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Phys. Ther. Korea 2021; 28(1): 1-12
Published online February 20, 2021
https://doi.org/10.12674/ptk.2021.28.1.1
© Korean Research Society of Physical Therapy
The Literature Review on the Effectiveness of Fall-related Hip Fracture Prevention Programs
Se-young Lee 
, PT, BPT, Seung-su Kim , PT, BPT, Kitaek Lim , PT, BPT, Woochol Joseph Choi , PT, PhD
Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, Korea
Correspondence to: Woochol Joseph Choi
E-mail: wcjchoi@yonsei.ac.kr
https://orcid.org/0000-0002-6623-3806
While efforts have been made to address fall-related injuries in older adults, the problem is unsolved to date. The purpose of this review is to provide a guideline for fall and injury prevention programs in older adults, based on evidence generated over the past 30 years. Research articles published between 1990 and 2020 have been searched on PubMed, using keywords, including but not limited to, falls, hip fracture, injuries, intervention, older adults, prevention, hip protector, vitamin D, safe landing strategy, and exercise. Total of 98 articles have been found and categorized into five intervention areas: exercise program, hip protector, safe landing strategy, vitamin D intake, and compliant flooring. Furthermore, the articles have been rated based on their study design: class 1, randomized controlled trials; class 2, nonrandomized controlled trials; class 3, experimental studies; class 4, all other studies. Exercise programs have shown to decrease the risk of fall, and associated injuries. Hip protectors, safe landing strategy, and vitamin D intake were effective in reducing a risk and incidence of hip fracture during a fall. Furthermore, compliant flooring has also decreased hip fracture risk without affecting balance. An integrated approach combining exercise program, wearing a hip protector, teaching safe landing strategies, scheduled vitamin D intake, and compliant flooring installation, is suggested to address fall-related injuries in older adults.
Keywords: Exercise, Falls, Hip fracture, Intervention, Older adults, Prevention
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Review Article
Phys. Ther. Korea 2021; 28(1): 1-12
Published online February 20, 2021 https://doi.org/10.12674/ptk.2021.28.1.1
Copyright © Korean Research Society of Physical Therapy.
The Literature Review on the Effectiveness of Fall-related Hip Fracture Prevention Programs
Se-young Lee , PT, BPT, Seung-su Kim , PT, BPT, Kitaek Lim , PT, BPT, Woochol Joseph Choi , PT, PhD
Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, Korea
Correspondence to:Woochol Joseph Choi
E-mail: wcjchoi@yonsei.ac.kr
https://orcid.org/0000-0002-6623-3806
Abstract
While efforts have been made to address fall-related injuries in older adults, the problem is unsolved to date. The purpose of this review is to provide a guideline for fall and injury prevention programs in older adults, based on evidence generated over the past 30 years. Research articles published between 1990 and 2020 have been searched on PubMed, using keywords, including but not limited to, falls, hip fracture, injuries, intervention, older adults, prevention, hip protector, vitamin D, safe landing strategy, and exercise. Total of 98 articles have been found and categorized into five intervention areas: exercise program, hip protector, safe landing strategy, vitamin D intake, and compliant flooring. Furthermore, the articles have been rated based on their study design: class 1, randomized controlled trials; class 2, nonrandomized controlled trials; class 3, experimental studies; class 4, all other studies. Exercise programs have shown to decrease the risk of fall, and associated injuries. Hip protectors, safe landing strategy, and vitamin D intake were effective in reducing a risk and incidence of hip fracture during a fall. Furthermore, compliant flooring has also decreased hip fracture risk without affecting balance. An integrated approach combining exercise program, wearing a hip protector, teaching safe landing strategies, scheduled vitamin D intake, and compliant flooring installation, is suggested to address fall-related injuries in older adults.
Keywords: Exercise, Falls, Hip fracture, Intervention, Older adults, Prevention
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Table 1 . The number of articles included in this review.
Interventions Class of evidencea Total 1 2 3 4 Exercise programs 33 2 8 1 44 Hip protector 14 5 9 0 28 Safe landing strategy 0 4 9 0 13 Vitamin D intake 8 1 0 0 9 Compliant flooring 1 2 3 0 6 aClass 1: randomized controlled trials. Class 2: non-randomized controlled trials. Class 3: experimental studies with no control group. Class 4: studies not belonging to Class 1, 2, and 3 (i.e., case study).
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Table 2 . Effect of exercise on static balance.
Articles Class of evidence Interventions Outcomes Improve Kurz et al., 2016 [3] 1 Unexpected perturbation training COP Yes Alfieri et al., 2012 [4] 1 Multisensory training COP Yes Hatzitaki et al., 2009 [5] 1 Visually guided weight-shifting COP Yes Li et al., 2004 [6] 1 Tai Chi FRT Yes Cyarto et al., 2008 [7] 1 Group exercise OLS Yes Szturm et al., 2011 [8] 1 Interactive computer game Loss of balance Yes Barnett et al., 2003 [9] 1 Group exercise COP Yes Jorgensen et al., 2013 [10] 1 Nintendo Wii COP No Martínez-Amat et al., 2013 [11] 2 Bosu and Swiss ball COP Yes Bulat et al., 2007 [12] 3 Group exercise 1. COP 2. CTSIB 1. Yes 2. Yes Springer et al., 2018 [13] 3 Thoracopelvic assisted movement FRT Yes Sung et al., 2018 [14] 4 Tai Chi FRT Yes COP, center of pressure; FRT, functional reach test; OLS, one leg standing test; CTSIB, clinical test of sensory integration on balance.
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Table 3 . Effect of exercise on dynamic balance.
Articles Class of evidence Interventions Outcomes Improve Gomeñuka et al., 2019 [15] 1 Nordic walking Gait speed Yes Niemelä et al., 2011 [16] 1 Home-based rocking-chair exercise Gait speed Yes Oh et al., 2012 [17] 1 Intensive exercise Gait speed Yes van Ooijen et al., 2016 [18] 1 Projected visual context treadmill Gait speed Yes Li et al., 2004 [6] 1 Tai Chi Dynamic gait index Yes Wolf et al., 2001 [19] 1 Physical therapeutic intervention Dynamic Gait Index Yes Conradsson and Halvarsson, 2019 [20] 1 Dual-task balance training Gait parameters Yes Barnett et al., 2003 [9] 1 Group exercise Gait speed No Springer et al., 2018 [13] 3 Thoracopelvic assisted movement Gait speed Yes Li, 2014 [21] 3 Tai Chi Gait speed Yes Dorfman et al., 2014 [22] 3 Dual-task training 1. Gait speed 2. Dynamic gait index 1. Yes 2. Yes Renfro et al., 2016 [23] 3 Modified Otago exercise program Total walk distance Yes
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Table 4 . Effect of exercise on balance (studies using clinical balance measurement tools).
Articles Class of evidence Interventions Outcomes Improve Binder et al., 2002 [24] 1 Intensive exercise training Performance test Yes Cyarto et al., 2008 [7] 1 Group-based resistance and balance training 8-foot up-and-go test Yes Frih et al., 2018 [25] 1 Combined exercise 1. TUG 2. Tinetti 3. BBS 1. Yes 2. Yes 3. Yes Irandoust et al., 2019 [26] 1 Aquatic exercise Tinetti Yes Jorgensen et al., 2013 [10] 1 Nintendo Wii 1. TUG 2. Chair stand test 1. Yes 2. Yes Lai et al., 2013 [27] 1 Video game with exercise 1. BBS 2. TUG 1. Yes 2. Yes Leiros-Rodríguez and García-Soidan, 2014 [28] 1 Balance training 1. BBS 2. TUG 1. Yes 2. Yes Li et al., 2004 [6] 1 Tai Chi BBS Yes Li et al., 2018 [29] 1 Biofeedback balance training with functional electrical stimulation BBS Yes Mihailov and Popa, 2010 [30] 1 Long term exercise 1. Tinetti 2. TUG 1. Yes 2. Yes Niemelä et al., 2011 [16] 1 Home-based rocking-chair exercise BBS Yes Pollock et al., 2012 [31] 1 Whole body vibration with strength and balance exercise TUG Yes Pooranawatthanakul and Foongchomcheay, 2015 [32] 1 Video game (Wii)-based exercise 1. BBS 2. Fullerton 1. Yes 2. Yes Steadman et al., 2003 [33] 1 Enhanced balance training BBS Yes Wolf et al., 2001 [19] 1 Balance training BBS Yes Zhang et al., 2014 [34] 1 Whole body vibration TUG Yes Szturm et al., 2011 [8] 1 Interactive computer game exercise 1. BBS 2. TUG 1. Yes 2. No Hale et al., 2012 [35] 1 Water based exercise TUG No Sherrington et al., 2020 [36] 1 Recovery exercise after fracture SPPB No Martínez-Amat et al., 2013 [11] 2 Proprioception training 1. BBS 2. Tinetti 1. Yes 2. Yes Bulat et al., 2007 [12] 3 Functional balance training BBS Yes Dorfman et al., 2014 [22] 3 Dual tasking on treadmill BBS Yes Li, 2014 [21] 3 Tai Chi TUG Yes Springer et al., 2018 [13] 3 Thoracopelvic assisted movement training TUG Yes
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Table 5 . Effect of exercise on balance (studies using questionnaires).
Articles Class of evidence Interventions Outcomes Improve Frih et al., 2018 [25] 1 Endurance-resistance exercise ABC Yes Smulders et al., 2010 [37] 1 Nijmegen fall prevention program ABC Yes Szturm et al., 2011 [8] 1 Interactive computer game ABC Yes Zhang et al., 2014 [34] 1 Whole body vibration ABC Yes Jorgensen et al., 2013 [10] 1 Nintendo Wii FES Yes Lai et al., 2013 [27] 1 Interactive video game FES Yes Li et al., 2018 [29] 1 Visual feedback-based training with functional electric stimulation FES Yes Pollock et al., 2012 [31] 1 Whole body vibration FES Yes van Ooijen et al., 2016 [18] 1 Projected visual context treadmill Fear of falling Yes Giné-Garriga et al., 2013 [38] 1 Functional circuit training Fear of falling Yes Sihvonen et al., 2004 [39] 1 Visual feedback-based balance training Fear of falling Yes Wolf et al., 1996 [40] 1 Tai Chi Fear of falling Yes Zeeuwe et al., 2006 [41] 1 Tai Chi Fear of falling Yes Cyarto et al., 2008 [7] 1 Group exercise ABC No Hale et al., 2012 [35] 1 Water-based exercise ABC No Kurz et al., 2016 [3] 1 Unexpected perturbations training FES No Barnett et al., 2003 [9] 1 Group exercise Fear of falling No Wolf et al., 2001 [19] 1 Physical therapeutic intervention Fear of falling No Miller et al., 2010 [42] 3 Home-based exercise program FES Yes Groen et al., 2010 [43] 3 Martial arts Fear of falling Yes ABC, activities-specific balance confidence scale; FES, fall efficacy scale.
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Table 6 . Effect of exercise on fall and fracture incidence.
Articles Class of evidence Interventions Outcomes Improve Campbell et al., 1997 [44] 1 Home based exercise Fall incidence Yes Duque et al., 2013 [45] 1 Balance exercise using Virtual Reality Fall incidence Yes Li et al., 2018 [29] 1 Visual feedback-based force platform training with functional electrical stimulation 1. Fall incidence 2. Fracture incidence 1. Yes 2. Yes Sihvonen et al., 2004 [39] 1 Biofeedback balance training Fall incidence Yes Swanenburg et al., 2007 [46] 1 Exercise with calcium and vitamin supplement Fall incidence Yes van Ooijen et al., 2016 [18] 1 Treadmill training with projected visual context Fall incidence No Sherrington et al., 2020 [36] 1 RESTORE intervention Fall incidence No
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Table 7 . Effect of a hip protector on fall-related hip fracture risk.
Articles Class of evidence Interventions Outcomes Improve Bentzen et al., 2008 [47] 1 Hip protector Hip fracture incidence Yes Cameron et al., 2000 [48] 1 Hip protector Fear of fall and injury risk Yes Kannus et al., 2000 [49] 1 Hip protector Hip fracture incidence Yes Koike et al., 2009 [50] 1 Hip protector Hip fracture incidence Yes Lauritzen et al., 1993 [51] 1 Hip protector Hip fracture incidence Yes Meyer et al., 2003 [52] 1 Hip protector Hip fracture incidence Yes Cameron et al., 2011 [53] 1 Hip protector 1. Fear of fall and injury risk 2. Hip fracture incidence 1. No 2. No Cameron et al., 2011 [54] 1 Hip protector Fear of fall and injury risk No Cameron et al., 2003 [55] 1 Hip protector 1. Fear of fall and injury risk 2. Hip fracture incidence 1. No 2. No Birks et al., 2004 [56] 1 Hip protector Hip fracture incidence No Kiel et al., 2007 [57] 1 Hip protector Hip fracture incidence No O'Halloran et al., 2004 [58] 1 Hip protector Hip fracture incidence No van Schoor et al., 2003 [59] 1 Hip protector Hip fracture incidence No Birks et al., 2003 [60] 1 Hip protector Hip fracture incidence No Harada et al., 2001 [61] 2 Hip protector Hip fracture incidence Yes Garfinkel et al., 2008 [62] 2 Hip protector Hip fracture incidence Yes Juby, 2009 [63] 2 Hip protector Hip fracture incidence Yes Korall et al., 2019 [64] 2 Hip protector Hip fracture incidence Yes Woo et al., 2003 [65] 2 Hip protector Hip fracture incidence Yes Bentzen et al., 2008 [66] 3 Hip protector Hip fracture incidence Yes Forsén et al., 2003 [67] 3 Hip protector Hip fracture incidence Yes Honkanen et al., 2005 [68] 3 Hip protector Hip fracture incidence Yes O'Halloran et al., 2007 [69] 3 Hip protector Hip fracture incidence No Laing et al., 2011 [70] 3 Hip protector Hip impact force Yes Laing and Robinovitch, 2008 [71] 3 Hip protector Hip impact force Yes Laing and Robinovitch, 2008 [72] 3 Hip protector Hip impact force Yes Choi et al., 2010 [73] 3 Hip protector Hip impact force Yes Choi et al., 2010 [74] 3 Hip protector Hip impact force Yes
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Table 8 . Effect of safe landing strategies on fall-related hip fracture risk.
Articles Class of evidence Interventions Outcomes Improve Martel et al., 2018 [75] 2 Hip muscle contraction Hip impact force Yes Pretty et al., 2017 [76] 2 Hip muscle contraction Hip impact force Yes Groen et al., 2007 [77] 2 Martial arts 1. Hip impact force 2. Hip impact velocity 1. Yes 2. Yes Weerdesteyn et al., 2008 [78] 2 Martial arts 1. Hip impact force 2. Hip impact velocity 1. Yes 2. Yes Robinovitch et al., 1997 [79] 3 Trunk position Hip impact force Yes van der Zijden et al., 2012 [80] 3 Martial arts Hip impact force Yes Lim and Choi, 2020 [81] 3 Knee boundary condition Hip impact force Yes Choi et al., 2010 [73] 3 Pelvis impact angle Hip impact force Yes DeGoede and Ashton-Miller, 2002 [82] 3 Arm configuration Hip impact force Yes Choi et al., 2017 [83] 3 Neck muscle activation Hip impact velocity Yes Lo and Ashton-Miller, 2008 [84] 3 Segment movement Hip impact force Yes Choi et al., 2015 [85] 3 Hip abductor muscle forces, Knee boundary conditions 1. Femoral neck stress 2. Femoral neck force 1. Yes 2. Yes Choi and Robinovitch, 2018 [86] 3 Pelvis impact angle 1. Femoral neck stress 2. Femoral neck force 1. Yes 2. Yes
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Table 9 . Effect of vitamin D intake on fall-related hip fracture risk.
Articles Class of evidence Interventions Outcomes Improve Uusi-Rasi et al., 2015 [87] 1 Vitamin D (800 IU) Fall and injury rate Yes Bischoff-Ferrari et al., 2016 [88] 1 Vitamin D Fall and injury rate Yes Smith et al., 2017 [89] 1 Vitamin D (4,000–4,800 IU) Fall and injury rate Yes Bogaerts et al., 2011 [90] 1 Vitamin D with squat 1. Fall and injury rate 2. Balance 1. Yes 2. Yes Swanenburg et al., 2007 [46] 1 Vitamin D with protein, balance exercise 1. Fall risk 2. Balance 1. Yes 2. Yes Bischoff-Ferrari et al., 2006 [91] 1 Vitamin D and calcium Fall risk Yes Law et al., 2006 [92] 1 Vitamin D Fall and injury rate No Sanders et al., 2010 [93] 1 Vitamin D Fall and injury rate No Boersma et al., 2012 [94] 2 Vitamin D Postural instability Yes
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Table 10 . Effect of compliant flooring on fall-related hip fracture risk.
Articles Class of evidence Interventions Outcomes Improve Mackey et al., 2019 [95] 1 Compliant (low-stiffness) flooring Fall and injury risk No Simpson et al., 2004 [96] 2 Wooden carpeted floors Fall and injury Yes Laing and Robinovitch, 2009 [97] 2 Smart Cell (low- stiffness) Hip impact Yes Gustavsson et al., 2018 [98] 3 Compliant (low-stiffness) flooring Fall and injury risk Yes Wright and Laing, 2011 [99] 3 Smart Cell and SofTile Femur peak force Yes Gustavsson et al., 2015 [100] 3 Impact absorbing flooring Fall and injury risk Yes