Falls among older people—are intervention durations and specificity the keys to making a difference?
I read the recent Acute Perspective article “David Oliver: Falls in older people—can we really make a difference?” [1] with great interest. As highlighted in the article, strength and balance training interventions reduce falls and the benefits are greater when the interventions have a weekly training duration of three hours or longer [2]. That fact that duration is related to the effect of interventions is certainly one potential reason for the lack of population level reduction in falls. As Oliver suggests, exposing enough people at risk of falls to interventions for enough time to yield population level improvements is one of the main challenges for falls prevention interventions [1]. It can therefore be argued that not only is the overall effectiveness of interventions important, but that the required exposure time for interventions is an essential consideration if we wish to have an impact on population level falls statistics.
One potential falls-reducing intervention that may not require the same duration of exposure to traditional strength and balance exercise is reactive balance training (or perturbation-based balance training) [3, 4]. While few randomised controlled trials of this relatively new approach have been conducted, there is reasonable evidence that single or a few training sessions including repeated, controlled slips or trips during standing or walking lead to long term benefits for older adults, reflected in reduced falls incidence and improved stability control [5-8]. The driving theory of this style of intervention is that task specificity will result in improvements in the skills required to avoid falls following disturbances to balance, such as rapid reactive stepping, counter rotations of the upper body and limbs, and grasping reactions [3, 9]. We do not expect elite athletes to win Olympic medals without specifically practicing the skills of their sports, so why should we expect older adults to fall significantly less often without practicing the skills required for avoiding falls?
The clinical implementation of such reactive balance training is naturally more challenging than that of traditional exercise interventions and should be conducted with care, but recent work has provided examples of how this can be achieved in both healthy and clinical populations [9, 10]. There is no doubt that further research on task-specific falls prevention interventions is required, but with the potential for similar or greater reductions in falls in a fraction of the time compared to current practice, there are opportunities to tackle some of the current challenges facing our healthcare systems with respect to falls.
References
[1] Oliver D. David Oliver: Falls in older people-can we really make a difference? BMJ. 2018;361:k1655.
[2] Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51:1750-8.
[3] Mansfield A, Wong JS, Bryce J, Knorr S, Patterson KK. Does perturbation-based balance training prevent falls? Systematic review and meta-analysis of preliminary randomized controlled trials. Phys Ther. 2015;95:700-9.
[4] Grabiner MD, Crenshaw JR, Hurt CP, Rosenblatt NJ, Troy KL. Exercise-based fall prevention: can you be a bit more specific? Exerc Sport Sci Rev. 2014;42:161-8.
[5] Bhatt T, Yang F, Pai YC. Learning to resist gait-slip falls: long-term retention in community-dwelling older adults. Arch Phys Med Rehabil. 2012;93:557-64.
[6] Pai YC, Bhatt T, Yang F, Wang E. Perturbation training can reduce community-dwelling older adults' annual fall risk: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2014;69:1586-94.
[7] Epro G, Mierau A, McCrum C, Leyendecker M, Bruggemann GP, Karamanidis K. Retention of gait stability improvements over 1.5 years in older adults: effects of perturbation exposure and triceps surae neuromuscular exercise. J Neurophysiol. 2018. doi: 10.1152/jn.00513.2017
[8] Rosenblatt NJ, Marone J, Grabiner MD. Preventing trip-related falls by community-dwelling adults: a prospective study. J Am Geriatr Soc. 2013;61:1629-31.
[9] Gerards MHG, McCrum C, Mansfield A, Meijer K. Perturbation-based balance training for falls reduction among older adults: Current evidence and implications for clinical practice. Geriatr Gerontol Int. 2017;17:2294-303.
[10] Mansfield A, Aqui A, Centen A, Danells CJ, DePaul VG, Knorr S, et al. Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial. BMC Neurol. 2015;15:87.
Rapid Response:
Falls among older people—are intervention durations and specificity the keys to making a difference?
I read the recent Acute Perspective article “David Oliver: Falls in older people—can we really make a difference?” [1] with great interest. As highlighted in the article, strength and balance training interventions reduce falls and the benefits are greater when the interventions have a weekly training duration of three hours or longer [2]. That fact that duration is related to the effect of interventions is certainly one potential reason for the lack of population level reduction in falls. As Oliver suggests, exposing enough people at risk of falls to interventions for enough time to yield population level improvements is one of the main challenges for falls prevention interventions [1]. It can therefore be argued that not only is the overall effectiveness of interventions important, but that the required exposure time for interventions is an essential consideration if we wish to have an impact on population level falls statistics.
One potential falls-reducing intervention that may not require the same duration of exposure to traditional strength and balance exercise is reactive balance training (or perturbation-based balance training) [3, 4]. While few randomised controlled trials of this relatively new approach have been conducted, there is reasonable evidence that single or a few training sessions including repeated, controlled slips or trips during standing or walking lead to long term benefits for older adults, reflected in reduced falls incidence and improved stability control [5-8]. The driving theory of this style of intervention is that task specificity will result in improvements in the skills required to avoid falls following disturbances to balance, such as rapid reactive stepping, counter rotations of the upper body and limbs, and grasping reactions [3, 9]. We do not expect elite athletes to win Olympic medals without specifically practicing the skills of their sports, so why should we expect older adults to fall significantly less often without practicing the skills required for avoiding falls?
The clinical implementation of such reactive balance training is naturally more challenging than that of traditional exercise interventions and should be conducted with care, but recent work has provided examples of how this can be achieved in both healthy and clinical populations [9, 10]. There is no doubt that further research on task-specific falls prevention interventions is required, but with the potential for similar or greater reductions in falls in a fraction of the time compared to current practice, there are opportunities to tackle some of the current challenges facing our healthcare systems with respect to falls.
References
[1] Oliver D. David Oliver: Falls in older people-can we really make a difference? BMJ. 2018;361:k1655.
[2] Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51:1750-8.
[3] Mansfield A, Wong JS, Bryce J, Knorr S, Patterson KK. Does perturbation-based balance training prevent falls? Systematic review and meta-analysis of preliminary randomized controlled trials. Phys Ther. 2015;95:700-9.
[4] Grabiner MD, Crenshaw JR, Hurt CP, Rosenblatt NJ, Troy KL. Exercise-based fall prevention: can you be a bit more specific? Exerc Sport Sci Rev. 2014;42:161-8.
[5] Bhatt T, Yang F, Pai YC. Learning to resist gait-slip falls: long-term retention in community-dwelling older adults. Arch Phys Med Rehabil. 2012;93:557-64.
[6] Pai YC, Bhatt T, Yang F, Wang E. Perturbation training can reduce community-dwelling older adults' annual fall risk: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2014;69:1586-94.
[7] Epro G, Mierau A, McCrum C, Leyendecker M, Bruggemann GP, Karamanidis K. Retention of gait stability improvements over 1.5 years in older adults: effects of perturbation exposure and triceps surae neuromuscular exercise. J Neurophysiol. 2018. doi: 10.1152/jn.00513.2017
[8] Rosenblatt NJ, Marone J, Grabiner MD. Preventing trip-related falls by community-dwelling adults: a prospective study. J Am Geriatr Soc. 2013;61:1629-31.
[9] Gerards MHG, McCrum C, Mansfield A, Meijer K. Perturbation-based balance training for falls reduction among older adults: Current evidence and implications for clinical practice. Geriatr Gerontol Int. 2017;17:2294-303.
[10] Mansfield A, Aqui A, Centen A, Danells CJ, DePaul VG, Knorr S, et al. Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial. BMC Neurol. 2015;15:87.
Competing interests: No competing interests