The Otago strength and balance exercise programme lowers the risk of death and falls in the older people at 12 months
- Correspondence to Lesley Day
Monash Injury Research Institute, Building 70, Monash University, Clayton, 3800 VIC, Australia;
Implications for practice and research
▪ The Otago exercise programme (OEP) can be recommended by nurses for independently ambulant community-dwelling older people, particularly those 80 years and above.
▪ Community health nurses could consider undertaking training, where available, to deliver the OEP.
▪ Older people considering the OEP should be advised of the kinds of adverse events they might experience and how these should be managed should they arise.
▪ Providing ongoing encouragement and examination of those undertaking the OEP will be important in securing the exercise dose required for falls prevention benefits.
▪ Future research of the factors associated with exercise compliance and motivating factors for home exercise programmes will assist in maximising the benefits of these programmes.
Falls are a significant threat to the safety, health and independence of our older citizens.1 Falls are relatively common, with about one-third of people aged 65 years and above experiencing at least one fall annually.1 2 A constellation of adverse health outcomes can follow, including serious injury; increased mortality risk; erosion of overall health status, confidence, mobility and independence; and decreased quality of life.1 2
There is robust evidence that exercise can reduce falls particularly among community-dwelling older people, with the types of exercise and minimum dose having been specified.2 3 One of the programmes that meets these specifications is the OEP. The OEP consists of muscle strengthening and balance retraining exercises that is individually prescribed in the participant's home and includes a walking programme.4 It has been subjected to a number of randomised controlled trials, mostly by the New Zealand team who developed it. One meta-analysis of four trials has already been published by this team5 in which falls and fall injury were the main outcomes examined. Neither risk of death nor compliance with the programme or adverse outcomes was included. Consequently, Thomas and colleagues undertook a systematic review and meta-analysis of the OEP that aimed to include all trials of the OEP and expand the outcomes examined.
This study examined (1) the effect of the OEP among older adults (65 years and above) on risk of death, fall rates and injurious falls; (2) compliance with the programme and (3) adverse events associated with the programme. The authors undertook a systematic review and meta-analysis of randomised controlled trials, or controlled trials with masked assessment of outcome, in which the OEP was a tested falls intervention. A robust review protocol was applied. Electronic searches were independently screened by two authors, and differences were resolved by discussion with a third author. The seven articles included in the review reported on 1503 community-dwelling participants in total although all examined outcomes were not available for the full sample size. The PEDro Scale was used by two authors to independently assess methodological quality. One study was excluded from the falls analysis because of large loss to follow-up for falls data. Two trials had a 2×2 factorial design where the OEP was combined with another intervention and the presence of interactive effects guided the way in which these data were used in the meta-analysis. Pooled estimates of the effects of OEP on mortality, falls and fall injury were calculated from summary level data, following Cochrane guidelines. Compliance data and adverse events were also summarised.
Study quality was relatively high, with four of the seven articles receiving a score of 8 which is effectively the highest possible score as it is impossible to set up a double-blind exercise intervention trial. Five studies obtained falls measures from more than 80% of participants. However, there was potential for fall-outcome reporting bias in all the studies because of self-report combined with participants not being blind to the result. The review reported a significant reduction in the risk of death, regardless of the effect model adopted for the analysis or the removal of one trial with a shorter follow-up period. The OEP was also associated with a significantly reduced fall rate but not a reduced risk of serious or moderate injury occurring as a result of a fall. The groups in the seven trials were homogeneous, and the effect of OEP on injury rates was consistent and pronounced in all trials. Slightly more than half (55.9%) of the participants randomised to OEP were still exercising twice weekly at 12 months, whereas 36.7% were still exercising three times a week (the actual prescribed dose in the programme). The authors reported six adverse events because of exercising although seven were listed and confirmed by reference to the original articles: three falls, three episodes of musculoskeletal pain while exercising and one moderate injury in the absence of a fall.
This review and meta-analysis confirmed the fall-reducing benefits of OEP that were reported in the previous meta-analysis, with both studies reporting very similar reductions in the fall rates. This is not surprising as the trials included in the previous study contributed a combined weight of 66% to the falls analysis of this current study. The injurious fall reduction reported previously was not confirmed. However, unlike Robertson and colleagues,5 Thomas and colleagues did not have access to individual-level data and were therefore unable to calculate the incidence rate ratio, rather relying on the RR.
The reduction in the risk of death associated with participation in the OEP is an important new finding and provides an even stronger rationale for delivering this programme to older community-dwelling people. Although the OEP was initially tested for delivery by physiotherapists, subsequent trials found similar benefits when the OEP was delivered by trained community health and general practice nurses.5
Compliance with an exercise programme is clearly an important determinant of the level of benefit gained.3 Although 63% of participants were not exercising at the prescribed dose at the end of 12 months, 56% were exercising at a level consistent with that recommended for falls exercise programmes in general.3 Thomas and colleagues speculated that the benefits of the OEP may be even greater if higher compliance levels could be achieved. A good understanding of the factors associated with missing exercise sessions and how to motivate older people to maintain the required exercise levels at home is critical to being able to transfer the benefits observed in a randomised trial, where participant motivation may be high, to the general population of community-dwelling older people. This may be particularly important for a home-based exercise programme where social connectedness, which has been shown to be strongly associated with adherence in group-based programmes,6 cannot be developed.
The adverse event summary provided by Thomas and colleagues is very useful for the clinical and community setting. Although the rate of adverse events was relatively low (6 per 1000 people), it is important to be able to advise older people considering the OEP of the kinds of adverse events they might experience and how these should be managed should they arise.
As the authors point out, evidence that the OEP is cost-saving among community-dwelling older people aged 80 years and above makes it an attractive option. However, the cost-effectiveness studies were all undertaken in New Zealand, and that finding may not be generalisable to other countries where input costs may be quite different. Economic modelling may be needed before similar economic benefits could be expected in other countries.