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A R T I C LE I N FO A B S T R A C T
Keywords: Exercise interventions focused on strength and balance are effective for falls prevention in older people, however
Otago Exercise Program compliance to exercise is often a problem. Tailored intervention programs are recommended to meet the person
Community-dwelling older adults preferences and increase compliance. Otago Exercise Program (OEP) is the most disseminated fall prevention
Balance program and is individually prescribed at home. The purpose of this study was to identify OEP modified formats
Personalized exercise
and investigate their effects on balance when compared to its original form of delivering.
Four electronic databases were searched, PubMed, PEDro, Science Direct and Scopus, between January and
February 2017. Eligibility criteria included experimental or qualitative design studies conducted among older
adults (≥50 years) at risk of falling, ongoing exercise interventions with modified formats of OEP. The primary
outcome was balance. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were
used.
Eight studies met the inclusion criteria, five were randomized controlled trials (RCTs), two were quasi-ex-
perimental and one was a qualitative study. Therefore, a qualitative analysis was performed. Modified formats of
OEP included additional vestibular or multisensory balance exercises, augmented reality, exercise in group and a
DVD delivering format (in group or individual). In general, all studies using OEP modified formats reported
improvements on balance and functional ability. However, it remains unclear if it is as effective as the original
OEP and which modified format is more effective.
1. Introduction Gillespie et al., 2012; Lacroix et al., 2016; Morris et al., 2016; Phelan
et al., 2015; Sherrington et al., 2008, 2011, 2017). In fact, exercise as a
Falls and fall-related injuries are a leading cause of morbidity and single intervention can prevent falls in this specific population
mortality among elderly, representing a serious public health problem (Sherrington et al., 2017). Both individual and group exercise programs
(Dadgari et al., 2016; National Institute for Care Excellence, 2013; are equally effective (Gillespie et al., 2012; Sherrington et al., 2008,
Otaka et al., 2017), and a significant threat to health, safety and in- 2017), producing positive effects on mobility and physical functioning
dependence (Chou et al., 2012). About one-third of people aged (de Vries et al., 2012). Additionally, preventive interventions com-
65 years or more experience at least one fall annually (World Health prising exercise with multiple components achieved a significant re-
Organization, 2007). Falls lead to social isolation, decrease of self- duction in the rate and risk of falling (Gillespie et al., 2012).
confidence and restriction on participation and activity limitations, The Otago Exercise Program (OEP) is the most widespread fall
promoting functional decline and dependence (Hartholt et al., 2011). prevention program. It was developed at Otago Medical School and
Health care direct costs related to this phenomenon reaches 25 bil- implemented across New Zealand by the Accident Compensation
lion euros/year in the European Union (Carande-Kulis et al., 2015; Corporation (Campbell and Robertson, 2003; Sherrington et al., 2011).
Davis et al., 2010; ESA on Falls, 2015). The program includes strength and balance exercises, with a progres-
Current research demonstrates the effectiveness of exercise pro- sion by increasing ankle cuff weights and number of sets, in association
grams to reduce fall rate in community-dwelling older people, mainly with a walking plan. It is recommended for community-dwelling older
strength and balance exercises for > 3 h/week (El-Khoury et al., 2013; adults who can exercise safely on their own and who are able to
⁎
Corresponding author at: ESTESC Coimbra Health School, Physiotherapy Department, Rua 5 de Outubro – S. Martinho do Bispo – Apartado 7006, 3040-162
Coimbra, Portugal.
E-mail address: anabelacmartins@estescoimbra.pt (A.C. Martins).
https://doi.org/10.1016/j.pmedr.2018.06.015
Received 14 February 2018; Received in revised form 21 June 2018; Accepted 24 June 2018
Available online 10 July 2018
2211-3355/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
A.C. Martins et al. Preventive Medicine Reports 11 (2018) 231–239
understand and follow the exercise instructions. Other inclusion criteria adults” AND “balance” AND “fall prevention”; “older adults” AND
are history of falls, decrease in balance and strength, frailty or high risk “Otago Exercise Program” AND “fall prevention”.
of falling. The program is particularly effective in individuals with To supplement the data provided, regarding exercise interventions
80 years or older and is considered safe, effective, practical and a cost- based on OEP, websites and relevant protocol papers referenced in the
effective approach for falls prevention (Campbell and Robertson, 2003; original publications were also searched.
Robertson et al., 2002; Stevens and Burns, 2015). Eligibility criteria included full-text RCTs and other experimental
The exercises are individually prescribed and delivered at partici- designs and qualitative studies, conducted among community dwelling
pant's home, with four visits of the physiotherapist over the first two adults, with non-syncopal falls during the previous 12 months and/or
months, one visit at 6 and another at 12 months. Participants complete functional ability indicating risk of falling (balance, strength and gait
the exercises for 30 min/3 times a week and are encouraged to walk tests), whose main exercise intervention strategy was a OEP modified
outside at least twice a week. To increase adherence and compliance, format. The studies must include a comparison with a control group
participants receive monthly phone calls between home visits performing the original OEP or, alternatively, a non-intervention or a
(Campbell and Robertson, 2003; Sherrington et al., 2011; Stevens and different type of exercise group. The primary outcome was balance
Burns, 2015). The program is delivered for 12 months (Dadgari et al., measured by Berg Balance Scale (BBS), One-leg Stand Test (OLS),
2016; Robertson et al., 2002; Stevens and Burns, 2015), but recently Functional Reach Test (FRT), Step Test, Functional Gait Assessment
Shubert et al. (2017) described an innovative delivery model of (FGA), Timed Up and Go Test (TUG) and 30-seconds Sit-to-Stand.
6 months. However, other outcome measures were considered for secondary
Several studies, including systematic reviews with meta-analysis, analysis and discussion (compliance to exercise and program, self-re-
recognize the OEP as an effective exercise prevention strategy with ported falls, participant attitudes, exercise facilitators and difficulties).
benefits in physical functioning and falls reduction (Dadgari et al.,
2016; El-Khoury et al., 2013; Liu-Ambrose et al., 2008; Robertson et al., 2.2.2. Study selection
2002; Sherrington et al., 2017; Shier et al., 2016; Thomas et al., 2010), Studies were scanned for inclusion based on title. The abstracts were
even in elderly stroke patients (Park and Chang, 2016) and individual only reviewed if their title identified all elements of PICO. If an abstract
with age-related visual problems (Kovács et al., 2012). Other studies had insufficient information to allow its inclusion, full-text reading was
also recognize benefits, but the results are not conclusive (Binns and performed. Any disagreement was resolved by consensus.
Taylor, 2011; Son et al., 2016).
Since falls are multifactorial, in addition to exercise, programs to 2.2.3. Quality assessment of studies
prevent falls should address individual characteristics (National The quality of the RCTs was assessed through PEDro scale, con-
Institute for Care Excellence, 2013), such as health conditions, age, fear sisting of 11 items based on a Delphi list (Verhagen et al., 1998).
of falling, history of previous fall or self-efficacy for exercise (Picha and The 11 items included Eligibility criteria (1); Random allocation (2);
Howell, 2017). Moreover, they should be focused on the person needs, Concealed allocation (3); Baseline comparability (4); Blind subjects (5);
preferences and interests (Haas and Haines, 2014; Otaka et al., 2017; Blind therapists (6); Blind assessors (7); Adequate follow-up (8);
Shier et al., 2016). The increased need of tailored exercise programs Intention-to-treat analysis (9); Between-group comparisons (10); Point
resulted in the development of other exercise approaches, such as group estimates and variability (11). The item eligibility criteria do not con-
exercise, technological support or health education. The combination of tribute to total score, since it is related to external validity (Maher et al.,
OEP with new approaches resulted in modified formats, however there 2003).
are still few published studies (Benavent-Caballer et al., 2016). The
main goals of this study were to identify other OEP delivering methods 2.2.4. Studies analysis
(modified formats) and analyze their effects on balance, functional All the included studies were described in terms of study design,
ability and self-reported falls. sample size, length of follow-up, sample characteristics, intervention
components, outcomes related with balance and compliance to the
2. Methods program. PEDro scale was used to assess quality of RCTs.
It was not possible to perform a full meta-analysis because few
2.1. Study design studies were identified and there was methodological variability in the
definition of the outcome to measure balance/postural stability.
This systematic review was developed with reference to the Therefore, a simple qualitative analysis (narrative synthesis of the
“Preferred Reporting Items for Systematic Reviews and Meta-Analysis” data) was conducted for the included studies.
(PRISMA) (Moher et al., 2015) and Cochrane Collaboration guidelines
(Higgins and Green, 2011), for randomized trials. 3. Results
2.2.1. Identification of studies 1249 studies were identified through database and hand searching.
Literature search was performed by two authors, between January After duplicates removal, the search was reduced to 1209 studies of
and February 2017 and four databases (PubMed, PEDro, Science Direct potential interest for title/abstract examination. After a critical review
and Scopus) were searched. No limits related to language, publication of the fifteen full-text studies selected, eight met the inclusion criteria
date and length of follow-up were set. (Fig. 1).
Key search terms followed the PICO (participants, intervention, Concerning study design, five relevant and recent articles were
comparison, and outcome) elements strategy. Search term for popula- RCTs (Benavent-Caballer et al., 2016; Kyrdalen et al., 2014; Liston
tion was “older adults”, related terms were added as alternatives using et al., 2014; Yang et al., 2012; Yoo et al., 2013), two were quasi-ex-
“OR” (“Older adults” OR “elderly” OR “community-dwelling older perimental (Davis et al., 2016; Waters et al., 2011) and one was a
adults”). Regarding intervention search term was “modified Otago”. For qualitative study carried out from a subsample of another experimental
comparison search term was “Otago Exercise Program”. Finally, out- study (Agha et al., 2015).
come measures search terms were “Fall prevention” and “balance”. Table 1 summarizes the characteristics of the included studies,
Search terms linked with “AND” were “older adults” AND “Otago concerning study design, participants, intervention, comparison, out-
Exercise Program”; “older adults” AND “modified Otago”; “older comes, follow-up and adherence.
232
A.C. Martins et al. Preventive Medicine Reports 11 (2018) 231–239
3.2. Studies quality Caballer et al., 2016) to a rural community (individual use at home)
(Agha et al., 2015; Davis et al., 2016).
On the quality assessment with PEDro scale two RCTs obtained a The included studies involved a total of 604 community-dwelling
score of 5 (Liston et al., 2014; Yoo et al., 2013), one a score of 6 adults, both men and women, with a mean age of 76.75 years
(Kyrdalen et al., 2014) and two a score of 7 (Yang et al., 2012; (SD = 5.5), except for Yoo et al. (2013) women-only study.
Benavent-Caballer et al., 2016) (Table 2). According to these scores, All RCTs had one intervention group and one control group, except
low/moderate quality of the studies is related with withdrawals during Waters et al. (2011), quasi-experimental study, that included two ex-
follow-up (criterion 8 of the scale), concealed allocation and blind as- ercise intervention groups and one control group. Qualitative study
sessment not clearly exposed by the authors (criterion 3 and 6 of the from Agha et al. (2015) described an 6 months OEP-DVD intervention.
scale) and one study did not provide measures of variability for some
key outcomes (criterion 11 of the scale). All RCTs had similar groups at
3.3.2. Balance and functional ability
baseline, although the sample size and the length of follow-up varied
In general, the five RCTs and the two quasi-experimental studies
between studies. Sample size ranged from 21 (Liston et al., 2014; Yoo
reported improvements in balance and general mobility outcomes with
et al., 2013) to 165 (Yang et al., 2012) and the length of follow-up
OEP modified formats.
varied between 2 (Liston et al., 2014) and 6 months (Yang et al., 2012).
Benavent-Caballer et al. (2016) reported that a video-supported
In the quasi-experimental study conducted by Waters et al. (2011) the
group-based OEP may significantly improve levels of mobility, func-
follow-up was extended to 12 months.
tional balance, one-leg balance and lower extremity strength when
compared to a control group (CG) (no intervention). After 4 months, the
3.3. Studies results TUG scores significantly decreased in the intervention group (IG) [IG
7.5 (2.0) vs CG 8.8 (1.9), mean difference −1.3 s, 95% confidence in-
3.3.1. Modified formats of OEP terval (CI) of the difference −2.3 to −0.1; p = 0.03]. A significant
All the seven experimental studies tested different modified OEP improvement was also recorded in functional balance (BBS) [IG 54.9
formats. Those formats involved additional vestibular exercises (Yang (2.5) vs CG 51.4 (5.3), mean difference 3.5 points, 95% CI 1.2 to 5.8;
et al., 2012), augmented reality (Yoo et al., 2013), exercise in group p = 0,003], one leg balance (OLS) [IG 39.1 (21.6) vs CG 15.6 (12.1),
(classes) with physiotherapists (Kyrdalen et al., 2014), peer-led (Waters mean difference 23.5 s, 95%CI 13.3 to 33.7; p < 0.001] and lower
et al., 2011) or supplemented with multisensory balance exercises at extremity strength [IG 8.7 (3.8) vs CG 10.9 (3.3), mean difference
home (Liston et al., 2014). The program was also delivered in a DVD −2.2 s, 95%CI −4.2 to −0.1; p = 0.035] in the intervention group
format both to community centre (group classes) and (Benavent- compared to the control group.
233
Table 1
Studies characteristics.
Study Study design Participants Intervention Comparison Outcome measures Follow-up Dropouts
A.C. Martins et al.
Benavent- RCT N = 51; age ≥ 65 years; Community- IG: Otago Exercise Program (OEP) CG: no intervention Primary: TUG 4 months Dropout (IG): 15%
Caballer dwelling older people; ambulate delivered by DVD in a community Maintained daily routine Secondary: BBS (assessments at 0 after 1st month; 30%
et al. independently without walking aid; no centre. 6 MWT and 4 months) at the end of
(2016) contraindication for physical activity; 3 Initial sessions supervised by a OLS intervention (4th
able to communicate; and have self- physiotherapist, with weekly visits to SPPB month)
reported visual and auditory the community centre. Individuals
capacities to follow the exercises. followed exercise instructions.
Risk of falling assessment: age and Each session included warm-up,
functional ability. strength and balance exercises,
Intervention group (IG): walking and a cool-down period. It
N = 28; Women = 82% was suggested to incorporate walking
Age (years) = 69,1 (SD = 4) times during daily activities.
Control group (CG): Frequency: 3 times/week
N = 23; Women = 69% Duration: 45 min/session
Age (years) = 69 (SD = 3,3) Format: group exercise
Kyrdalen et al. RCT N = 125; mean age (years) = 82,5 IG: OEP protocol in classes – group CG: Original OEP at home Primary: T1 – baseline Dropout (IG):
(2014) (SD = 5,6); training (4–8 individuals in each class)Physiotherapist visits: weeks 1, 2, 4 TUG T2–12 weeks T2–24%
Risk of falling assessment: Older Supervised by physiotherapists; and 8. Secondary: T3–3 months after T3–35%
people referred to a Falls Outpatient Individualized load and progression. Visit duration: 1 h. BBS the end of Dropout (CG):
Clinic with high risk of falling (73% Frequency: 2 times/week Participants received a phone call 30 STS intervention T2–25%
had fallen; 36% had a fall-related Duration: 45 min/session once a month between home visits. 7 Item FES T3–32%
hospital stay; 58% lived alone) Format: group exercise Frequency: 3 times/week SF-36
Intervention group (IG): Duration: 30 min/session Number of falls (T2)
N = 62; Women = 69,4% Format: individual exercise
Age (years) = 82,9 (SD = 5) Both groups were encouraged to walk 3 or more times/week for 30 min and to
234
Concomitant diseases = 3 (SD = 1,3) continue the OEP after the end of intervention.
Prescribed medications = 5,5
(SD = 2,7)
Control group (CG):
N = 63; Women = 76,2%
Age (years) = 82,1 (SD = 6,4)
Concomitant diseases = 2,9
(SD = 1,6) Prescribed
medications = 6,2 (SD = 2,8)
Liston et al. RCT N = 21; age ≥ 65 years; community- IG: Modified OEP in group class CG: Modified OEP in group class Primary: 2 months Dropout (IG):
(2014) dwelling older people with ≥2 falls supplemented with supervised home- supplemented with supervised FGA Telephone follow- 2 months – 30%
during previous 12 months; no based multisensory balance exercises home-based stretching exercises (4/ Secondary: up at 6 months Dropout (CG):
vestibular dysfunction. (4/5 exercises) 5 exercises) Number of falls at 6 months 2 months – 27,3%
Risk of falling assessment: age and fall Modified OEP in group class included warm-up, strength and balance
history in the previous 12 months exercises based on the original OEP.
Intervention group (IG): Assessments at baseline, 4 and 8 weeks.
N = 10; Women = 80% Delivery of a worksheet with diagrams and written explanations of exercises
Age (years) = 77,8 (69–87) (depending on group) to be independently practiced twice a day (with
Control group (CG): exception of the days with supervised home sessions)
N = 11; Women = 82% Frequency: 2 times/week (group exercise class + supervised home sessions)
Age (years) = 76,7 (69–86) Duration: 1 h exercise class + 45 min supervised home exercise
Format: group exercise + individual exercise at home
Yoo et al. RCT N = 21; community-dwelling older IG: augmented reality-based Otago CG: OEP at home Primary: 3 months No dropouts
(2013) women with sufficient cognitive exercise BBS
ability to participate; without Subjects stood in front of a computer Secondary:
disabilities in visual, auditory with a web camera, which had an Gait Function (GAITRite system)
sensation and vestibular organs, or SVGA resolution head-mounted FES-I
fractures in the past year. display and followed the movement
Risk of falling assessment: age and displayed. The computer sensed the
(continued on next page)
Preventive Medicine Reports 11 (2018) 231–239
Table 1 (continued)
Study Study design Participants Intervention Comparison Outcome measures Follow-up Dropouts
235
Format: individual exercise
Individuals were encouraged to
perform exercises 5 times per
week
6 months Dropout at
6 months:
IG – 28%
CG – 25,3%
Davis et al. Pre-post N = 82; age ≥ 75 years; community- IG: Otago Exercise Program delivered CG: no intervention Primary: 6 months Dropout (IG):
(2016) intervention (non- dwelling older people able to walk by an interactive DVD (OEP-DVD) in a Individuals from an urban Feasibility (withdrawal rate) 6 months – 28%
randomization) 100 m independently (with or without rural community. community completed monthly falls SPPB
assistive device); MMSE score > 24 One home visit by a physiotherapist at calendars. PPA
Risk of falling assessment: age and the beginning. Monthly phone calls to After 6 months, all individuals in ABC
functional ability discuss progress, concerns and answer the control group were also given
Intervention group (IG): questions. Each phone session was the OEP-DVD and one home visit by
N = 61; Women = 65,6% scheduled for 15 min. a physiotherapist
Mean age (years) = 79,5 (SD = 4,8) Frequency: 3 times/week
Control group (CG): Duration: 30 min/session
N = 21; Women = 76,2% Format: Individual exercise
Mean age (years) = 79,9 (SD = 5)
Agha et al. Qualitative N = 21; aged from 74 to 97 years; Group and individual interviews in – Understanding of participants' – –
(2015) rural community-dwelling older subjects who participated in a experience with the OEP-DVD
people 6 months OEP-DVD intervention.
Risk of falling assessment: age and For individual interview participants
functional ability could choose between face to face or
Mean age (years) = 81,48; telephone interview
Women = 78,9%
Group interview – N = 5
Individual interview – N = 16
(continued on next page)
Preventive Medicine Reports 11 (2018) 231–239
A.C. Martins et al. Preventive Medicine Reports 11 (2018) 231–239
Table 2
Study quality on PEDro scale.
FGA – Functional Gait Assessment; FRT – Functional Reach Test; SPPB – Short Performance Physical Battery; PPA – Physiological Profile Assessment; ABC – Activities-Specific Balance Confidence Scale.
1 Benavent-Caballer et al. x x x x x x x x 7/10
(2016)
23%
T3–6 months
T2–10 weeks
intervention
Follow-up
SLS
ST
lated hospital stay during the previous year. According to the results,
the modified OEP was more effective improving functional balance,
muscle strength and physical health. After 12 weeks of intervention
(T2), BBS (mean difference 3.2 points, 95%CI = 0.7–5.8, p = 0.014)
Comparison
exercises)
Three months after the end of the intervention (T3) the intervention
adapted from OEP delivered in a
by a professional instructor)
Duration: 60 min/session
abductor strength and gait step (p < 0.001). Yoo et al. (2013) analysed
the effect of augmented reality-based OEP on balance, gait, and falls
N = 52; Women = 83%
p < 0.01; cadence, p < 0.001) and falls efficacy (p < 0.05).
Group 1:
Group 2:
Group 3:
fall risk.
leaders (Group 1), paid professional (Age Concern Otago group - Group
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A.C. Martins et al. Preventive Medicine Reports 11 (2018) 231–239
2), and a comparison group (CG with standardized seated exercises - DVD + walking). During a 12-weeks intervention, other researchers
Group 3). Functional measures (TUG, 30 STS, OLS, FRT, Step Test) (Kyrdalen et al., 2014) noticed that the mean number of exercise ses-
significantly improved, after 10 weeks of intervention and at 1-year sions attended by the IG (OEP in group) was 21.9 (SD = 2.7) (total of
follow-up, in both intervention groups, when compared to control 24 sessions) and by the CG (OEP at home) was 32.8 (SD = 2.8) (total of
group (p = 0.02). 36 recommended sessions).
Agha et al. (2015), in a qualitative study, aimed to understand older
adults' experiences using DVD-delivered OEP and to explore barriers 3.3.5. Exercise maintenance after intervention
and facilitators to implementing this modified OEP from the partici- Concerning exercise maintenance, two studies analysed compliance
pants' perspective. Thirty-two older adults met the eligibility criteria, 5 to exercise after intervention (Kyrdalen et al., 2014; Waters et al.,
participated in group interviews and 16 in individual interviews. Most 2011). One trial investigated compliance to exercise between the end of
participants found the DVD-delivered OEP a useful training tool and intervention (T2) and three months later (T3) (Kyrdalen et al., 2014). It
appreciated the flexibility of the program. They considered it positively was found that 19 individuals in IG (n = 40) and 14 in CG (n = 43)
impacted their physical and mental health by improving their balance continued to perform the home exercise program at least twice a week.
and lower body strength, and consequently reduced their fear of falling. In other study, at 6 months' post-intervention 84,7% of the participants
Although they mentioned possible barriers for engaging certain do- reported to perform the once-weekly strength and balance exercise
mestic activities and exercise, such as living with chronic health con- classes and at 12-months this percentage decreased slightly to 79,1%
ditions and living very busy lives, most participants intended to con- (Waters et al., 2011). Exercise maintenance after intervention was
tinue the OEP. In a social context, some participants described lack of higher in the intervention groups (OEP exercise classes) when com-
social contact and that the program as becoming boring and repetitive pared to control group.
as they became familiar with exercises. Some suggested adding a group
exercise option to the home-based program, however others preferred 4. Discussion
to exercise alone and with minimal instructions. All participants con-
sidered the guidance and motivation given by the physiotherapist This review primarily aimed to identify modified formats of deli-
beneficial. vering OEP and study their effects on balance and fall prevention.
Recent systematic reviews and meta-analysis have investigated the ef-
3.3.3. Self-reported falls fects of different exercise programs (including OEP) to prevent falls, but
Four studies assessed fall history in the previous 12 months and the not OEP modified formats (Gillespie et al., 2012; Sherrington et al.,
number of falls occurred during intervention programs and/or at the 2008, 2011, 2017; Shier et al., 2016; Thomas et al., 2010).
end of follow-up. These data were mainly used as descriptive in- Nevertheless, the few studies and the methodological differences, all
formation or a secondary outcome. OEP modified formats showed improvements on balance and other
In Yang et al. (2012) trial, 20% of the participants in the IG (12 out physical functioning related outcomes. They all provide insights on how
of 59) and 29% in the CG (18 out of 62) fell during the 6-months in- other components and/or strategies added to the original OEP may act
tervention period. In addition, the IG registered less multiple fallers (2 in falls occurrence.
out of 59) than the CG (8 out of 62). Despite these differences the re- Some studies had no intervention in the control group which did not
sults were not statistically significant. allow the comparison between modified and original OEP interven-
Kyrdalen et al. (2014), reported falls occurrence during the 3- tions. Besides, it is expected physical benefits with exercise interven-
months intervention, 31% for the IG (group training) and 27% for the tions when compared with no intervention.
CG (home training). After 3-months follow-up, 29% from the group Despite the constraints mentioned, the results suggest that modified
training and 22% from the home training reported a fall. OEP can be beneficial for physical functioning improvement (especially
Liston et al. (2014) reported that 3 individuals fell in both IG on balance outcomes) if delivered by video/DVD (individual at home or
(multisensory rehabilitation group) and CG (stretching exercise group), in group), as exercise group classes, as OEP with supplementary mul-
during the 2-months intervention period. Six months after intervention, tisensory balance exercises and as augmented reality-based Otago.
one individual in the IG reported two falls and two individuals in the When applied in different contexts, modified OEP also showed a good
CG reported two and three falls, respectively. acceptance, met the participants' expectations and improved social
After a 12-month period, Waters et al. (2011) recorded a total of participation (group interventions).
123 reported falls in their study, 84 did not result in injuries, with no There are benefits in the use of OEP modified formats. For instance,
significant differences between the two interventional groups and the direct visual feedback can be provided with an augmented reality-based
control group. Nevertheless, the results showed a tendency for a 27% OEP environment (Yoo et al., 2013). Other authors suggest that exercise
decrease in falls in the peer-led group (Group 1) and no tendency for programs can be delivered in group or individually home-based con-
decrease in the Age Concern Otago group (Group 2), compared to sidering individual preferences (Sherrington et al., 2011; Shier et al.,
control group. 2016). This review found that both home-based and group-based OEP
can be successfully implemented, even if supported by DVD/Video. The
3.3.4. Compliance to program and exercise during intervention importance of OEP in group is recognized, since exercising in class can
With the exception of Yoo et al. (2013), which did not register any bring additional psychological and social benefits to a falls prevention
dropout, withdrawal rate ranged between 23% (Waters et al., 2011) program. For some authors, OEP in group is consistent with best-
and 30% (Benavent-Caballer et al., 2016; Liston et al., 2014) (Table 1). practice in public health, because it is more effective for empowering
Compliance to exercise was not assessed in all studies. In one study people to promote their health, decrease costs and achieve long-
(OEP-DVD in group) (Benavent-Caballer et al., 2016) the intervention standing exercise adherence compared with an individual approach
group attended 77% of the planned sessions. Yang et al. (2012) verified (Waters et al., 2011). Agha et al. (2015) reinforced that implementing
that, of the 59 individuals who completed the intervention, 44,1% OEP in group allows reaching to older people living in outlying geo-
performed the exercise program 5 or more times per week, 39% ex- graphical areas, and may be useful for participants to perform OEP with
ercised 3 or 4 times, and 13,6% exercised less than twice a week. Davis family members or peers.
et al. (2016) observed that of the 44 individuals who completed the Additional home-based exercises supplementing OEP group sessions
intervention, 16 demonstrated 100% compliance performing the OEP- are a strategy that can be effective (Liston et al., 2014). Multisensory
DVD exercises at least twice a week, 33 demonstrated 100% walking balance exercises in combination with OEP were used to add some
compliance and 30 showed 100% overall compliance (OEP- components that are not considered in OEP exercises and may be
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A.C. Martins et al. Preventive Medicine Reports 11 (2018) 231–239
implicated in the cause of falls (e.g. anticipatory postural adjustments). Authors' contributions
Multisensory balance exercises combined with OEP (32 h/8 weeks) had
positive effects on balance and fall risk. According to the current evi- ACM, CS and DB contributed to the design of this systematic review;
dence (Sherrington et al., 2017), exercises that challenge balance, and CS and DB contributed to literature searching, eligible study identifi-
use a higher total dose of exercise (3 h/week minimum) are re- cation, data extraction, data analysis and manuscript drafting; CS, DB,
commended to improve the effectiveness of falls prevention programs. CatS, JM and NT contributed to the manuscript editing and ACM, CatS
This study showed that, even within the OEP modified formats, and JM reviewed the final version.
compliance to exercise is a concern, with the number of dropouts
reaching 30%. After 2 months of intervention, improvements were References
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