StandingTall program shows efficacy in fall reduction over 2 years

Preventing falls in older individuals also prevents comorbidities and the mortality that can result from falls. A home-based, e-health balance exercise program delivered via an app showed promising efficacy in a randomized, controlled trial. While missing its primary outcome of reducing falls and the proportion of people who fell, the exercise program did show promising results over two years.

“[A]t 24 months we did observe a significant 16% reduction in fall rate and a significant 20% reduction in the proportion of people who had injurious falls,” Kim Delbaere, PhD, from Neuroscience Research, Randwick, Australia, and colleagues reported in the BMJ. “The effect size of a 16% reduction in fall rate at 12 months was similar to that at 24 months, although it was not statistically significant (P=0.07). The observed reduction in fall rate is comparable to that reported in previous studies—21% reduction with individually delivered exercise programs over 12 months and 14% over 24 months. However, the 20% reduction in the proportion of people who had injurious falls over 24 months seems to be higher than the 12% reduction previously reported in other studies. These findings indicate that technology can be used to deliver an e-health balance exercise program to older people that is effective at reducing fall rates and the proportion of injurious falls over 24 months.”

The program—dubbed “StandingTall“—recruited 503 participants, age 70 or older, who lived independently in the community. For inclusion, participants had to be able to independently perform activities of daily living and be without cognitive impairment, progressive neurological disease, or any other unstable or acute medical condition that would limit their ability to exercise.

All of the participants received a tablet computer that provided health education appropriate for their age—healthy diet, drugs, fall risk factors, and exercise—throughout the two years. Those randomized to the control group (n=249) only received the tablet-based education. Those randomized to the intervention group were given exercise equipment—foam cushion, stepping box, and exercise mat—as well as information about the StandingTall program that was delivered through the tablet “with embedded behavioral change techniques, including a weekly calendar for scheduling exercises, goal setting, and educational fact sheets. The exercises focus on standing balance, targeted stepping, and step-up (box) exercises,” the study authors wrote.

Participants in the intervention group were to exercise at least two hours per week over the 24-months of the trial. “The intervention was introduced gradually; participants started with 40 min/week of exercise, which was increased by 20 minutes fortnightly until they reached the required amount of two hours per week in week 9,” Delbaere and colleagues explained.

As previously stated, the primary outcome was the rate of falls and the proportion of people who fell over the first year. “A fall was defined as ’an unexpected event in which the participant comes to rest on the ground, floor or lower level.’ Falls were monitored by using prospective weekly fall diaries through the tablet computer,” the researchers wrote.

Secondary outcomes included the same parameters as the primary outcome as well as adherence, mood, health related quality of life, and activity levels over the two years, and measured at baseline, six months (for acute effects), and at 12, 18, and 24 months (for retention).

The study ran from February 2015 to October 2017, and during the two-year follow-up, 90 participants were lost—53 in the intervention group and 37 in the control group.

“The fall rates were not statistically different in the two groups after the first 12 months (0.60 falls per year (standard deviation 1.05) in the intervention group; 0.76 (1.25) in the control group; incidence rate ratio 0.84, 95% confidence interval 0.62 to 1.13, P=0.071),” Delbaere and colleagues wrote. “Additionally, the proportion of people who fell was not statistically different at 12 months (34.6% in intervention group, 40.2% in control group; relative risk 0.90, 95% confidence interval 0.67 to 1.20, P=0.461).”

However, over two years, the picture was different.

“In the intervention group, 68.1% and 52.0% of participants exercised for a median of 114.0 min/week (interquartile range 53.5) after 12 months and 120.4 min/week (38.6) after 24 months, respectively,” the study authors wrote. “Groups remained similar in mood and activity levels. The intervention group had a 0.03 (95% confidence interval 0.01 to 0.06) improvement on the EQ-5D-5L (EuroQol five dimension five level) utility score at six months, and an improvement in standing balance of 11 s (95% confidence interval 2 to 19 s) at six months and 10 s (1 to 19 s) at 12 months. No serious training related adverse events occurred.”

Notably, the study authors pointed out that adherence in the intervention group was relatively high, with 40% full adherence in the first six months, and 30% full adherence over the two years of the study.

“These rates are particularly encouraging because adherence was recorded automatically and is therefore a true representation of the actual amount of balance training people received; often adherence rates have lower accuracy because of self-reports or estimates based on number of sessions attended,” Delbaere and colleagues wrote. “Eighty per cent of participants in the intervention group had a median adherence of 105 min/week over six months, and over half sustained a median adherence of 120 min/week over 24 months, despite the low level of contact during the study (two home visits in the first month and incidental follow-up calls during the first six months).”

“Our results show that a tailored e-health exercise program is an effective intervention in preventing falls in older people,” the researchers concluded. “StandingTall is a scalable intervention and can be easily incorporated into clinical practice, providing healthcare professionals with a platform to remotely set up, monitor, and tailor the program for their patients.”

They noted that an economic evaluation of the program will be forthcoming.

Limitations of the study include the reliance on self-reported falls, inability to mask participants, the study included the use of more than one outcome measure for falls, and the inclusion of participants who were highly educated and computer savvy, which might limit the generalizability of the program.

  1. A falls prevention exercise program delivered via a computer tablet to community dwelling seniors appears to be beneficial in reducing falls and the proportion of people falling over two years.

  2. Be aware that this study did not meet its primary endpoint of reducing falls and the proportion of those who fell in the first 12 months of the trial; however, it did show the viability of this delivery system.

Candace Hoffmann, Managing Editor, BreakingMED™

The study authors declare support from the Australian National Health and Medical Research Council, Gandel Philaptropy, NeuRA Foundation, National Heart Foundation, and Human Frontier Science Program for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Cat ID: 494

Topic ID: 398,494,282,494,438,730,130,142,192,255,925