Evidence based practice and nursing research

R E V I E W P A P E R

The effectiveness of exercise for fall prevention in nursing home residents: A systematic review meta‐analysis

Pei-ye Cao1 | Qing-hua Zhao1 | Ming-zhao Xiao2 | Ling-na Kong3 | Ling Xiao1

1Department of Nursing, The First Affiliated

Hospital of Chongqing Medical University,

Chongqing, China

2Department of Urology, The First

Affiliated Hospital of Chongqing Medical

University, Chongqing, China

3Nursing College of Chongqing Medical

University, Chongqing, China

Correspondence

Qing-hua Zhao, Department of Nursing, The

First Affiliated Hospital of Chongqing

Medical University, Chongqing, China.

Email: qh20063@163.com

Abstract

Aim: The aim of this study was to determine the effectiveness of exercise on fall

prevention in nursing home residents.

Background: Nursing home residents have a high risk of falling. No conclusive evi-

dence exists on the effectiveness of exercise on fall prevention in nursing home res-

idents.

Design: Systematic review and meta‐analysis of randomized controlled trials. Data resources: Databases of PubMed, Web of Science, EMBASE, Cochrane Cen-

tral Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Lit-

erature and China Biology Medicine were searched from inception to March 2017,

with no language limitation.

Review methods: The review was conducted according to the guidelines of the

Cochrane Collaboration. Studies on exercise interventions to prevent falls in nursing

home residents were eligible. The primary outcome was the odds ratio with 95%

confidence intervals of falls.

Results: Nine studies were included in the meta‐analysis where exercise was com- pared with daily routine, social activities, and other methods in preventing falls.

About falls, the pooled effect size of seven studies showed that exercise had no

effect on fall prevention in nursing home residents. There was low heterogeneity.

No significant publication bias was observed.

Conclusions: The results of the systematic review and meta‐analysis suggested that exercise did not play a role in preventing falls. Further studies with high quality and

larger samples are required to support or counter the results.

K E Y W O R D S

accidental falls, exercise, nursing homes, prevention, systematic review

1 | INTRODUCTION

Nursing home residents have a high risk of falling. The fall incidence

in nursing home residents is estimated to be 33.9%, which is three

times higher than older adults living in community (Hewitt, Ref-

shauge, Goodall, Henwood, & Clemson, 2014; Kaya et al., 2012).

Falls in nursing homes often lead to fractures, subdural haematoma,

and soft‐tissue injuries, causing death or disability (Blain & Bousquet,

2015; Chin, 2012). Apart from the physical consequences, falls also

have psychological burden. Residents who have fallen may have dif-

ferent levels of fear of falling. They might lose confidence in social

interactions and perceive a poor quality of life (Blain & Bousquet,

2015). Falls also have been proved to increase additional costs of

nursing home care, including the need for more rehabilitation and an

increased level of care (Heinrich, Rapp, Rissmann, Becker, & Konig,

2011).

Received: 26 September 2017 | Revised: 18 April 2018 | Accepted: 1 May 2018 DOI: 10.1111/jan.13814

J Adv Nurs. 2018;74:2511–2522. wileyonlinelibrary.com/journal/jan © 2018 John Wiley & Sons Ltd | 2511

Multiple factors result in falls, such as the external environment

and the individual's intrinsic physical and cognitive condition (Ungar et

al., 2013). Impaired balance and mobility and gait abnormalities are

considered significant factors by which interventions to prevent falls

are usually modified or aggravated (Barker, Nitz, Choy, & Haines,

2012; Giuliani et al., 2008). Among these interventions, whether exer-

cise has an effect on fall prevention is not clear (Kendrick et al., 2014).

1.1 | Background

Previous systematic reviews and meta‐analyses have demonstrated that exercise played a beneficial role in preventing falls by older adults

living in community (Petridou, Manti, Ntinapogias, Negri, & Szczerbin-

ska, 2009; Sherrington et al., 2008). Stubbs, Denkinger, Brefka, and

Dallmeier (2015) conducted a comprehensive umbrella review of sys-

tematic reviews including meta‐analyses of RCTs and found the effec- tiveness of exercise on reducing falls was not clear in long‐term care facilities, but did not remind some possible reasons of the unclear con-

clusion. Some reasons may explain why evidence on the effectiveness

of exercise on fall prevention was not adequate. On the one hand,

some studies only reviewed multifactorial interventions, such as per-

sonal educational consultation combined with environment medica-

tion and exercise programme combined with medication review

(Cusimano, Kwok, & Spadafora, 2008; Quigley et al., 2010). On the

other hand, the more important reason was that previous reviews

included studies with heterogeneous groups of residents from differ-

ent care settings that were defined by different terminology such as

institutionalized, care facilities, care homes, residential facilities, and

long‐term care facilities (Cameron et al., 2012; Guo, Tsai, Liao, Tu, & Huang, 2014; Oliver et al., 2007; Sherrington, Tiedemann, Fairhall,

Close, & Lord, 2011). Guo et al. (2014) defined institutionalized as

medical centres, hospitals, nursing homes, and care centres. Sherring-

ton et al. (2011) took no account of the difference of settings and

included 54 randomized controlled trials (RCTs) conducted in commu-

nity and residential care settings. These settings may have significant

differences in care intensity and content. A Cochrane review concen-

trating on falls in care facilities conducted subgroup analysis according

to levels of care in care facilities and further found that the effective-

ness of exercise remained uncertain due to conflicting results, possibly

associated with differences in levels of care provided (Cameron et al.,

2012). Furthermore, a recent systematic review and meta‐analysis showed fall prevention interventions significantly reduced the number

of recurrent fallers by 21% (Vlaeyen et al., 2015). In this review, nurs-

ing homes clearly defined as a residential facility that provides per-

sonal care and limited clinical care for persons, but the effectiveness

of exercise intervention has not been noticed.

Consequently, the current systematic review and meta‐analysis aimed to determine the effectiveness of exercise on fall prevention for

adults who permanently reside in nursing homes. In our study, nursing

homes are different from long‐term care facilities only providing per- sonal care and defined as “high level care facilities that are primarily engaged in providing inpatient nursing and rehabilitative services for

long‐term care patients. The care is generally provided for an extended

period of time to individuals requiring nursing care. These care facili-

ties have a permanent core staff of registered or licensed practical

nurses that, along with other staff, provide nursing care in combination

with personal care” (NLM 2012, OECD 2011, Sorensen et al., 2006). They excluded posthospital‐skilled care, rehabilitation, and long‐term care for young people suffering from physical and mental impairment.

2 | THE REVIEW

2.1 | Aims

The aim of this systematic review and meta‐analysis was to identify the effectiveness of exercise on fall prevention in nursing home resi-

dents and provide reference for clinical practice and future research.

2.2 | Design

The study was a systematic review and meta‐analysis of RCTs, focusing on the effectiveness of exercise on fall prevention in nurs-

ing home residents. The review was conducted according to the

guidelines of the Cochrane Collaboration (Higgins & Green, 2011)

and reported in concordance with a Preferred Reporting Items for

Why is this review needed?

• Nursing home residents have a high risk of falling, which always leads to physical and psychological decline.

• Whether exercise has an effect on fall prevention for nursing home residents remains controversial.

• Previous reviews have been conducted to identify the effect of exercise on fall prevention in older adults living

in community and other care settings, but no conclusive

evidence exists in nursing home residents.

What are the key findings?

• The current systematic review and meta-analysis sug- gested that exercise did not reduce the incidence of falls

in nursing home residents.

• The small number of included studies may result in a lack of data about some confounding factors, which may

affect the accuracy of the results.

How should the findings be used to influence

policy/practice/research/education?

• Nurses and other health providers should take other measures to prevent falls in nursing home residents

rather than simply exercise.

• Further studies are required to support or counter the result or to find whether there is an optimal and safe

level of exercise for nursing home residents.

2512 | CAO ET AL.

Systematic Reviews and Meta‐Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, Altman, & Group, 2009).

2.3 | Search methods

We searched the electronic databases of PubMed, Web of Science,

EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL),

Cumulative Index to Nursing and Allied Health Literature (CINAHL), and

China Biology Medicine (CBM) for articles related to exercise on fall

prevention in nursing home residents from database inception to March

2017, with no language limitation. We mainly used the following mesh

terms or key words when searching: (“nursing homes” OR “long term care” OR “nursing care” OR “care home” OR “nursing facility” OR “in- stitutionalization” OR “residential”) AND (“exercise” OR “training” OR “activity” OR “movement” OR “physical exercise” OR “physical train- ing” OR “physical activity”) AND (“accidental falls” OR “fall” OR “fall- ing”) AND (“prevention and control” OR “prophylaxis” OR “prevention measures” OR “prevention” OR “control” OR “prevent”). The search strategies in PubMed and Web of Science were showed in Supporting

Information Figures S1 and S2, respectively. To ensure the most com-

prehensive search, reference lists of retrieved trails and review articles

were also hand‐screened to search any other relevant studies. The inclusion criteria were as follows: (a) Design: randomized con-

trolled trials (RCTs); (b) Population: residents in nursing homes; Nurs-

ing homes were defined as “high level care facilities that are primarily engaged in providing inpatient nursing and rehabilitative services for

long‐term care patients. The care is generally provided for an extended period of time to individuals requiring nursing care. These care

facilities have a permanent core staff of registered or licensed practical

nurses that, along with other staff, provide nursing care in combination

with personal care” (NLM 2012, OECD 2011, Sorensen et al., 2006). If the setting was used other terms, such as long‐term care facility/set- ting/institute, institutionalized and residential care facility and was

accorded with the definition of nursing homes, the study was also

included; (c) intervention: exercise in the intervention group versus no

intervention or just placebo training in the control group; (d) outcome:

adequate information provided to calculate odds ratios (ORs) or stan-

dardized mean differences (SMDs) with 95% confidence intervals (CIs)

for falls or other results related to falls. A fall was defined as “an unex- pected event where the participant comes to rest on the ground, floor,

or lower level” (Lamb, Jorstad‐Stein, Hauer, & Becker, 2005). Studies were excluded if they (a) used exercise combined other

fall preventions (such as vitamin D) in the intervention group; (b)

with no control group; (c) were duplicate articles.

2.4 | Search outcome

The initial search found 4,130 articles, among which 4,099 were

searched from databases and 31 were identified from citation in the

retrieved articles. After excluding duplicates, 2,981 articles remained.

A further 2,907 articles (180 reviews and 2,727 irrelevant articles)

were excluded based on titles and abstracts, leaving 74 articles

requested for full texts. According to the inclusion and exclusion cri-

teria, three articles were reviews, 10 articles were non‐RCT, 21 arti- cles were not conducted in nursing homes, 13 articles were not a

blank or placebo controlled, four articles did not use physical

Records identified through Additional records identified through other sources

(N = 31)

(N = 2,981)

(N = 74)

(N = 9) Studies included in the meta-analysis

Full-text articles assessed for eligibility Records excluded based on title or abstract (N = 2,907)

Review (N = 180)

Full-text articles excluded (N = 65)

Non-RCT (N = 10) Not in nursing homes (N = 21) Not a blank or placebo control (N = 13) Not using physical exercise as the only intervention (N = 4) Not relevant outcome (N = 14)

Review (N = 3)

Not relevant (N = 2,727)

Records after duplicates removed

database searching (N = 4,099)

FIGURE 1 Flow diagram for the selection of included studies

CAO ET AL. | 2513

exercise as the only intervention, and 14 articles did not report rele-

vant outcomes on falls. Thus, nine articles were included in the

meta‐analysis. The results of the search process were shown in Figure 1.

2.5 | Quality appraisal

The Cochrane collaboration's tool for assessing risk of bias was used

by two independent reviewers to assess the quality of the included

studies (Higgins & Green, 2011). The quality items were the following:

random sequence generation, allocation concealment, blinding of par-

ticipants and personnel, blinding of outcome assessment, incomplete

outcome data, selection of reporting, and other sources of bias (Hig-

gins & Green, 2011). Each entry was rated as “low risk,” “high risk,” or “unclear risk” (Higgins & Green, 2011). Information involved with these entries was obtained from the published reports and an attempt

was made to contact the authors if additional information was

required. Disagreement was resolved by discussion and consensus.

The results of risk of bias were summarized in Figures 2 and 3. The

interrater agreement of the quality appraisal was 0.949. Six studies

(Beaudart et al., 2013; Buckinx et al., 2014; Choi, Moon, & Song, 2005;

Kovács, Sztruhár Jónásné, Karóczi, Korpos, & Gondosraquo, 2013;

Rosendahl, Gustafson, Nordin, Lundin‐Olsson, & Nyberg, 2008; Sieva- nen, Karinkanta, Moisio‐Vilenius, & Ripsaluoma, 2014) reported ade- quate random sequence generation by computer, tossing a coin, or

drawing lots. The other three studies did not mention the method of ran-

dom sequence generation. Two studies (Kovács et al., 2013; Rosendahl

et al., 2008) described adequate allocation concealment by sealed envel-

opes. The other seven studies did not provide the information about

allocation concealment. As the blinding of participants and personnel to

the intervention in the studies were not feasible, the studies were

assessed to be adequate for blinding of participants and personnel and

blinding of outcome assessment if the outcomes were not likely to be

affected by lack of blinding. For incomplete outcome data, five studies

(Beaudart et al., 2013; Buckinx et al., 2014; Kovács et al., 2013; Rosen-

dahl et al., 2008; Sievanen et al., 2014) analysed data based on the

method of intention to treat. One study (Kato, Izumi, Hiramatsu, & Sho-

genji, 2006) reported no dropout after intervention. The remaining three

studies reported dropouts but did not analyse missing data. The report-

ing bias was assessed by whether all outcomes mentioned were ade-

quately provided. About “other sources of bias,” nine studies seemed free according to the Cochrane Collaboration's domain‐based evaluation.

2.6 | Data abstraction

Data were extracted by two independent investigators by using a

standardized form with the following variables: the first author,

publication year, country, language, type of care setting, sample

size (intervention group and control group), characteristics of partic-

ipants, characteristics of the exercise in the intervention group such

as mode, time, frequency, duration, method in the control group,

and outcome data: number of falls and some other results related

to falls.

2.7 | Synthesis

Literature data such as authors, publication year, and sample size

were input into Review Manager 5.3 software and STATA 14.0 soft-

ware for quality assessment and meta‐analysis. For dichotomous data, ORs with 95% CI were calculated. p value (two‐tailed) less than 0.05 was considered statistically significant. For continuous data,

SMDs with 95% CIs were calculated. For the models of meta‐analy- sis, the random effect was used if there was a significant difference

between study heterogeneity; otherwise, the fixed effect was used.

Heterogeneity was considered significant for I2 >50% and p value of

Cochran's Q statistic <0.10 (Higgin, Thompson, Deeks, & Altman,

2003; Higgins & Thompson, 2002). If significant heterogeneity

existed, sensitivity analysis was conducted to assess the stability and

R a n d o m

s e q u e n ce

g e n e ra

tio n (

se le

ct io

n b

ia s)

A llo

ca tio

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e le

ct io

n b

ia s)

O th

e r

b ia

s

S e le

ct iv

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e p o rt

in g (

re p o rt

in g b

ia s)

In co

m p le

te o

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a ta

( a tt ri

tio n b

ia s)

B lin

d in

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m e n t (d

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f p a rt

ic ip

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p e rf

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b ia

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Beaudart (2013) + +

?

?

?

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?

?

??

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+ –

–

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+ +

++

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+ +

++

+

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+ + +

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+ + +

++++

+ + + + +

+ +

+

++++++

+

+

+

+

+

+

Bösner (2012)

Brustio (2015)

Buckinx (2014)

Choi (2005)

Kato (2006)

Kovács (2013)

Rosendahl (2008)

Sievanen (2014)

FIGU RE 2 The result of risk of bias assessment: each risk of bias item for included studies (Green means low risk of bias, yellow means unclear risk of bias, red means high risk of bias)

2514 | CAO ET AL.

reliability of results. Publication bias was assessed by using a funnel

plot and Egger's test. If the funnel plot shapes revealed obvious evi-

dence of asymmetry and the p values of Egger's tests were less than

0.05, publication bias was considered statistically significant.

3 | RESULTS

3.1 | Characteristics of the included studies

A total of nine studies (Beaudart et al., 2013; Bösner et al., 2012;

Brustio et al., 2015; Buckinx et al., 2014; Choi et al., 2005; Kato et

al., 2006; Kovács et al., 2013; Rosendahl et al., 2008; Sievanen et al.,

2014) were included in the meta‐analysis. They were all published in English between 2005 and 2015. The studies were conducted in

Belgium (N = 2) (Beaudart et al., 2013; Buckinx et al., 2014), Ger-

many (N = 1) (Bösner et al., 2012), Italy (N = 1) (Brustio et al., 2015),

Korea (N = 1) (Choi et al., 2005), Japan (N = 1) (Kato et al., 2006),

Hungary(N = 1) (Kovács et al., 2013), Sweden(N = 1) (Rosendahl et

al., 2008), and Finland(N = 1) (Sievanen et al., 2014). The types of

care setting were nursing home, long‐term care setting, institutional- ized, long‐term care facility, long‐term care institute and residential care facility. The sample size ranged from 13 to 191 participants and

included a total of 551 participants (exercise group = 280, control

group = 271). For the intervention, the intervention mode of three

studies (Beaudart et al., 2013; Buckinx et al., 2014; Sievanen et al.,

2014) was whole‐body vibration exercise (WBV), where exercises were performed on a platform that produced vertical sinusoidal

vibrations to generate a stimulation of muscle spindles and make

muscles contractions (Bogaerts, Verschueren, Delecluse, Claessens, &

Boonen, 2007). The intervention modes of the remaining studies

were weight training and balance exercises, sun‐style Tai Chi exer- cise, etc. The intervention time varied between 75 s and 80 min.

One study (Kovács et al., 2013) had no time limit. The intervention

frequency was between twice and thrice every week. The interven-

tion duration ranged from 9 weeks to 12 months. For the outcomes,

seven studies (Beaudart et al., 2013; Bösner et al., 2012; Buckinx et

al., 2014; Choi et al., 2005; Kato et al., 2006; Kovács et al., 2013;

Rosendahl et al., 2008) measured falls. Five studies (Beaudart et al.,

2013; Brustio et al., 2015; Buckinx et al., 2014; Kovács et al., 2013;

Sievanen et al., 2014) measured the Timed Up and Go test (TUG).

The TUG measured the time subjects took to rise from a sitting posi-

tion, walk 3 m, walk back, and sit down again (Podsiadlo &

Richardson, 1991). A longer time suggested a worse mobility and a

time more than 14 s indicated a high risk of falls (Shumway‐Cook, Brauer, & Woollacott, 2000). Four studies (Beaudart et al., 2013;

Bösner et al., 2012; Buckinx et al., 2014; Kovács et al., 2013) mea-

sured the POMA. The POMA scale consisted of the balance scale

(POMA‐B) and gait scale (POMA‐G) (Tinetti, 1986). The POMA‐B included seven items: sitting balance, arising from chair, immediate

standing balance (first 3–5 s), standing balance, turning balance, one leg standing balance, and sitting down. The POMA‐G included nine items: initiation of gait, step height, length, symmetry, and continuity

and path direction, trunk away, walk stance, and turning while walk-

ing. Each item was scored 2 or 3. A total score (POMA‐T) less than 19 points suggested a severe risk of falls, a score between 19 and

24 points suggested a moderate risk of falls, and a score of more

than 24 points suggested a low risk of falls. The characteristics of

the included studies were listed in Table 1.

3.2 | Effects of interventions

3.2.1 | Falls

Seven of nine studies involving 505 participants (exercise group =

253, control group = 252) provided falls outcome. There was low

heterogeneity (I2 = 48%, p = 0.073 < 0.1) and the random effects

model was used in the meta‐analysis. Compared with the control groups, exercise groups showed no statistically significant differences

in falls outcome (OR = 0.88, 95% CI = 0.48–1.59, p = 0.663) (Fig- ure 4). According to the results of sensitivity analysis, the pooled

effect size was not changed by sequential omission of the individual

studies (Supporting Information Table S1). There was no publication

bias based on the funnel plot's shape (Figure 5) and Egger's test

(p = 0.419).

To explore the specific role of exercise on falls, subgroup analyses

were conducted according to the intervention mode, time, frequency,

and duration. The results of subgroup analysis were shown in Table 2.

For the intervention mode, there was no significant difference for falls

in the WBV group (OR = 1.86, 95% CI = 0.89–3.91, p = 0.100; Heterogeneity: I2 = 0%, p = 0.495 > 0.1) and in the group of other

intervention modes (OR = 0.62, 95% CI = 0.31–1.23, p = 0.170; Heterogeneity: I2 = 38.6%, p = 0.164 > 0.1). With respect to the

intervention time, both the studies with time less than 30 min (OR =

1.59, 95% CI = 0.79–3.18, p = 0.191) and time more than 30 min

Random sequence generation (selection bias)

Blinding of participants and personnel (performance bias)

Incomplete outcome data (attrition bias)

Other bias

Low risk of bias Unclear risk of bias High risk of bias

0% 25% 50% 75% 100%

Selective reporting (reporting bias)

Blinding of outcome assessment (detection bias)

Allocation concealment (selection bias)

FIGURE 3 The result of risk of bias assessment: each risk of bias item shown as percentages across all included studies

CAO ET AL. | 2515

T A B L E

1 C h ar ac te ri st ic s o f in cl u d e d st u d ie s

S tu d y ID

(c o u n tr y )

C ar e se tt in g

N o . o f

p ar ti ci p an

ts M e an

ag e

M e an

M M S E

In te rv e n ti o n m o d e

In te rv e n ti o n

ti m e

In te rv e n ti o n

fr e q u e n cy

In te rv e n ti o n

d u ra ti o n

C o n tr o l g ro u p

O u tc o m e

m e as u re

B e au

d ar t e t al .

(2 0 1 3 )

(B e lg iu m )

N u rs in g h o m e

6 2 (2 6 /3 1 ;2 5 /3 1 )

8 3 .2

(8 2 .8 ;8 4 .2 )

N A

W B V

w it h 3 0 H z fr e q u e n cy

7 5 s

3 /w

e e k

3 m o n th s

D ai ly

ro u ti n e

F al l; T U G ,

T in e tt i

B ö sn e r e t al .

(2 0 1 2 )

(G e rm

an y )

N u rs in g h o m e

5 2 (2 3 /3 2 ;1 6 /2 0 )

N A

(8 5 .1 ;8 5 .5 )

N A

W e ig h t tr ai n in g an

d b al an

ce

e xe

rc is e s

4 5 m in

3 /w

e e k

6 m o n th s

V is it m o n th ly

F al l, T in e tt i

B ru st io

e t al .

(2 0 1 5 ) (I ta ly )

L o n g ‐t e rm

ca re

se tt in g

3 5 (2 0 /2 0 ;1 3 /1 5 )

8 4 .1 8 (8 5 .3 1 ;8 2 .6 9 )

N A

N e u ro m o to r tr ai n in g

6 0 m in

2 /w

e e k

4 m o n th s

D ai ly

ro u ti n e

T U G

B u ck in x e t al .

(2 0 1 4 ) (B e lg iu m )

N u rs in g h o m e

6 2 (2 3 /3 1 ;2 2 /3 1 )

8 3 .2

(8 2 .2 ;8 4 .2 )

N A (2 6 .0 ;2 3 .0 )

W B V

w it h 3 0 H z fr e q u e n cy

7 5 s

3 /w

e e k

6 m o n th s

D ai ly

ro u ti n e

F al l, T U G ,

T in e tt i

C h o i e t al .

(2 0 0 5 ) (K o re a)

In st it u ti o n al iz e d

6 8 (2 9 /N

A ;3 0 /N

A )

7 7 .8

(7 6 .9 6 ;7 8 .7 3 )

N A

S u n ‐s ty le

T ai

C h i e xe

rc is e

3 5 m in

3 /w

e e k

3 m o n th s

D ai ly

ro u ti n e

F al l

K at o e t al .

(2 0 0 6 ) (J ap

an )

L o n g ‐t e rm

ca re

fa ci lit y

3 0 (1 6 /1 6 ;1 4 /1 4 )

N A

(8 6 .3 ;8 2 .8 )

N A

A n e xe

rc is e p ro g ra m m e

co n si st in g o f a w ar m ‐u p ,

st at ic

st re tc h in g , m u sc le

st re n g th e n in g in

th e lo w e r

e xt re m it ie s, to e e xe

rc is e ,

p ro p ri o ce p ti v e

n e u ro m u sc u la r fa ci lit at io n ,

an d co

o l‐d

o w n

1 0 –1

5 m in

3 /w

e e k

3 m o n th s

D ai ly

ro u ti n e

F al l

K o v ác s e t al .

(2 0 1 3 )

(H u n g ar y )

L o n g ‐t e rm

ca re

in st it u te

8 6 (3 2 /4 3 ;3 0 /4 3 )

N A

(7 6 .3 9 ;7 9 .2 9 )

N A (2 0 .8 5 ;2 0 .9 3 )

M u lt im o d al ex er ci se

in cl u d in g

① in d iv id u al ly ta ilo re d

st re n gt h tr ai n in g ta rg et in g th e

m aj o r lo w er

lim b m u sc le s an d

p ro gr e ss iv e b al an ce

e xe rc is es ;

② w al ki n g p ro gr am

m e

N o lim

it e d

① :2 /w

e e k ;

② :1 /w

e e k

1 2 m o n th s

S o ci al

ac ti v it ie s

F al l, T U G ,

T in e tt i

R o se n d ah

l

e t al .(2

0 0 8 )

(S w e d e n )

R e si d e n ti al

ca re

fa ci lit y

1 9 1 (8 7 /9 1 ;9 6 /1 0 0 )

8 4 .7

(8 5 .3 ;8 4 .2 )

1 7 .8

(1 7 .5 ;1 8 .0 )

A h ig h ‐in

te n si ty

fu n ct io n al

e xe

rc is e p ro g ra m m e th at

in cl u d e d st at ic an

d d yn

am ic

b al an

ce e xe

rc is e s in

co m b in at io n w it h lo w e r lim

b

st re n g th

e xe

rc is e s, d yn

am ic

b al an

ce e xe

rc is e s in

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2516 | CAO ET AL.

(OR = 0.83, 95% CI = 0.52–1.32, p = 0.423) showed no significant difference between the exercise group and control group. There were

no heterogeneities in the two subgroups. The subgroup analyses also

showed that exercise did not reduce falls in studies with intervention

frequency less than three times a week (OR = 0.33, 95% CI = 0.03– 3.79, p = 0.370; Heterogeneity: I2 = 80.4%, p = 0.024 < 0.1), studies

with intervention frequency more than three times a week (OR =

1.09, 95% CI = 0.57–2.07, p = 0.795; Heterogeneity: (I2 = 29.6%, p = 0.224 > 0.1), studies with intervention duration less than

6 months (OR = 0.87, 95% CI = 0.56–1.34, p = 0.518; Heterogeneity: I2 = 00%, p = 0.418 > 0.1), and studies with intervention duration

more than 6 months (OR = 0.75, 95% CI = 0.13–4.23, p = 0.747; Heterogeneity: I2 = 76.8%, p = 0.014 < 0.1).

3.2.2 | Tug

Five studies (Beaudart et al., 2013; Brustio et al., 2015; Buckinx et

al., 2014; Kovács et al., 2013; Sievanen et al., 2014) reported TUG,

involving 249 participants (exercise group = 131, control group =

118). The pooled effect size showed a significant difference (SMD =

−0.39, 95% CI = −0.64 to −0.13, p = 0.003; Heterogeneity:

I2 = 0%, p = 0.527) in favour of exercise, compared with the control

group (Figure 6).

3.2.3 | Poma

Four studies (Beaudart et al., 2013; Bösner et al., 2012; Buckinx et

al., 2014; Kovács et al., 2013), involving 242 participants (exercise

group = 127, control group = 115), provided the POMA outcome.

Three studies (Beaudart et al., 2013; Buckinx et al., 2014; Kovács et

al., 2013) provided the total score and two subscale scores (balance

and gait). Compared with the control group, exercise had no effect

on the total POMA score (SMD = 0.20, 95% CI = −0.05 to 0.45,

p = 0.1222; Heterogeneity: I2 = 0%, p = 0.855) and balance score

(SMD = 0.27, 95% CI = −0.27 to 0.82, p = 0.327; Heterogeneity:

I2 = 73.4%, p = 0.023), but improved the gait score (SMD = 0.36,

95% CI = 0.07–0.66, p = 0.017; Heterogeneity: I2 = 11.5%, p = 0.323) (Figure 7).

4 | DISCUSSION

4.1 | Summary of main findings

The objective of the systematic review and meta‐analysis was to assess the effectiveness of exercise on fall prevention in nursing

home residents. After a comprehensive search of literature, nine

studies were included according to the predefined inclusion criteria.

For the quality of the included studies, three of nine studies lacked

of adequately random sequence generation, most studies were lim-

ited in allocation concealment and three studies reported dropouts

but did not analyse the missing data. All studies compared exercise

with daily routine, social activities, and other methods. The exercise

intervention modes were WBV, weight training and balance exer-

cises, sun‐style Tai Chi exercise, etc. They were all developed accord- ing to the mechanism of falling. In the mechanism of falling, impaired

NOTE: Weights are from random effects analysis

Overall (I-squared = 48.0%, p = 0.073)

Choi (2005)

Kovacs (2013)

Study

Kato (2006)

Beaudart (2013)

Rosendahl (2008)

ID

Buckinx (2014)

Bosner (2012)

0.88 (0.48, 1.59)

0.45 (0.16, 1.30)

0.08 (0.01, 0.64)

0.52 (0.07, 3.70)

1.47 (0.54, 4.01)

0.92 (0.52, 1.62)

OR (95% CI)

2.48 (0.82, 7.47)

1.18 (0.33, 4.25)

100.00

16.00

6.33

%

7.24

17.00

25.04

Weight

15.40

13.00

1.00902 1 111

FIGURE 4 The forest plots of falls for included studies [Colour figure can be viewed at wileyonlinelibrary.com]

0 0 .2

0 .4

0 .6

0 .8

1

S E

( lo

g O

R )

–1 0 1 2 3

OR

Funnel plot with pseudo 95% confidence limits

FIGURE 5 Funnel plot analysis for falls [Colour figure can be viewed at wileyonlinelibrary.com]

CAO ET AL. | 2517

balance and mobility and gait abnormalities were the most common

fall risk factors (Gschwind et al., 2013). All exercise intervention

modes in this review were developed according to balance, mobility,

and gait training. Thus, the various exercise intervention modes have

similar mechanism of action, which was in accordance with previous

reviews (Chan et al., 2015; Silva, Eslick, & Duque, 2013).

To reduce the heterogeneity between the studies, nursing home

was clearly defined to obtain low heterogeneous participants in this

study. In addition, exercise programme without other fall preventions

was the unique intervention. Although, there was low heterogeneity

between the included studies, an attempt was also conducted to find

the source of heterogeneity by subgroup analyses according to inter-

vention mode, time, frequency, and duration. The results of sub-

group analyses showed intervention mode and time may be the

source of heterogeneity.

Three outcomes were measured: falls, TUG, and POMA. Seven

studies reported falls, five studies reported TUG, and four studies

reported POMA. For the falls, there was no statistically significant

differences between the two groups (OR = 0.88, 95% CI = 0.48– 1.59, p = 0.663) and the results did not change according to sensitiv-

ity analyses. The shape of the funnel plot was symmetrical and no

publication bias was observed by Egger's test (p = 0.419). For TUG,

exercise reduced the time in the TUG tests and suggested the

improvement of mobility (SMD = −0.39, 95% CI = −0.64 to −0.13).

For POMA, the results showed no statistical difference between the

two groups in total score (SMD = 0.20, 95% CI = −0.05 to 0.45) and

balance score (SMD = 0.27, 95% CI = −0.27 to 0.82), but showed

improvement in gait score (SMD = 0.36, 95% CI = 0.07 to 0.66).

Previous systematic reviews and meta‐analyses have examined the effectiveness of fall prevention programmes, among which the

effectiveness of exercise remains controversial. The study of Hill,

Hunter, Batchelor, Cavalheri, and Burton (2015) showed that the

exercise programme did not reduce falls for older adults in the com-

munity. However, Chan et al.'s (2015) study showed that exercise

TABLE 2 Subgroup analyses of falls

Subgroup Number of studies Study

Heterogeneity OR

Q P I2 (%) OR 95%CI Z P

Intervention mode

WBV 2 Beaudart et al. (2013), Buckinx et al. (2014) 0.47 0.495 0.0% 1.86 0.89–3.91 1.65 0.100

Other 5 Bösner et al. (2012), Choi et al. (2005), Kato et al. (2006),

Kovács et al. (2013), Rosendahl et al. (2008)

6.52 0.164 38.6% 0.62 0.31–1.23 1.37 0.170

Intervention time

<30 min 3 Beaudart et al. (2013), Buckinx et al. (2014), Kato et al. (2006) 1.88 0.391 0.0% 1.59 0.79–3.18 1.31 0.191

≥30 min 3 Bösner et al. (2012), Choi et al. (2005), Rosendahl et al. (2008) 1.68 0.433 0.0% 0.83 0.52–1.32 0.80 0.423

Intervention frequency

<3/week 2 Kovács et al. (2013), Rosendahl et al. (2008) 5.10 0.024 80.4% 0.33 0.03–3.79 0.90 0.370

≥3/week 5 Beaudart et al. (2013), Bösner et al. (2012), Buckinx et al. (2014), Choi et al. (2005), Kato et al. (2006)

5.68 0.224 29.6% 1.09 0.57–2.07 0.26 0.795

Intervention duration

<6 months 4 Beaudart et al. (2013), Choi et al. (2005), Kato et al. (2006) Rosendahl et al. (2008)

2.83 0.418 0.0% 0.87 0.56–1.34 0.65 0.518

≥6 months 3 Bösner et al. (2012), Buckinx et al. (2014), Kovács et al. (2013) 8.61 0.014 76.8% 0.75 0.13–4.23 0.32 0.747

NOTE: Weights are from random effects analysis

Overall (I-squared = 0.0%, p = 0.527)

Brustio (2015)

Sievanen (2014)

Study

Buckinx (2014)

Beaudart (2013)

Kovacs (2013)

ID

–0.39 (–0.64, –0.13)

–1.00 (–1.74, –0.26)

–0.16 (–1.25, 0.93)

–0.26 (–0.76, 0.24)

–0.28 (–0.81, 0.25)

–0.37 (–0.80, 0.05)

SMD (95% CI)

100.00

11.61

5.35

%

25.52

22.43

35.09

Weight

0–1.74 1.74

FIGURE 6 The forest plots of TUG for included studies (TUG: Timed Up and Go test) [Colour figure can be viewed at wile yonlinelibrary.com]

2518 | CAO ET AL.

may have a role in falls for older adults with cognitive impairment.

Silva et al.'s (2013) study reported that exercise had a preventive

effect on falls in long‐term care facilities. The inconsistent results may be due to the heterogeneous nature of participants and the

vague terminology that defined care settings. Our study focused on

nursing homes as defined before and found that there was no statis-

tically significant differences between the exercise group and control

group in falls (OR = 0.88, 95% CI = 0.48–1.59). Usually, lack of exercise was proven to be a risk factor for falls

and exercise has been regarded as a successful intervention to pre-

vent falls (Chang, Wang, Chen, & Hu, 2017; Wu et al., 2013). This

seems to be different from our findings. About the mechanism of

exercise in fall prevention, some ideas would make sense. Exercise

helped improve balance, thus protecting against falls and reacting to

falls by maintaining neuromuscular function (Shimada et al., 2009).

However, exercise may increase the risk of falls in multiple ways.

Exercise may lead to a higher level of physical activity than usual,

which implies a greater exposure to risk‐bearing situations (Graaf- mans, Lips, Wijlhuizen, Pluijm, & Bouter, 2003). Meanwhile, exercise

by frail older people may increase the level of unintended daily phys-

ical activity and a reduction in the use of walking aid due to the

improvement of fall prevention efficacy by exercise intervention

(Fiatarone et al., 1994; Kendrick et al., 2014; McMurdo & Rennie,

1993). Thus, the balance in these contrasting effects gave one possi-

ble explanation of our results that exercise did not have a positive

effect on fall prevention but improved mobility and strengthened

balance through transforming gait.

4.2 | Strengths and limitations

The strengths of this systematic review and meta‐analysis were as follows: (a) a broad search of both mesh terms and keywords was

conducted to cover exercise to prevent falls; (b) multiple databases

were searched; (c) most of the included studies had a low risk of

bias; (d) sensitivity analysis was conducted to ensure the stability

and reliability of the results; and (e) there was no publication bias in

this meta‐analysis, as the results in statistical analyses show. The main limitation of this systematic review and meta‐analysis

was the small number of included studies. It may result in a lack of

data about some confounding factors, which may affect the accuracy

of the results. Second, there were different kinds of exercise in the

meta‐analysis: WBV, weight training and balance exercises, neuro- motor training, and so on. We did not analyse the studies within

each kind of exercise separately due to the small number of included

NOTE: Weights are from random effects analysis

.

.

.

POMA-T

Beaudart (2013)

Bosner (2012)

Buckinx (2014)

Kovacs (2013)

Subtotal (I-squared = 0.0%, p = 0.855)

POMA-B

Beaudart (2013)

Buckinx (2014)

Kovács (2013)

Subtotal (I-squared = 73.4%, p = 0.023)

POMA-G

Beaudart (2013)

Buckinx (2014)

Kovács (2013)

Subtotal (I-squared = 11.5%, p = 0.323)

ID

Study

0.02 (–0.51, 0.55)

0.18 (–0.46, 0.82)

0.21 (–0.29, 0.71)

0.32 (–0.10, 0.75)

0.20 (–0.05, 0.45)

–0.17 (–0.70, 0.37)

0.17 (–0.33, 0.67)

0.77 (0.33, 1.20)

0.27 (–0.27, 0.82)

0.22 (–0.31, 0.75)

0.16 (–0.34, 0.66)

0.62 (0.19, 1.05)

0.36 (0.07, 0.66)

SMD (95% CI)

22.85

15.75

25.83

35.56

100.00

31.81

33.00

35.20

100.00

28.05

31.54

40.40

100.00

Weight

%

–1.2 0 1.2

FIGURE 7 The forest plots of POMA for included studies (POMA‐T: the total score of Performance Oriented Mobility Assessment (POMA) scale, POMA‐B: the balance scale of POMA scale; POMA‐G: the gait scale of the POMA scale) [Colour figure can be viewed at wileyonlinelibrary.com]

CAO ET AL. | 2519

studies, which would lead to some bias for conclusion because dif-

ferent exercises may result in different size of effects. Consequently,

the results of the meta‐analysis should be generalized and inter- preted with caution.

4.3 | Implications for future research and practice

In contrast to previous reviews, we concentrated on residents in

nursing homes and got some evidence from RCTs to find that exer-

cise may not reduce falls but may improve mobility and strengthen

balance through transforming gait. However, further studies with

high quality and larger sample size are needed to support the conclu-

sion. Studies with different kinds of exercise are needed to find

whether there is an optimal and safe level of exercise for residents

in nursing homes. Furthermore, there is a need to recognize whether

potential barriers exist in the process of exercise and influence the

effect when implementing interventions. Studies are also required to

provide some advice to avoid and overcome these potential difficul-

ties. In addition, although the single exercise intervention may not

play a role in fall prevention in nursing homes, multifactorial inter-

ventions that combine exercise with other interventions may need

to be tried.

5 | CONCLUSION

Usually, exercise has been regarded as a successful intervention to

prevent falls, but when focused on residents in nursing homes, exer-

cise may not have an effect on fall prevention but only improve

mobility and strengthen balance through transforming the gait, com-

pared with daily routine, social activities, and other methods without

exercise. In consideration of some limitations described earlier, fur-

ther RCTs with high quality and larger samples are required to sup-

port or counter the results we showed.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHORS CONTRIBUTIONS

All authors have agreed on the final version and meet at least one

of the following criteria [recommended by the ICMJE (*http://www.

icmje.org/recommendations/)]:

• substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;

• drafting the article or revising it critically for important intellectual content.

ORCID

Qing-hua Zhao http://orcid.org/0000-0002-3115-3128

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How to cite this article: Cao P, Zhao Q, Xiao M, Kong L, Xiao

L. The effectiveness of exercise for fall prevention in nursing

home residents: A systematic review meta‐analysis. J Adv Nurs. 2018;74:2511–2522. https://doi.org/ 10.1111/jan.13814

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