The Best Fall Prevention Program
This article is designed to help decide which (if any) is the Best Fall Prevention Program for you. And to help you choose between the programs available in your town, state and country."
There are a large number of distinct risk factors for falls in older adults. If you want to do a good job of reducing fall risk, you really need to tackle many or all of those risk factors in parallel. And there are a number of "Fall Prevention Programs" designed to help you do this. But which one should you choose?
The best program for you depends on your particular lifestyle, and your particular level of risk for falling. For more background, see our prior articles on Fall Risk, and the things you can do to make falling less likely.
Four components of fall prevention
The first thing to note is that there are four components of a complete Fall Prevention program:
- behavior change;
- an initial exercise intervention designed to improve to a certain baseline level those physical attributes that affect fall risk (balance, gait, strength and flexibility); and
- an ongoing exercise program that you take part in indefinitely, and which is designed to maintain and improve the physical attributes that relate to falls.
Most available Fall Prevention programs only tackle some of these components. So it is up to you to find a way to mix and match available programs so you cover all four components.
Education: what to do
The purpose of the education component is to make sure you fully understand the risk factors that impact falls, and what you can do to mitigate them. For example, it helps to know about the likely tripping hazards and other fall hazards in the home. And it helps to know to get a medication review to make sure you are not using medications that unnecessarily increase the chances of falling due to dizziness.
Behavior change: help me take action
The purpose of the behavior change component is to help you take action. For example, it is all very well to acknowledge the importance of wearing the right (but ugly) shoes, or of picking up all those nice rugs you have lived with for the last 20 years. It is quite another thing to move from "I understand" to "I am taking action".
Some Fall Prevention programs use various, behavior-change-inducing techniques, such as peer-to-peer interaction among older adults, to help people make that transition from "I know" to "I am doing it". The research literature suggests that this behavior-change component is a very important part of a successful fall prevention program.
The right types of exercise are at the heart of any successful fall prevention initiative. There is a lot to say about this. For now, just note the distinction between the initial intervention and the ongoing program. In evaluating any fall prevention program, it helps to decide whether one is looking at an initial intervention or an ongoing, long term exercise program. We argue that all adults wishing to reduce fall risk need the ongoing exercise component. Whether or not you also need the initial exercise intervention depends on your level of current physical capability.
Multi-factorial intervention or Stand-alone exercise program
We have not found any programs that do a good job of covering all four of the components of fall prevention described above. Instead there seem to be two types of program available. There are stand-alone exercise programs of various types, targeting the initial exercise intervention or the longer term, ongoing exercise program. And then there are a class of multi-factorial fall prevention programs that tackle education, behavior change, and (usually) some type of initial exercise intervention.
All the multi-factorial programs we found are fixed-length interventions, typically 8-12 weeks. Some of the multi-factorial fall prevention programs try and teach you how to do your own ongoing exercise program at home after the program finishes. But they don't typically help, or provide ongoing support with that.
So, for people who want or need help with the education or behavior change components, the best approach seems to be a combination of an initial, multi-factorial program, followed by a longer term, ongoing, stand-alone exercise program of the right type.
People who don't feel a need for the education or behavior change components might go straight to a stand-alone exercise program.
How do we know a program "works"?
Two very important questions to ask about any fall prevention program are "How do we know it works?" And "How well does it work?"
There has been a lot of work done by public health experts over the last two decades to develop Fall Prevention programs and measure their effectiveness, and both the CDC (Centers for Disease Control and Prevention) and the NCOA (National Council on Aging) have collected lots of useful background information on their websites and in various documents (See reference section of Fallproofing Me).
The starting point for answering these questions is to know whether or not there is a published, peer-reviewed, scientific study which evaluated a specific program and showed that the program did indeed have some beneficial effect. Programs for which there is such a study are called "evidence-based" programs, and the public health community and the governmental funding agencies take the position that you really want to choose an evidence-based program.
There is more to be said on this topic, however. First, the quality and strength of any piece of evidence varies. Not having any evidence is certainly a weakness. But once you have some evidence, it takes a bit of expert review to decide just how strong that evidence is.
Helpfully, the CDC has compiled a list of programs it recognizes as being "specific interventions for which there is published evidence of the intervention’s ability to reduce falls among community-dwelling older adults" (2). This list, and a similar list on the NCOA website ("evidence-based programs than have been proven to help older adults reduce their risk of falling") (3), are great places to start in selecting a program, and we draw on them in the rest of this article as our source of "evidence-based" programs. Note that each of these lists is based on specific (and different) criteria for evidence strength. There are additional programs that are still "evidence-based", but which the NCOA and CDC do not feel have strong enough evidence to make their lists.
The second important point to make about evidence-based programs is that one needs to understand what exactly the "evidence" is evidence of. Note that studies in the CDC list have evidence that they "reduce [the incidence of] falls". Whereas studies on the NCOA list have evidence that they "reduce the risk of falling". These are subtly different.
An interesting illustration of the importance of understanding what exactly the "evidence" shows came when we looked at the Stepping On, A Matter of Balance, and SAIL programs discussed below. Of the three, only Stepping On is on the CDC list, which requires a study to have actually demonstrated reduction in incidence of falling. The other two programs appear on the NCOA list which appears to have a lower standard of evidence than the CDC list. A Matter of Balance has been to shown to reduce fear of falling and increase activity, but has not been shown to reduce fall incidence (4). SAIL has been shown to improve a number of physical characteristics related to falls (eg balance, mobility, leg strength), and the study of SAIL even suggests it may well reduce fall incidence (5). However the results for reducing fall incidence were not statistically significant. Despite these quite significant differences in the strength of the evidence behind these programs, all three are advertised as being "evidence based".
If you are looking at a fall prevention program which describes itself as "evidence-based", but which is not on the CDC list or the NCOA list, it is worth digging deeper to understand why that is, and making sure that the "evidence" behind the program is indeed strong.
The third point to make about evidence-based programs is that, almost by definition, such a program was most likely developed some time ago (because time has to have passed for the study and publishing process to take place). So, a suitably qualified expert may well be able to develop an improved fall prevention program, that builds on the principles of prior, evidence-based programs, but incorporates new knowledge. Because of the newness of the program, actual published studies showing effectiveness may not yet exist.
The big question for a new, "improved" fall prevention program is how to tell whether it is actually "better", rather than just "different" and maybe worse.
When it comes to multi-factorial programs, we don't think it makes sense to venture beyond the evidence-based programs because (a) the existing programs seem rather good, and (b) we really don't know how to tell if a program is actually good, if it is unsupported by peer reviewed studies.
However, in part 2 of this article when we discuss stand-alone exercise programs for fall prevention, we find the situation is less clear cut.
Starting with a Multi-factorial Fall Prevention Program
For many readers, it will make sense to start with a multi-factorial program of some type and then graduate to an ongoing exercise program. The remainder of this part 1 article is on how to choose the right multi-factorial fall prevention program. For more about choosing the right stand-alone exercise program, see Part 2: Exercise to Prevent Falls.
Choosing the Right Multi-factorial Fall Prevention Program for You
Here is CDC Fall-expert panel member Dr. Mindy Renfro's response when asked for advice on how one should choose a fall prevention program*.
I recommend people think of it as a progression, depending on their level of fitness. If they can walk alone in the community, go up and down two flights of stairs, and stand on one foot for 10 seconds, then I recommend a suitable stand-alone exercise program, such as Tai Chi, to improve balance.
If they are not at that level, then I recommend they try Stepping On and some balance exercises they learn in that program until they reach that level, after which they should go on to the longer term, stand-alone exercise program.
If a person is fearful about going out and afraid of falling, then A Matter of Balance is a multi-factorial intervention specifically designed to reduce a person's fear of falling. I would take that, then move on to Stepping On, and then to Tai Chi.
If a person is very frail and does not have sufficient balance to tackle Stepping On, then I recommend one-on-one sessions with a Physical Therapist** trained in the Otago method, to help them gain sufficient balance to graduate to Stepping On and then to Tai Chi.
For someone who is scared of doing anything at all in the way of exercise, I encourage them to start with Sit and Be Fit on PBS, and then move up the chain above.
And, adds kinesiology professor Dr. Christian Thompson:
... certain issues (such as illness, extended travel, a fall-related or non fall-related injury) might warrant moving someone BACKWARDS into an earlier program. And often these fall prevention programs can be done IN ADDITION TO other physical exercise programs which can provide health and physical benefits but do not reduce falls risk (e.g. a walking program or aquatic exercise program).
Editor Note: Stepping On and A Matter of Balance are multi-factorial programs. The Otago Method and Tai Chi are stand-alone exercise programs, with the Otago Method being designed as what we call an initial intervention, while Tai Chi is an ongoing, long term exercise program.
Evidence-based Multi-factorial Programs
While there are a number of studies mentioned in the CDC compendium of proven fall prevention programs, only a few of them have been translated to programs that are actually offered in the community (ie to you and me). Here are the evidence-based, multi-factorial fall prevention programs we found:
A Matter of Balance (USA)
This program is managed by a healthcare system in Maine, USA called MaineHealth. The program's website is here. The program includes 8 two hour group sessions led by a trained facilitator, and focuses especially on reducing fear of falling, and increasing activity level among older adults. The website is targeted at people who would like to become certified to teach this program, and to institutions that would like to offer the program. According to its website, the program is "based on research conducted by the Roybal Center for Enhancement of Late-Life Function at Boston University."
A Matter of Balance is on the NCOA list of "proven, evidence-based programs that have been proven to help older adults reduce their risk of falling". However, this program is not included in the CDC Falls Compendium, because the research on A Matter of Balance has focused on reducing fear of falling and increasing activity, but has not demonstrated an actual reduction in the incidence of falling (4).
What this means is that A Matter of Balance makes sense if you are afraid of falling and that fear is hindering your desire to get up and go out and do things. If that is not your challenge, then it is unclear how this program would help.
We set out to find a class we could take for A Matter of Balance in California. Here is what we found:
- a list of classes in Silicon Valley;
- a handy map of "master trainers" (people able to train others) by state. You can download a list of master trainers names, phone numbers, emails, and institutions for your state. This is a great place to start some detective work to find an actual class.
Stepping On (USA & Australia)
This program seems to be one of the most highly regarded, evidence-based, multi-factorial, fall prevention programs, and it is in the CDC Fall Compendium and on the NCOA list of effective fall prevention programs. Originally developed in Australia, the CDC funded its translation for delivery in the USA, and it has its US home at the Wisconsin Institute for Healthy Aging.
There is quite a lot of information on the WIHA program's website on who the program is for, how it works, and what the results have been. The program addresses the first three of the four fall prevention components we describe at the beginning of this article. But not the ongoing exercise component.
We set out to find a class to take for Stepping On in California. Here is what we found:
- A state by state list of organizations with Stepping On licenses (ie they could and probably do offer Stepping On programs).
- Here is the website for Stepping On in Australia.
SAIL: Stay Active and Independent for Life (USA)
This program was developed in Washington State and includes a group exercise program as well as self assessment and educational materials. The SAIL program is being disseminated by Sail Seminars, which offers a training and certification program for people who wish to become leaders of SAIL classes and programs.
This program is on the list of NCOA "effective fall prevention programs", but does not make the CDC list since, as explained in the section on "Does it Work" above, it falls short of having actual evidence that it reduces fall incidence (5).
According to the Sail Seminars website, SAIL is "widely disseminated" across Washington State. But it does not appear to be easy to find elsewhere.
The Fallscape System (USA)
Also on the NCOA list of proven programs, but not on the CDC list, The Fallscape System appears to be a system of multimedia that can be used by "trainers" and facilities to teach people how to reduce their risk of falling through education but not through actual exercise.
From their website, it appears that this is solely a multimedia teaching tool, targeting improved knowledge and perhaps behavior change, and that it does not include actual exercises. If that is correct it would represent the first two components only of the four that are needed for a complete fall prevention program.
There is no easy way we have discovered to find where classes are being taught using the Fallscape system. The upcoming training classes for program leaders are in Colorado and Vermont. The program website has little about the people behind the work or behind the business. Overall, this program, while on the NCOA website, appears to us to be a less good alternative than any of the other programs mentioned here.
The Exercise Component of Fall Prevention
Once you have graduated from one of the multi-factorial programs above, you need a longer term, stand-alone exercise program. And if you prefer to mix and match your own programs rather than take the swiss army knife approach of a multi-factorial program, you need a stand-alone exercise program also for the initial exercise intervention.
In part 2 of this article we look at stand-alone exercise programs for fall prevention, and how to choose the right exercise program for you.
Footnotes and References
*Note: This is a generalization, and does not take into account a person's exact circumstance, which of course would be important before making a specific recommendation.
** Dr. Renfro recommends that the Physical Therapist (PT) one consults in the context of the Otago Method should ideally be either a Geriatric-certified specialist (PT, GCS), or a Neuro-certified specialist (PT, NCS).
References and background reading
1. For various references on Fall Risk, and much more, see the references section of our companion article:
Fall proofing ME: What Can I Do?
Lead author: Richard Caro