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The role of exercise in falls prevention for older patients.

The National Institute for Clinical Excellence (NICE) draft guidance on the assessment and prevention of falls in older people (NICE, 2004) includes evidence to show that t’ai chi taught in 15-week courses can improve muscle strength and balance therefore reducing the risk of falls in older people (NICE, 2004).

Abstract

VOL: 100, ISSUE: 18, PAGE NO: 28

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times.

 

The National Institute for Clinical Excellence (NICE) draft guidance on the assessment and prevention of falls in older people (NICE, 2004) includes evidence to show that t’ai chi taught in 15-week courses can improve muscle strength and balance therefore reducing the risk of falls in older people (NICE, 2004).

 

 

Falls prevention is a key area of health promotion for all nurses who work with older people but the suggestion that t’ai chi should be used as a prevention intervention may be new to many nurses.

 

 

Falls prevention
The prevention and management of falls in older people is a key government target outlined in the National Service Framework for Older People (Department of Health, 2001). Falls are a major cause of disability and the leading cause of mortality due to injury in people over 75 in the UK. Preventing falls in frail older people will save lives and decrease disability (DoH, 2001).

 

 

Standard six of the NSF aims to reduce the number of falls in older people and ensure effective treatment and rehabilitation for those who have fallen. Among the several risk factors the NSF identifies as implicated in falls in older people (Box 1), there are some that may be improved by exercise - such as balance problems.

 

 

To underpin the falls standard of the NSF, NICE is developing its own clinical practice guidelines on falls. The provisional guideline recommendations (NICE, 2004) are currently under consultation and as well as covering the key areas of falls prevention, such as basic risk assessment, they also provide evidence-based guidance on the types of exercise that may or may not be useful in falls prevention.

 

 

There are numerous studies examining interventions for the prevention of falls, and these are used to inform the guidance. However, only a few of these trials have been carried out in the UK.

 

 

Interventions with insufficient evidence
The NICE falls prevention guidance highlights several exercise interventions for which it suggests that there is currently insufficient evidence to recommend that they are successful in falls prevention:

 

 

- Brisk walking, despite the possibility that it may have other health benefits, has been shown to increase the risk of falling in post-menopausal women in an unsupervised brisk walking trial (Gillespie et al, 2004);

 

 

- Exercise combined with health education programmes also has insufficient evidence supporting its effectiveness. The studies informing this recommendation included a programme combining low intensity exercise with continence promotion, which provided no evidence of fall reduction in extended care settings. Also, complex interventions, in which group activities included health education and exercise, were studied (Gillespie et al, 2004);

 

 

- Group exercise that is untargeted and not individually prescribed has insufficient evidence to suggest it is effective in falls prevention (Gillespie et al, 2004).

 

 

However, a study by Liu-ambrose et al (2004) in Canada has recently found evidence to suggest that group agility or resistance training in older women who have a low bone mass can improve postural stability and thus reduce the risk of falls. In addition, Weatherall (2004) has recently published a study that suggests that there is moderate evidence of efficacy for falls prevention with multiple intervention strategies.

 

 

Interventions with good evidence for effectiveness
The NICE guidance lists the preferred strategies for exercise interventions to reduce falls as:

 

 

- A programme of muscle strengthening and balance retaining, that is individually prescribed at home by a trained health professional;

 

 

- A 15-week t’ai chi group exercise intervention.

 

 

These recommendations are made from evidence discussed in a Cochrane review (Gillespie et al, 2004) into interventions for preventing falls in older people. The review found that three trials provided evidence that muscle strengthening and balance retraining programmes individually prescribed at home by a trained health professional are likely to be effective in reducing falls.

 

 

And one trial which consisted of 200 participants undertaking a 15-week t’ai chi group exercise intervention also provided evidence that t’ai chi is likely to be beneficial.

 

 

The reviewers highlight that although there is now evidence regarding interventions to prevent falls, less is known about their effectiveness in preventing fall-related injuries and so further research is needed into this important area.

 

 

Other studies support the findings of the Cochrane review regarding the value of t’ai chi. A study by the Hong Kong Polytechnic University in China (Tsang and Hui-Chan, 2004) of 49 older people who volunteered for an intervention programme of either supervised t’ai chi or general education concluded that even four weeks of intensive t’ai chi training was sufficient to improve balance control in older people.

 

 

A more unusual approach to exercise for the prevention of falls was taken by Australian researchers. Older people who were at risk of falls were recruited to a randomised, controlled, crossover pilot study where they were invited to undertake a wobble-board training programme (Waddington and Adams, 2004). The study examined the effects of wobble-board training on the subjects’ ability to discriminate between different extents of ankle inversion movements and concluded that training with a wobble-board could provide a simple in-home intervention to improve ankle movements. However, the researchers acknowledge that research on trip and fall frequency after wobble-board use is needed before such training could be recommended.

 

 

Another Australian study has investigated a specific balance strategy training intervention presented in a workstation format for small groups of older people (Nitz and Choy, 2004). It concluded that specific balance strategy training using workstations is superior to traditional exercise classes for improving function and balance and reducing the risk of falls in older people.

 

 

A further systematic review (Chang et al, 2004) has recently suggested that exercise programmes could be implemented to a general population of older adults and are effective in reducing falls.

 

 

They also highlight the fact that more research is needed to focus on making these programmes more cost-effective and to establish what particular characteristics of exercise programmes are essential to contribute to falls reduction.

 

 

Practical considerations
Despite the mounting evidence for the use of balance and muscle strengthening exercises such as t’ai chi in the prevention of falls it must be recognised that older people may be reluctant to participate in prevention programmes that have an exercise-based component. The NSF highlights the need for interventions to be agreed with the older person.

 

 

There is evidence on the factors that appear to be barriers to either initial participation or the long-term maintenance of falls prevention programmes. These are mainly personal issues, rather than a result of the programme format. They include:

 

 

- Low self-efficacy or lack of perceived ability to undertake components of the programme;

 

 

- Fear of falling;

 

 

- Fear of exertion;

 

 

- Illness;

 

 

- Denial or underestimating personal risk of falling;

 

 

- Embarrassment (NICE, 2004).

 

 

Factors that have been identified as contributing to an increased likelihood in participation of falls prevention programmes include:

 

 

- High self-efficacy or good perceived ability to undertake components of the programme;

 

 

- Past exercise history;

 

 

- General good health;

 

 

- Functional ability;

 

 

- Home-based programme;

 

 

- Peer role models;

 

 

- Low intensity exercise (for example, walking);

 

 

- Moderate frequency (two or three times per week);

 

 

- Perceived as relevant, beneficial, and fun (NICE, 2004).

 

 

Nurses trying to encourage older patients to participate in exercise interventions to reduce the risk of falls should remember that the social aspects of falls prevention programmes are probably their strongest selling point.

 

 

Implications for practice
The incidence of falls in older people, the morbidity and mortality as a result of falls, and the increasing age of the population make falls prevention a key issue for all nurses who work with older people. The NICE guidelines highlight the need to use evidence-based practice in the planning and delivery of health promotion interventions. The guidelines also provide clear information for nurses regarding current research findings in the field and their application to practice.

 

 

Exercise is important in falls prevention. However, this should be aimed at muscle strengthening and balance retaining interventions such as t’ai chi. It is vital to consider factors that may be barriers to participation in exercise programmes and ensure that sufficient time is taken to fully discuss the planned intervention and describe its likely benefits to the individual, as well as allaying any fears.

 

 

This article has been double-blind peer-reviewed.

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