Modelling the population-level impact of tai-chi on falls and fall-related injury among community-dwelling older people

Tai Chi for fall prevention and balance improvement in older adults: a systematic review and meta-analysis of randomized controlled trials

Background and objective

As the population ages, the health of older adults is becoming a public health concern. Falls are a significant threat to their health due to weakened balance. This study aims to investigate the beneficial effects of Tai Chi on fall prevention and balance improvement in older adults.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials related to Tai Chi, falls, and balance ability, searching PubMed, Embase, and Cochrane Library databases from their establishment until December 31, 2022. Two independent reviewers performed the search, screening of results, extraction of relevant data, and assessment of study quality. This study followed the PRISMA guidelines for systematic review and meta-analysis.

Results

Totally 24 RCTs were included for meta-analysis, and the results showed that Tai Chi can effectively reduce the risk of falls in older adults (RR: 0.76, 95% CI: 0.71 to 0.82) and decrease the number of falls (MD [95% CI]: -0.26 [-0.39, -0.13]). Tai Chi can also improve the balance ability of older adults, such as the timed up and go test (MD [95% CI]: -0.69 [-1.09, -0.29]) and the functional reach test (MD [95% CI]: 2.69 [1.14, 4.24]), as well as other balance tests such as single-leg balance test, Berg balance scale, and gait speed (p < 0.05). Subgroup analysis showed that Tai Chi is effective for both healthy older adults and those at high risk of falls (p < 0.001), and its effectiveness increases with the duration and frequency of exercise. In addition, the effect of Yang-style Tai Chi is better than that of Sun-style Tai Chi.

Conclusion

Tai Chi is an effective exercise for preventing falls and improving balance ability in older adults, whether they are healthy or at high risk of falling. The effectiveness of Tai Chi increases with exercise time and frequency. Yang-style Tai Chi is more effective than Sun-style Tai Chi.

Systematic review registration

https://clinicaltrials.gov/, identifier CRD42022354594.

Barriers and facilitators to injury prevention in ladies Gaelic football: A qualitative study

OBJECTIVES

Injury rates have remained high in ladies Gaelic football over the last decade and treatment costs continue to increase significantly. Injury prevention programmes are a proposed solution and their efficacy has been demonstrated in Gaelic games, however, anecdotally their adoption is low. The aim of this study was to determine the barriers and facilitators to uptake, implementation, and long-term adoption of an injury prevention strategy for adult Ladies Gaelic football players and coaches.

DESIGN

Semi-structured interviews were conducted with 23 participants (13 coaches, 10 players). Four coaches were at intercounty level and nine were at club level, while two players competed at intercounty and club level and eight played solely at club level. The interviews were audio-recorded, transcribed verbatim and thematically analysed.

RESULTS

Stakeholder attitudes, accessibility, education, communication, and injury prevention programme characteristics were perceived as key barriers to an injury prevention strategy succeeding. Injury prevention promotion, injury prevention programme characteristics, leadership, and communication, were identified as the main factors that would facilitate the success of a strategy.

CONCLUSIONS

By utilising the views of stakeholders, the initial uptake, adherence, and long-term adoption of an injury prevention strategy in Ladies Gaelic football may be maximised.

Economic evaluations of fall prevention exercise programs: a systematic review

Objective

To investigate cost-effectiveness and costs of fall prevention exercise programmes for older adults.

Design

Systematic review.

Data sources

Medline, Embase, Web of Science, Scopus, National Institute for Health Research Economic Evaluation Database, Health Technology Assessment database, Tufts Cost-Effectiveness Analysis Registry, Research Papers in Economics and EconLit (inception to May 2022).

Eligibility criteria for study selection

Economic evaluations (trial-based or model-based) and costing studies investigating fall prevention exercise programmes versus no intervention or usual care for older adults living in the community or care facilities, and reporting incremental cost-effectiveness ratio (ICER) for fall-related outcomes or quality-adjusted life years (QALY, expressed as cost/QALY) and/or intervention costs.

Results

31 studies were included. For community-dwelling older adults (21 economic evaluations, 6 costing studies), results ranged from more effective and less costly (dominant) interventions up to an ICER of US$279 802/QALY gained and US$11 986/fall prevented (US$ in 2020). Assuming an arbitrary willingness-to-pay threshold (US$100 000/QALY), most results (17/24) were considered cost-effective (moderate certainty). The greatest value for money (lower ICER/QALY gained and fall prevented) appeared to accrue for older adults and those with high fall risk, but unsupervised exercise appeared to offer poor value for money (higher ICER/QALY). For care facilities (two economic evaluations, two costing studies), ICERs ranged from dominant (low certainty) to US$35/fall prevented (moderate certainty). Overall, intervention costs varied and were poorly reported.

Conclusions

Most economic evaluations investigated fall prevention exercise programmes for older adults living in the community. There is moderate certainty evidence that fall prevention exercise programmes are likely to be cost-effective. The evidence for older adults living in care facilities is more limited but promising.

PROSPERO registration number

PROSPERO 2020 CRD42020178023.

Systematic review and critical methodological appraisal of community-based falls prevention economic models

BACKGROUND

Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research.

METHODS

The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results.

RESULTS

46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made.

CONCLUSION

Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.

Economic models of community-based falls prevention: a systematic review with subsequent commissioning and methodological recommendations

Background

Falls impose significant health and economic burdens among older populations, making their prevention a priority. Health economic models can inform whether the falls prevention intervention represents a cost-effective use of resources and/or meet additional objectives such as reducing social inequities of health. This study aims to conduct a systematic review (SR) of community-based falls prevention economic models to: (i) systematically identify such models; (ii) synthesise and critically appraise modelling methods/results; and (iii) formulate methodological and commissioning recommendations.

Methods

The SR followed PRISMA 2021 guideline, covering the period 2003–2020, 12 academic databases and grey literature. A study was included if it: targeted community-dwelling persons aged 60 and over and/or aged 50–59 at high falls risk; evaluated intervention(s) designed to reduce falls or fall-related injuries; against any comparator(s); reported outcomes of economic evaluation; used decision modelling; and had English full text. Extracted data fields were grouped by: (A) model and evaluation overview; (B) falls epidemiology features; (C) falls prevention intervention features; and (D) evaluation methods and outcomes. A checklist for falls prevention economic evaluations was used to assess reporting/methodological quality. Extracted fields were narratively synthesised and critically appraised to inform methodological and commissioning recommendations. The SR protocol is registered in the Prospective Register of Systematic Reviews (CRD42021232147).

Results

Forty-six models were identified. The most prevalent issue according to the checklist was non-incorporation of all-cause care costs. Based on general population, lifetime models conducting cost-utility analyses, seven interventions produced favourable ICERs relative to no intervention under the cost-effectiveness threshold of US$41,900 (£30,000) per QALY gained; of these, results for (1) combined multifactorial and environmental intervention, (2) physical activity promotion for women, and (3) targeted vitamin D supplementation were from validated models. Decision-makers should explore the transferability and reaches of interventions in their local settings. There was some evidence that exercise and home modification exacerbate existing social inequities of health. Sixteen methodological recommendations were formulated.

Conclusion

There is significant methodological heterogeneity across falls prevention models. This SR’s appraisals of modelling methods should facilitate the conceptualisation of future falls prevention models. Its synthesis of evaluation outcomes, though limited to published evidence, could inform commissioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07647-6.

Tai Chi for Risk of Falls. A Meta-analysis

OBJECTIVES

To analyze the effectiveness of tai chi for falls prevention.

DESIGN

Systematic review and meta-analysis.

SETTING

Pubmed, Scopus, CINHAL, and Physiotherapy Evidence Database (PEDro) were searched to May 26, 2016.

PARTICIPANTS

Older adult population and at-risk adults.

INTERVENTION

Randomized controlled trials analyzing the effect of tai chi versus other treatments on risk of falls.

MEASUREMENTS

The incidence rate ratio (IRR) for falls incidence and hazard ratio (HR) for time to first fall.

RESULTS

The search strategy identified 891 potentially eligible studies, of which 10 met the inclusion criteria. There was high-quality evidence of a medium protective effect for fall incidence over the short term (IRR = 0.57; 95% CI = 0.46, 0.70) and a small protective effect over the long term (IRR = 0.87; 95% CI = 0.77, 0.98). Regarding injurious falls, we found very low-quality evidence of a medium protective effect over the short term (IRR = 0.50; 95% CI = 0.33, 0.74) and a small effect over the long term (IRR = 0.72; 95% CI = 0.54, 0.95). There was no effect on time to first fall, with moderate quality of evidence (HR = 0.98; 95% CI = 0.69, 1.37).

CONCLUSION

In at-risk adults and older adults, tai chi practice may reduce the rate of falls and injury-related falls over the short term (<12 months) by approximately 43% and 50%, respectively. Tai chi practice may not influence time to first fall in these populations. Due to the low quality of evidence, more studies investigating the effects of tai chi on injurious falls and time to first fall are required.

The impact of preventive measures on the burden of femoral fractures - a modelling approach to estimating the impact of fall prevention exercises and oral bisphosphonate treatment for the years 2014 and 2025

BACKGROUND

Due to the demographic transition with a growing number of old and oldest-old persons the absolute number of fragility fractures is expected to increase in industrialized countries unless effective preventive efforts are intensified. The main causes leading to fractures are osteoporosis and falls. The aim of this study is to develop population based models of the potential impact of fall-prevention exercise and oral bisphosphonates over the coming decade.

METHODS

The German federal state of Bavaria served as the model population. Model interventions were limited to community-dwelling persons aged 65 years and older. Models are based on fall-prevention exercise being offered to all persons aged 70 to 89 years and oral bisphosphonate treatment offered to all persons with osteoporosis as defined by a T-score of ≤ - 2.5. Treatment effect sizes are estimated from meta-analyses. Reduction in all femoral fractures in the population of community-dwelling persons aged 65 years and older is the outcome of interest. A spreadsheet-based modelling approach was used for prediction.

RESULTS

In 2014, reduction of femoral fractures by 10 % required 21 % of all community-dwelling persons aged 70-89 to participate in fall-prevention exercise, or 37 % of those with osteoporosis to receive oral bisphosphonates. Without intervention, demographic changes will result in a 24 % increase in femoral fractures by 2025. To lower the increase of fractures between 2014 and 2025 to 10 %, fall-prevention-exercise participation rate needs to be 25 % and bisphosphonate treatment rates 41 %, whereas to hold the 2025 rates flat at 2014 rates require 43 % fall-prevention-exercises participation, and is not achievable using oral bisphosphonates.

CONCLUSIONS

Unrealistic high treatment and participation rates of the two analysed measures are needed to achieve substantial effects on the expected burden of femoral fractures at present and in the future.

A population-based intervention for the prevention of falls and fractures in home dwelling people 65 years and older in South Germany: protocol

Background

Falls and fall-related injuries pose a major threat to older peoples’ health, and are associated with increased morbidity and mortality. In the course of demographic changes, development and implementation of fall prevention strategies have been recognized as an urgent public health challenge. Various risk factors for falls and a number of effective interventions have been recognized. A substantial proportion of falls occur for people who are neither frail nor at high risk. Therefore, population-based approaches reaching the entire older population are needed.

Objective

The objective of the study presented is the development, implementation, and evaluation of a population-based intervention for the prevention of falls and fall-related injuries in a medium sized city in Germany.

Methods

The study is designed as a population-based approach. The intervention community is a mid sized city named Reutlingen in southern Germany with a population of 112,700 people. All community dwelling inhabitants 65 years and older are addressed. There are two main measures that are defined: (1) increase of overall physical activity, and (2) reduction of modifiable risk factors for falls such as deficits in strength and balance, home and environmental hazards, impaired vision, unsafe footwear, and improper use of assistive devices. The implementation strategies are developed in a participatory community planning process. These might include, for example, training of professionals and volunteers, improved availability of exercise classes, and education and raising awareness via newspaper, radio, or lectures.

Results

The study starts in September 2010 and ends in December 2013. It is evaluated primarily by process evaluation as well as by telephone survey.

Conclusions

Physical activity as a key message entails multiple positive effects with benefits on a range of geriatric symptoms. The strength of the design is the development of implementation strategies in a participatory community planning. The problems that we anticipate are the dependency on the stakeholders’ willingness to participate, and the difficulty of evaluating population-based programs by hard end points.

Cost per fall: a potentially misleading indicator of burden of disease in health and residential care settings

RATIONALE

Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person.

METHOD

Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study.

RESULTS

The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year).

CONCLUSIONS

This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use.

Effectiveness of Web-based versus face-to-face delivery of education in prescription of falls-prevention exercise to health professionals: randomized trial

Background

Exercise is an effective intervention for the prevention of falls; however, some forms of exercises have been shown to be more effective than others. There is a need to identify effective and efficient methods for training health professionals in exercise prescription for falls prevention.

Objective

The objective of our study was to compare two approaches for training clinicians in prescribing exercise to prevent falls.

Methods

This study was a head-to-head randomized trial design. Participants were physiotherapists, occupational therapists, nurses, and exercise physiologists working in Victoria, Australia. Participants randomly assigned to one group received face-to-face traditional education using a 1-day seminar format with additional video and written support material. The other participants received Web-based delivery of the equivalent educational material over a 4-week period with remote tutor facilitation. Outcomes were measured across levels 1 to 3 of Kirkpatrick’s hierarchy of educational outcomes, including attendance, adherence, satisfaction, knowledge, and self-reported change in practice.

Results

Of the 166 participants initially recruited, there was gradual attrition from randomization to participation in the trial (n = 67 Web-based, n = 68 face-to-face), to completion of the educational content (n = 44 Web-based, n = 50 face-to-face), to completion of the posteducation examinations (n = 43 Web-based, n = 49 face-to-face). Participant satisfaction was not significantly different between the intervention groups: mean (SD) satisfaction with content and relevance of course material was 25.73 (5.14) in the Web-based and 26.11 (5.41) in the face-to-face group; linear regression P = .75; and mean (SD) satisfaction with course facilitation and support was 11.61 (2.00) in the Web-based and 12.08 (1.54) in the face-to-face group; linear regression P = .25. Knowledge test results were comparable between the Web-based and face-to-face groups: median (interquartile range [IQR]) for the Web-based group was 90.00 (70.89–90.67) and for the face-to-face group was 80.56 (70.67–90.00); rank sum P = .07. The median (IQR) scores for the exercise assignment were also comparable: Web-based, 78.6 (68.5–85.1), and face-to-face, 78.6 (70.8–86.9); rank sum P = .61. No significant difference was identified in Kirkpatrick’s hierarchy domain change in practice: mean (SD) Web-based, 21.75 (4.40), and face-to-face, 21.88 (3.24); linear regression P = .89.

Conclusion

Web-based and face-to-face approaches to the delivery of education to clinicians on the subject of exercise prescription for falls prevention produced equivalent results in all of the outcome domains. Practical considerations should arguably drive choice of delivery method, which may favor Web-based provision for its ability to overcome access issues for health professionals in regional and remote settings.

Trial Registration

Australian New Zealand Clinical Trials Registry number: ACTRN12610000135011; http://www.anzctr.org.au/ACTRN12610000135011.aspx (Archived by WebCite at http://www.webcitation.org/63MicDjPV)

A protocol for evidence-based targeting and evaluation of statewide strategies for preventing falls among community-dwelling older people in Victoria, Australia

Background

Falls are a significant threat to the safety, health and independence of older citizens. Despite the now substantial evidence about effective falls prevention interventions, translation into falls reductions has not yet been fully realised. While the hip fracture rate is decreasing, the number and rate of fall-related hospital admissions among older people is increasing. The challenge now is to deliver the most effective interventions efficiently at a population level, and for these interventions to be taken up by older people.

Objective

To support the development, and evaluation of, effective falls prevention policy and practice in the state of Victoria, Australia.

Methods

The RE-AIM model (Reach, Efficacy, Adoption, Implementation, Maintenance) was used to identify strategies for an effective programme. Research objectives were developed to support the strategies. These include: (1) identification of subgroups of older people most frequently admitted to hospital for falls; (2) examining the acceptability of established falls interventions; (3) identification of factors that encourage and support relevant lifestyle changes; (4) identifying opportunities to incorporate confirmed interventions in existing programmes and services; (5) developing guidelines for sustainability. The research results will subsequently guide strategy details for the falls prevention plan. RE-AIM will provide the framework for the evaluation structure.

Outcome measures

Measures to monitor the implementation of the selected interventions will be determined for each intervention, based on the five key factors of the RE-AIM model. The overall effect of the falls prevention plan will be monitored by time series analysis of fall-related hospital admission rates for community-dwelling older people.