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Falls and Frailty – Reduces falls and falls risk

Evidence summary (Updated 2022)
Multiple-component group exercise significantly reduces the rate of falls (RaR 0.71, 95% CI 0.63 to 0.82) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96), as do multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80 and RR 0.78, 95% CI 0.64 to 0.94) [1].
Classes that included just gait, balance or functional training achieved a statistically significant reduction in rate of falls (RaR 0.72, 95% CI 0.55 to 0.94) but not in risk of falling (RR 0.81, 0.62 to 1.07) [1].
In community-dwelling older people, greater intervention effects are seen in trials that include exercise programmes which provide a high challenge to balance and 3 or more hours per week of prescribed exercise over the programme period [2].
Exercise may have a preventive effect on the rate of falls (risk ratio [RR] 0.81, 95% CI 0.68-0.97) in those in a care-facility. This effect is stronger when exercise is combined with other fall interventions (RR 0.61, 95% CI 0.52-0.72) [3]. However other meta-analyses show a lack of fall prevention effect from exercise as a single intervention in residential care settings [1,2] This does not mean that there is no role for exercise as a component of a multiple-intervention fall prevention programme.
Recent review of evidence since 2018 finds stronger evidence both in community and residential care.

One study 2500+ residents showed significant reduction in number of fallers (SMD = 0.85 (0.73-0.98). Longer interventions, and those involving balance training, are more effective [4]

Even healthy adults may benefit: Most types of exercise reduce falls rate, especially 3D exercise, strength/resistance training, and mixed exercises. Taken together (more power), exercise interventions reduce fall-related fracture risk. Fear of falling was slightly decreased with endurance exercises. [5]
Eccentric Resistance Training (RT) was as effective as conventional RT in reducing falls incidence and improving functional performance [6].

Pilates is effective for improving balance, strength, flexibility, and functionality and reducing the risk of falls. Certainty (GRADE): low for balance, flexibility and functionality; moderate for strength and risk of falls [7].

Exercise interventions do reduce risk of fall-related fractures among older adults. SMD = 0.74 (0.59-0.92). P = 0.007. [8].
A very large SR (>25000): Overall, PA reduces falls incidence by 23% (CI 0.71 to 0.83, high certainty). Effect size varied by type: balance/functional training = 24% (CI 0.70-0.82, high certainty); multi-component = 28% (CI 0.56-0.93, moderate certainty); Tai Chi = 23% (CI 0.61-0.97, moderate certainty). Effects of RT, dance, and walking interventions remain unclear. Most effective Interventions were ≥3h and included balance and functional exercises (42% falls rate reduction, CI 0.45-0.76) [9]

3 moderate to large MA:
Exercise interventions reduced falls rate (RR = 0.71, CI 0.62-0.82, p < 0.0001). Larger effect for females (RR = 0.64, CI 0.49-0.83, p = 0.00009). Exercise interventions reduced facture incidence (RR = 0.54, CI 0.35-0.83, p = 0.005), also with a larger effect for females (RR = 0.37, CI 0.20-0.67, p = 0.001). Exercise interventions combining strength and balance training reduced falls risk the most. Interventions involving RT or jumping reduced fracture rates the most [10].
Overall, exercise interventions did not significantly reduce falls incidence, or the number of fallers. Balance training did reduce falls incidence (low certainty). Interventions that used technical devices (e.g. Wii) reduced falls incidence (low-to-moderate certainty). Tai chi reduced fear of falling (moderate certainty). Interventions lasting longer than ≥6 months were more effective (moderate certainty). Among frail residents, exercise interventions increased falls rate [11].
No difference in dropout (RR = 1.05, CI 0.95–1.17) or mortality rates (RR = 0.93, CI 0.83–1.04) between exercise and control groups. Exercise reduced mortality rate among clinical populations (RR = 0.67, CI 0.48–0.95). Exercise significantly reduced number of falls and fall-associated injuries, and improved physical function and cognition [12]

6 of 8 RCTs found multicomponent exercise programmes to reduce risk of falls. There were improvements in balance, muscle strength, and mobility. 4 of RCTs showed that whole-body vibration training (WBV) reduced falls risk [13].

For community based: Significant reduction in falls rate (RaR 0.79, CI 0.71 to 0.88), and risk of falling (RR 0.83, CI 0.76 to 0.92). Benefit was not seen beyond 2 years, but few studies followed up for this long. Gait, balance, and functional training exercises are essential elements in falls prevention interventions (in agreement with Sherrington et al).[14].

Very large SR/MA:
Exercise significantly reduced number of fallers (RR 0.89, CI 0.81-0.97) and injurious falls (IRR 0.81, CI 0.73-0.90); it caused a nonsignificant reduction in falls incidence (IRR 0.87; CI 0.75-1.00); no association with mortality. Few exercise trials reported fall-related fractures. [15].

Moderate SR : Exercise significantly reduced falls incidence (RaR 0.68, CI 0.58 to 0.80, p <0.001) and number number of fallers (RR 0.78, CI 0.68 to 0.89, p <0.001). Interventions that applied posture-challenging exercises showed the highest effects [16]

Smaller heterogenous SR but strong messaging: Multicomponent exercise interventions all resulted in positive trends or significant improvements in gait ability (except one, which attenuated it vs control). Not a single serious accident/injury reported – exercise is safe.[17]

Quality of evidence
Community: High quality
Residential Care: Moderate quality

Strength of recommendation
Community: Strong
Residential Care: Strong

Physical activity can be recommended for the prevention of falls in most community dwelling people in most circumstances.
For those in residential care, there is increasing evidence regarding the effects of physical activity especially if multi-modal. The benefits are not seen consistently, but as there are few significant adverse events, exercise could be considered alongside other falls-prevention strategies

[1] Gillespie, Lesley D., et “Interventions for preventing falls in older people living in the community.” Cochrane Database Syst Rev 9.11 (2012).
[2] Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, Cumming RG, Herbert RD, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2016 Oct 4:bjsports-2016.
[3] Lee SH, Kim HS. Exercise Interventions for Preventing Falls Among Older People in Care Facilities: A Meta‐Analysis. Worldviews on Evidence‐Based Nursing. 2017 Feb 1;14(1):74-80.
[4] Wang F, Tian B. The effectiveness of physical exercise type and length to prevent falls in nursing homes: A systematic review and meta-analysis. J Clin Nurs. 2022 Jan;31(1-2):32-42. doi: 10.1111/jocn.15942. Epub 2021 Jul 8. PMID: 34240489.

[5] Caristia S, Campani D, Cannici C, Frontera E, Giarda G, Pisterzi S, Terranova L, Payedimarri AB, Faggiano F, Dal Molin A. Physical exercise and fall prevention: A systematic review and meta-analysis of experimental studies included in Cochrane reviews. Geriatr Nurs. 2021 Nov-Dec;42(6):1275-1286. doi: 10.1016/j.gerinurse.2021.06.001. Epub 2021 Sep 21. PMID: 34555570.

[6] Kulkarni D, Gregory S, Evans M. Effectiveness of eccentric-biased exercise interventions in reducing the incidence of falls and improving functional performance in older adults: a systematic review. Eur Geriatr Med. 2021 Oct 11:1–14. doi: 10.1007/s41999-021-00571-8. Epub ahead of print. PMID: 34633637; PMCID: PMC8503729.

[7] Fernández-Rodríguez R, Álvarez-Bueno C, Ferri-Morales A, Torres-Costoso A, Pozuelo-Carrascosa DP, Martínez-Vizcaíno V. Pilates improves physical performance and decreases risk of falls in older adults: a systematic review and meta-analysis. Physiotherapy. 2021 Sep;112:163-177. doi: 10.1016/ Epub 2021 Jun 7. PMID: 34332493.

[8] Wang, Q., Jiang, X., Shen, Y., Yao, P., Chen, J., Zhou, Y., Gu, Y., Qian, Z., & Cao, X. (2020). Effectiveness of exercise intervention on fall-related fractures in older adults: a systematic review and meta-analysis of randomized controlled trials. BMC geriatrics, 20(1), 322.

[9] Sherrington C, Fairhall N, Kwok W, Wallbank G, Tiedemann A, Michaleff ZA, Ng CACM, Bauman A. Evidence on physical activity and falls prevention for people aged 65+ years: systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act. 2020 Nov 26;17(1):144. doi: 10.1186/s12966-020-01041-3. PMID: 33239019; PMCID: PMC7689963.

[10] Wong RMY, Chong KC, Law SW, Ho WT, Li J, Chui CS, Chow SKH, Cheung WH. The effectiveness of exercises on fall and fracture prevention amongst community elderlies: A systematic review and meta-analysis. J Orthop Translat. 2020 Jun 1;24:58-65. doi: 10.1016/ PMID: 32695605; PMCID: PMC7349939.

[11] Schoberer D, Breimaier HE. Meta-analysis and GRADE profiles of exercise interventions for falls prevention in long-term care facilities. J Adv Nurs. 2020 Jan;76(1):121-134. doi: 10.1111/jan.14238. Epub 2019 Nov 8. PMID: 31642090; PMCID: PMC6972676.

[12] García-Hermoso A, Ramirez-Vélez R, Sáez de Asteasu ML, Martínez-Velilla N, Zambom-Ferraresi F, Valenzuela PL, Lucia A, Izquierdo M. Safety and Effectiveness of Long-Term Exercise Interventions in Older Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sports Med. 2020 Jun;50(6):1095-1106. doi: 10.1007/s40279-020-01259-y. PMID: 32020543.

[13] Abdullah Alfadhel SA, Vennu V, Alotaibi AD, Algarni AM, Saad Bindawas SM. The effect of a multicomponent exercise programme onelderly adults’ risk of falling in nursing homes: A systematic review. J Pak Med Assoc. 2020 Apr;70(4):699-704. D
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[14] Finnegan S, Seers K, Bruce J. Long-term follow-up of exercise interventions aimed at preventing falls in older people living in the community: a systematic review and meta-analysis. Physiotherapy. 2019 Jun;105(2):187-199. doi: 10.1016/ Epub 2018 Sep 20. PMID: 30846193.

[15] Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL. Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018 Apr 24;319(16):1705-1716. doi: 10.1001/jama.2017.21962. PMID: 29710140.

[16] Hamed A, Bohm S, Mersmann F, Arampatzis A. Follow-up efficacy of physical exercise interventions on fall incidence and fall risk in healthy older adults: a systematic review and meta-analysis. Sports Med Open. 2018 Dec 13;4(1):56. doi: 10.1186/s40798-018-0170-z. PMID: 30547249; PMCID: PMC6292834.

[17] Arrieta H, Rezola-Pardo C, Gil SM, Irazusta J, Rodriguez-Larrad A. Physical training maintains or improves gait ability in long-term nursing home residents: A systematic review of randomized controlled trials. Maturitas. 2018 Mar;109:45-52. doi: 10.1016/j.maturitas.2017.12.003. Epub 2017 Dec 6. PMID: 29452781.