Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossébo randomised controlled trialBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3830 (Published 22 July 2015) Cite this as: BMJ 2015;351:h3830
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Re: Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossébo randomised controlled trial - responses to readers'comments
We thank Dr Bonten for his comments and questions regarding how our results may be translated in clinical practice and integrated into current clinical guidelines. It also gives us the opportunity to talk about the place that exercise programmes such as Ossébo may have in a comprehensive strategy of fall prevention in the older population.
There are two main approaches to fall prevention in community-dwelling older adults that have been proven to be effective in RCTs: the multifactorial and multidisciplinary approach which involves an individual clinical assessment of risk factors for falling, followed by multiple interventions targeting all remediable risk factors (normally within a specialist falls service), and single community-based interventions targeting common risk factors (such as impaired strength and balance).
Multifactorial intervention community programmes are resources and staff intensive and there is no evidence that they are more effective than single intervention programmes such as balance and strength training . Hence, a common view is that the multifactorial approach, especially if delivered by a multidisciplinary team, should be reserved to older adults at high risk such as frail patients who have had recurrent falls or older adults presenting to the Emergency department with a fall or fracture [2,3]. Single interventions, in particular community-based exercise programmes designed to improve balance and reduce falls and injuries, will help gain population coverage at lower individual cost . Referral to this type of programmes must be based on simple criteria or tests that can be easily used by GPs as well as other experienced and appropriately trained professionals in the health or physical activity domains. The eligibility criteria must also allow the selection of a large portion of the “at risk” population who is likely to benefit from the proposed intervention, in order for this intervention to have a significant impact at the population level (in terms of number of falls and injuries prevented).
In the Ossébo experiment, the recruitment strategy is based on the use of voting registration lists (rather than GPs’ lists of patients, for instance) because we wanted the population source to be as broad and unselected as possible. We used 2 functional tests (gait speed and the tandem walk test) rather than a history of fall as the primary tool to select older women into the trial because this allowed selecting a larger number of at-risk older women who were likely to benefit from our group-based exercise program. Among the women examined, approximately 42% had the required functional criteria (“not too fit, not too frail”) and, ultimately, 27% were selected for the trial (after exclusion of women who had medical contra-indications or other exclusion criteria). Among women selected for the trial, approximately 40% reported having fallen in the past year. But the functional tests allowed us to identify a large number of other women who, although they had not fallen yet, were at increased risk of falls and injuries because of impaired balance and gait (and, hence, were likely to benefit from a balance training programme such as Ossébo).
We believe that exercise programmes that have proven to be safe and effective like the Ossébo programme should be largely recommended based on simple criteria that are directly linked to the particular intervention. However, we acknowledge that some functional tests (e.g., the measure of gait speed, or the TUG test which is often recommended in guidelines as a second-line criteria for older adults who report having fallen in the previous year) may not be so easy to implement in routine clinical care. We agree with Sarah and Jill Lamb , that future research should aim at assessing the value of simpler clinical tests (such as the tests of single leg stance and tandem stance) that would be more acceptable by GPs and at developing simple test criteria that could be used by the older people themselves for self-referral, in order to increase uptake of fall prevention exercise programmes in the older population.
As Dr Bonten suggests, the participants’ primary care physicians may have provided advice or care during follow-up that may have contributed to lower the risk of falling. However, there is no reason to believe that this happened more in the intervention group than in the control group and, hence, that it has biased our results towards an overestimation of the intervention’s effect. Note that, as mentioned in the article, at the end of the baseline examination, all the women, included in the trial or not, were offered brochures about fall and fracture prevention which discussed the importance of physical activity, a balanced diet, and vitamin D supplementation and offered suggestions for assessing home hazards and managing drugs. Participants in both groups also received newsletters twice a year reminding them about major risk factors for falls and prevention measures. We were able to monitor changes in risk factors for falling during follow-up by including in the 1- and 2-years examinations, questions regarding significant health problems that might have happened or become significantly worse since the last visit (newly diagnosed diseases, hospitalisations, vision problems, move to an institution, etc) and by recording medication use at each examination. We have also checked that the “contrast” between the two comparison groups regarding physical activity was maintained over time (same physical activity questionnaire at baseline, 1 and 2 years, which includes, among others, a question regarding participation in fall prevention exercise classes).
We also thank Drs Sugiyama and colleagues for their comment, and fully agree with them that both falling and bone fragility should be targeted to prevent hip fracture. However, anti-osteoporosis drugs are currently recommended for women with low BMD and a high risk of fracture, but there is no consensus regarding the definition of the high risk groups and the best strategy to identify those groups, especially among older women 75+ who have a high average risk of hip fracture .
In the EPIDOS prospective population-based cohort of women aged 75-85 years, women with very low BMD (T-score ≤ -3.5) had an absolute risk of hip fracture more than twice the average risk in the cohort , i.e., a level of risk above which bone-active treatments such as bisphosphonates have been shown to be reasonably cost-effective , and that most clinicians would probably consider as unacceptably high in such an old subgroup. But this sub-group contributed only a quarter of all hip fracture cases recorded in the cohort . Our research group has assessed the clinical usefulness of different screening strategies aimed at identifying this high risk subgroup as well as other subgroups with a comparable level of risk that may also be considered for an anti-osteoporosis treatment (e.g., osteoporotic women with a somewhat higher BMD - a T-score between -2.5 and -3.5 - but with several other clinical risk factors for fracture) , but the sensitivity of these different strategies for hip fracture remains modest (including strategies based on systematic BMD screening for all women), which means that the majority of hip fractures occur in women who do not belong to these high risk groups. Hence, although a high risk strategy based on screening for low BMD and then treating older women who are at highest risk of hip fracture with a bone-specific drug is fully justified, it is clear that it won’t be sufficient to significantly reduce the population burden of hip fractures. Additional effective measures, such as fall prevention measures that can be recommended to a larger number of older women, are necessary if we want to significantly reduce the number of fractures in this population.
We agree that there is no definite proof that specific exercise programmes are effective to reduce hip fractures (such a demonstration would require to set up a trial including several thousands of older participants). However, we believe that the Ossébo study, that focuses on women aged 75-85 years, selected based on their heightened risk of falls and hip fracture, provides high quality additional evidence that balance and strength training may be particularly useful to reduce fractures among community-dwelling older women. Although the study was not large enough to show a definitive effect of the intervention on the most serious falls (more than two thirds of which being falls causing fractures), the effect size is comparable to the one observed for moderately severe falls. Furthermore, women in the intervention group had significantly higher scores on all balance and mobility tests, that are major tools to identify older women at higher risk of hip fracture (note that in the EPIDOS cohort, close to 70% of hip fractures occurred in women with gait speed below median , which is one of the 2 inclusion criteria in Ossébo). Additionally, the study suggests many broader positive benefits of the intervention, including a sense of improved physical functioning and vitality, which is remarkable for such an old subgroup of women.
Fabienne El-Khoury, Bernard Cassou and Patricia Dargent-Molina
1 Campbell AJ, Robertson MC. Rethinking individual and community fall prevention strategies: a meta-regression comparing single and multifactorial interventions. Age Ageing 2007;36:656–62. doi:10.1093/ageing/afm122
2 Close JCT. How can you prevent falls and subsequent fractures? Best Pract Res Clin Rheumatol 2013;27:821–34. doi:10.1016/j.berh.2013.12.001
3 Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148–57. doi:10.1111/j.1532-5415.2010.03234.x
4 Campbell AJ, Robertson MC. Fall Prevention: Single or Multiple Interventions? Single Interventions for Fall Prevention. J Am Geriatr Soc 2013;61:281–4. doi:10.1111/jgs.12095_2
5 Lamb SE, Lamb JE. Better balance, fewer falls. The BMJ 2015;351:h3930. doi:10.1136/bmj.h3930
6 Dargent-Molina P, Benhamou C-L, Cortet B, et al. Devising global strategies for fracture-risk evaluation. Joint Bone Spine 2007;74:240–4. doi:10.1016/j.jbspin.2006.11.004
7 Dargent-Molina P, Poitiers F, Bréart G. In elderly women weight is the best predictor of a very low bone mineral density: evidence from the EPIDOS study. Osteoporos Int 2000;11:881–8.
8 Jonsson B, Kanis J, Dawson A, et al. Effect and Offset of Effect of Treatments for Hip Fracture on Health Outcomes. Osteoporos Int 1999;10:193–9. doi:10.1007/s001980050215
9 Dargent-Molina P, Schott AM, Hans D, et al. Separate and Combined Value of Bone Mass and Gait Speed Measurements in Screening for Hip Fracture Risk: Results from the EPIDOS Study. Osteoporos Int 1999;9:188–92. doi:10.1007/s001980050134
10 Dargent-Molina P, Douchin MN, Cormier C, et al. Use of Clinical Risk Factors in Elderly Women with Low Bone Mineral Density to Identify Women at Higher Risk of Hip Fracture: The EPIDOS Prospective Study. Osteoporos Int 2014;13:593–9. doi:10.1007/s001980200078
Competing interests: No competing interests
Re: Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossébo randomised controlled trial
I congratulate the authors of this paper with their important results in the field of fall prevention. However, as a general practitioner I have a few comments.
First, the UK NICE guideline as well as the Dutch CBO guideline about fall prevention advise to identify older patients at risk for falls most importantly by assessment of their falling history. However, in the current study of El-Khoury et al, participants were selected from the general population (by voting lists). Why did the authors use such an approach, contrary to the current guidelines? And how should this strategy be translated to the current practice?
Second, current guidelines recommend a multifactorial and multidisciplinary approach to fall prevention in risk groups. This consists of medication assessment, visual assessment, adaptions to the home environment, vitamin D supplementation and balance training. However, the study of El-Khoury et al assessed only one of these evidence based interventions. Also, no insight is given on the administration of these other compound to the participants during the study. If, for example, other components were also administered to the women in the intervention group by their physicians, the effect of the intervention under study could be largely overestimated. In my opinion, these questions should be addressed before widespread implementation of this possibly beneficial intervention.
Competing interests: No competing interests
We do agree with El-Khoury and colleagues (1) and Sarah and Jill Lamb (2) that balance training is strongly recommended to reduce falls in older adults, but fall prevention is a very hard task.
It has been recently suggested that exercise can effectively reduce hip fracture risk by quoting a recent meta-analysis including 17 trials (3); however, the number of trials with participant selection criteria ≧75 years was only 3 (4). More than 75% of hip fractures occur among people over 75, indicating that evidence for hip fracture prevention by exercise is insufficient. Here, in women aged 75-85, two-year balance training did not significantly reduce serious falls associated with fractures (hazard ratio 0.83, confidence interval 0.60 to 1.16), although frail women at high risk of injurious falling (thus high risk of hip fracture) were excluded (1).
In future, it is highly expected that the effectiveness of this kind of exercise could be enhanced by pharmacological therapies of sarcopenia currently in development. Nevertheless, it is important to note that not only falling but also bone fragility should be targeted to prevent hip fractures (5, 6).
Toshihiro Sugiyama, Yoon Taek Kim and Hiromi Oda
Department of Orthopaedic Surgery, Saitama Medical University, Saitama, Japan
1 El-Khoury F, Cassou B, Latouche A, et al. Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossebo randomised controlled trial. BMJ 2015;351:h3830. (22 July.)
2 Lamb SE, Lamb JE. Better balance, fewer falls. BMJ 2015;351:h3930. (23 July.)
3 Jarvinen TL, Michaelsson K, Jokihaara J, et al. Overdiagnosis of bone fragility in the
quest to prevent hip fracture. BMJ 2015;350:h2088. (26 May.)
4 El-Khoury F, Cassou B, Charles MA, et al. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f6234.
5 Sugiyama T, Kim YT, Oda H. Both falling and bone fragility should be targeted. www.bmj.com/content/350/bmj.h2088/rr-4. (2 June.)
6 Sugiyama T, Kim YT, Oda H. Both falling and bone fragility should be targeted: the
limited effectiveness of exercise on fall www.bmj.com/content/350/bmj.h2088/rr-30. (25 July.)
Competing interests: No competing interests