the abstract on PubMed, click here.]
This randomized clinical trial concluded that an individually based exercise program consisting of physical therapy in the home was effective in reducing falls and improving function in women who were 80 years of age and older. Tests and measures that were used included an instrumental activities of daily living scale, the Physical Self-Maintenance Scale, fear of falling, and the Physical Activity Scale for the Elderly.
Participants in the control group received regular “social visits” during the first 2 months and were then telephoned regularly during the year as a follow-up. Participants in the exercise group were prescribed a selection of strengthening and balance exercises from a program at appropriate and increasing levels of difficulty. Strengthening exercises included moderate intensity exercises with ankle cuff weights for the following muscles: hip extensor and abductors, knee flexors and extensors, and ankle plantar flexors and dorsiflexors. Balance exercises consisted of: walking and standing with one foot in front of the other, walking on toes and heels, walking backwards and sideways, and turning around. Stepping over objects, climbing stairs, squats, and sit-to-stand movements from a chair also were performed to increase strength and balance. The exercise protocol was performed for 30 minutes 3 times a week. In addition, subjects were encouraged to walk 3 times a week on their own.
We were pleased with the results of this study, which showed that, after 1 year of training, balance had improved significantly and the number of falls had decreased in the exercise group compared with the control group. Furthermore, the control group became less active and their fear of falling increased. This study clearly supports the notion that implementing an individualized exercise program would be beneficial for elderly people living in independent living centers.
Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. BMJ 2001;322(7288):697–701.
[Editor's Note: Physical Therapy was unable to secure permission to reprint this abstract online. For access to the abstract on PubMed, click here.]
This randomized controlled trial reported that a home exercise program to prevent falls delivered by a nurse could be effective and cost-efficient in people who were 75 years of age and older. Like the first article reviewed (Campbell et al, 1999), this article gave limited information on the specifics of the home exercise program and referred the reader to their 1997 article for details. The difference between this study and the previous 2 studies that we reviewed was the fact that the exercise program was prescribed by a nurse and not a physical therapist. The nurse was trained by a qualified physical therapist in a 1-week course; however, the specifics of this training were not mentioned.
Overall, a significant 46% reduction in falls was observed in the exercise group. This study confirmed the effectiveness of strength and balance training in reducing falls in elderly people, and further suggests that the success of an exercise program depends on whether it has been individualized.
When we saw the center administrator again, we told him that there was scientific evidence that exercise could reduce falls in elderly people. Based on the conclusions of the Cochrane systematic review, we also suggested that an individually prescribed strength and balance program would likely be more effective than a group exercise program. In our opinion, a fall prevention program could be implemented rather inexpensively, because the 3 studies we reviewed all used home exercise programs, thereby negating the need for expensive equipment and space requirements. It also was clear to us that the initial program development for each participant would need to be based on identified impairments and functional limitations and that the services of a physical therapist should be employed. Based on the 1999 Campbell et al study, it was apparent that the physical therapist also would have to participate in occasional follow-ups to aid exercise progression, answer questions, and provide motivation.
As a result of our search, we felt confident in advocating for the development of a fall prevention program. The findings of the trials we discussed were based on a relatively large number of subjects (566 combined), and the average age and demographics of the residents of our facility were consistent with the study populations. Therefore, the decision to initiate such a program was justified in our opinion.
Tips for Using the History Feature in PubMed
PubMed's History function—located on the Features bar directly beneath the query box—automatically holds and displays up to 100 search statements (a numbered line containing a completed search strategy, the time of the search, and the number of citations produced). These search statement numbers can be combined or used with new search queries.
To combine 2 searches, type the pound (#) sign and the search statement number for each search, separate them by adding AND (ie, #1 AND #4), and click Go.
To combine a search with a new keyword, type the pound sign and the search statement number, then type AND in all capitals, then type the new keyword, and finally click Go.
To refine a search, type the pound sign and the search statement number, then click on the Limits feature on the Features bar and select the appropriate limits.
The Search History is automatically lost after 1 hour of inactivity.
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