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The Effectiveness of E-Interventions on Fall, Neuromuscular

Functions and Quality of Life in Community-Dwelling Older Adults: A
Systematic Review and Meta-Analysis

Janice Kuang Yeung CHAN , Piyanee YOBAS , Yuchen CHI ,

Javeil Ke En GAN , Gigi CHOW , Xi Vivien WU

PII: S0020-7489(20)30270-4
DOI: https://doi.org/10.1016/j.ijnurstu.2020.103784
Reference: NS 103784

To appear in: International Journal of Nursing Studies

Received date: 28 May 2020

Revised date: 20 August 2020
Accepted date: 27 September 2020

Please cite this article as: Janice Kuang Yeung CHAN , Piyanee YOBAS , Yuchen CHI ,
Javeil Ke En GAN , Gigi CHOW , Xi Vivien WU , The Effectiveness of E-Interventions on
Fall, Neuromuscular Functions and Quality of Life in Community-Dwelling Older Adults: A
Systematic Review and Meta-Analysis, International Journal of Nursing Studies (2020), doi:
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The Effectiveness of E-Interventions on Fall, Neuromuscular Functions and
Quality of Life in Community-Dwelling Older Adults: A Systematic Review and
Meta-Analysis

Author names:
Janice Kuang Yeung CHANb
Piyanee YOBASa
Yuchen CHIa
Javeil Ke En GANa
Gigi CHOW a
Xi Vivien WUa*

Affiliations:
a
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National
University of Singapore, Level 2, Clinical Research Centre, Block MD 11,10 Medical
Drive, Singapore 117597
b
Changi General Hospital, 2 Simei Street, 3 Singapore 529889

e0036498@u.nus.edu (Janice Kuang Yeung CHAN)

nurpk@nus.edu.sg (Piyanee YOBAS)
nurcy@nus.edu.sg (Yuchen CHI)
javeil.gan@u.nus.edu (Javeil Ke En GAN)
gigi.chow@u.nus.edu (Gigi CHOW)
nurwux@nus.edu.sg (Xi Vivien WU)

Corresponding author:

*Xi Vivien WU, nurwux@nus.edu.sg, Alice Lee Centre for Nursing Studies, Yong Loo
Lin School of Medicine, National University of Singapore, Level 2, Clinical Research
Centre, Block MD 11,10 Medical Drive, Singapore 117597

1
ABSTRACT

Background: Falls in older adults result in serious, life-limiting consequences. An increasing

number of fall prevention interventions have used technology to reduce the number of falls in

community-dwelling adults. Various types of e-interventions are being tested in clinical trials

and in the community. These include telehealth, exergames, cognitive games, socialized

training, smart home systems and non-conventional balance training. Currently, no systematic

review and meta-analysis has assessed the overall effectiveness of e-interventions and

compared the effectiveness of the different types.

Objectives: The aim of this review was to synthesize best available evidence concerning the

effectiveness of e-interventions on fall, neuromuscular functions and quality of life in community-

dwelling older adults.

Methods: A rigorous three-step search was conducted in nine online databases for published

and unpublished randomized controlled trials studying e-interventions. Studies were screened

and assessed for individual and overall risk of bias by two independent reviewers. Six fall-

related outcomes were evaluated in the meta-analysis: fall risk, balance, lower extremity

strength, fall efficacy, cognitive function and health-related quality of life. Subgroup and

sensitivity analysis were conducted during meta-analysis.

Results: Thirty-one studies fit the eligibility criteria and had an overall 74.7% low risk of bias. A

total of 4,877 older adults from 17 countries were included in narrative synthesis and meta-

analysis. Telehealth combined with exercise programmes and smart home systems were able to

reduce fall risk significantly (risk ratio=0.79, 95% CI [0.72, 0.86]). E-interventions also

2
significantly improved balance and fall efficacy (standardized mean difference=0.28, 95% CI

[0.04, 0.53]). However, lower extremity strength, cognitive function and health-related quality

of life did not show significant improvements.

Conclusion: Telehealth combined with exercise and smart home systems demonstrated the

best evidence of effectiveness in reduction of falls in community-dwelling older adults. Future

research should focus on forecasting falls using smart home technology and Artificial

Intelligence, and testing promising e-interventions on larger samples to improve the strength of

evidence of fall prevention by e-interventions.

Keywords:

Older adults, community-dwelling, fall, cognition, quality of life, technology, telehealth,

exergames, cognitive training, non-conventional balance training, smart home systems,

socialized exercise

3
What is known about the topic

 Preventing falls in older adults is important to ensure that they can live in a fulfilling and

meaningful manner with high quality of life.

 Both traditional and electronic interventions have shown effectiveness on fall

prevention.

 Currently, there is no systematic review and meta-analysis evaluated the overall effect

of different e-interventions for fall prevention.

What this paper adds

 This review filled in a gap in existing literature by assessing the effectiveness of various

types of e-interventions for the prevention of falls in community-dwelling older adults.

 E-interventions significantly reduce fall incidence, improve balance, fall efficacy.

However, e-interventions were not able to significantly improve lower extremity

strength, cognitive function or health-related quality of life.

 Telehealth and exercise, and smart home systems showed the best evidence of

effectiveness and could be considered by healthcare professionals and policymakers

seeking to implement e-interventions for the older adults in the community.

4
 1. Introduction

World Health Organization (WHO, 2007) defines a fall as an event in which a person

unintentionally comes to rest on the ground or floor or lower level. WHO estimated that

646,000 people died from falls worldwide and the older adults were the group that suffer the

greatest number of falls (WHO, 2018). Furthermore, more than 37 million individuals suffered

from medications relating to falls each year. Injurious falls may result in serious and

permanently disabling consequences, such as hip fractures and traumatic brain injuries, which

decrease subsequent quality of life and even cause death (WHO, 2007). Beside the immediate

physical consequences to the faller, financial, emotional and social repercussions of falls

reverberate through multiple levels of society, including their families. Treatments of falls take

a toll on manpower and resources in acute and primary healthcare sectors such as emergency

departments, step-down care, rehabilitation facilities, and nursing homes (WHO, n.d.; Stevens,

Corso & Finkelstein, 2006). With worldwide ageing populations growing and people living

longer, it is essential for older adults to live independently and healthily within community.

Hence, preventing falls is one of the key factors to ensure they can maintain a high quality of

life at older age.

Traditional interventions of fall prevention have focused on exercise and multifactorial

fall prevention programmes. Exercise programmes such as Tai Chi, yoga and resistance training

aim to increase muscle strength and balance, which reduce falls. These exercise programmes

show low to medium protective effects and significantly improve functional performance

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(Lomas-Vega, Obrero-Gaitán, Molina-Ortega & Del-Pino-Casado, 2017; Youkhana, Dean, Wolff,

Sherrington & Tiedemann, 2016; Papa, Dong & Hassan, 2017). Multifactorial programmes

include medication reviews, home modification, vision correction, vitamin supplementation,

and education in different combinations (Tricco et al., 2017; Gillespie et al., 2012), to reduce

risk of falls by limiting the use of drugs that affect alertness, removing fall hazards, and

eliminating poor vision. Additionally, the interventions also aim to optimize the physical

function and knowledge of older adults to improve their safety. Medium protective effects

(RR=0.63 to 0.78) were found for various combinations of interventions (Gillespie et al., 2012).

Falls are multifactorial and e-intervention may be an appropriate approach to target

these factors. With the rapid development of digital health solutions, there are various

electronic interventions (e-interventions) were developed to enhance fall prevention. E-

interventions are fall prevention interventions that entail Internet of Things (IoT) such as

computers, mobile phones or tablets. E-interventions are broadly classified into 6 categories:

Telehealth, Gamified Exercise (exergames), Cognitive Training, Non-Conventional Balance

Training, Smart Home Systems and Socialized Exercise. Telehealth involves communicating with

patients at home via telephone or video calls (Light et al., 2016; Hong, Kong & Yoon, 2018). The

combination of telehealth and exercise (T&E) is a common fall prevention prescription. T&E

allows healthcare providers to assess patients at home and provide feedback and

encouragement, thereby improving performance and increasing adherence to home exercise.

Therefore, T&E may improve fitness and reduce falls.

Exergames are gamified forms of exercise, typically utilizing motion-sensing technology

to detect players’ movements. Some examples are treadmill training with virtual reality

6
(Mirelman et al., 2016), dance games (Schoene et al., 2013) or Bingo (Crandall & Shake, 2016).

Exergames simultaneously engage cognitive-motor areas of the brain, addressing both physical

and cognitive aspects of balance. Exergames have the potential to be more effective in fall

prevention due to the complex interplay of executive, attentional and motor factors in

balancing (van het Reve, Silveira, Daniel, Casati & de Bruin, 2014). The gamification of exercise

increases adherence due to their fun and engaging nature.

In contrast to exergaming, cognitive training usually takes the form of sit-down games

on computers. It improves executive function (Gajewski, Freude & Falkenstein, 2017). Game

difficulty can be adjusted to keep players engaged and challenged throughout the training

period (Smith-Ray, Makowski-Woiden & Hughes, 2014). Cognitive training is often combined

with non-gamified exercise programmes in order to maximize benefits brought about cognitive-

motor training (van het Reve & de Bruin, 2014). Computerized cognitive training is

advantageous as it can be used at home with minimal supervision and reduces falls (Blackwood,

Shubert, Fogarty & Chase, 2016).

Non-conventional balance training (NCBT) targets neurosensory deficits of old age.

NCBT retrains balance control by providing additional feedback to a user to correct posture.

Body-worn sensors detect body positions and provide visual, auditory or tactile cues to the user

when the body is in a precarious position (Bao et al., 2018; Hagedorn & Holm, 2010). The user

then readjusts the body position accordingly. NCBT’s advantage is its ability to quantitatively

detect and retrain poor posture. NCBT increases users’ awareness and attention to posture and

trains them to autocorrect risky posture, thereby increasing balance control and decreasing

falls (Lajoie, 2004).

7
 Smart home systems aim to decrease environmental hazards and forecast potentially

impending falls using sensors and Artificial Intelligence (AI) technology. Passive in-house

sensors and vision-based sensors can help with identifying and eliminating potential risk factors.

Meanwhile, wearable sensors can help with detection and prediction of fall (Forbes, Massie &

Craw, 2019). Key fall prevention technologies include a nightlight path and a remote intercom

coupled with an electronic bracelet (Tchalla et al., 2013; Tchalla et al., 2012). The nightlight

path automatically switches on when movement is detected at night. This increases night time

visibility and guides elderly to light switches and toilets. This aids in negotiation around

obstacles in low light, reducing the risk of falls. If a fall occurs, activating the electronic bracelet

triggers the remote intercom, which calls a central hotline with round-the-clock telephone

support. Elderly can seek help if they have sustained injurious falls. These technologies increase

safety and provide timely support otherwise less accessible (Tchalla et al., 2013; Tchalla et al.,

2012).

Socialized exercise are exercise programmes conducted via tablet computer applications.

Exercise programmes in virtual gyms are tailored to individuals’ abilities and needs and to

increase in difficulty as the participant becomes fitter. Applications such as tablet-based

strength balance training send participants motivational messages and allow participants to

contact a physical trainer for consultations (van het Reve et al., 2014). Participants can see

others who are concurrently online and exercise together, introducing a social component.

Socialization is a motivating factor in physical training and encourages adherence (de Groot &

Fagerström, 2011). A systematic review has evidenced that information communication

technology is an effective tool to tackle social isolation among the older adults through

8
connecting to outside world, gaining social support, engaging in activities of interests, and

boosting self-confidence (Chen & Schulz, 2016). The use of virtual applications motivate older

adults to socialise more with others, and decrease the chances of social isolation (Chen & Schulz,

2016). The threefold benefits of tailored exercise, motivational support and socialization makes

this a promising technology.

A search of existing reviews on fall prevention intervention was conducted. The result

showed that majority of the existing reviews focused on various exercise programmes to

improve strength, balance and functional mobility by monitoring gait parameters and falls

(Cadore et al., 2013; Tricco et al., 2017). Novel forms of training to reduce falls included square

stepping, backward walking training and whole-body vibration. None of the reviews focused on

telehealth or non-conventional balance training methods as feasible e-interventions. Although

there were two reviews on exergaming (Choi et al., 2017; Ogawa et al., 2016) and two on

cognitive interventions (Lipardo et al., 2017; Schoene et al., 2014), they did not include meta-

analysis due to high heterogeneity. To the knowledge of the authors, no review has evaluated

the overall effect of different e-interventions. Due to the growing importance of fall prevention

and the gaps in the existing literature, this systematic review aimed to synthesize new

information to add to the current body of knowledge regarding the effectiveness of e-

interventions on fall, neuromuscular functions and quality of life in community-dwelling older

adults. The primary outcomes of this review are proportion of fallers and balance. The

secondary outcomes are lower extremity strength, fall efficacy, cognitive function, and quality

of life.

9
 2. Method

This systematic review followed the Preferred Reporting Items for Systematic Review

and Meta-analyses (PRISMA) (Moher, Liberati, Tetzlaff, Altman & PRISMA Group, 2009). To

prevent duplication of reviews, a search for previous and ongoing systematic reviews (SRs)

similar to this study was conducted. This SR has been registered with PROSPERO.

2.1 Search strategy

Three-step searching for relevant randomised controlled trials (RCTs) as recommended

by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins et al., 2019) was

conducted. First, nine online databases were searched for published work, namely: Cochrane,

PubMed, EMBASE, CINAHL, PsycINFO, Scopus, Ovid MEDLINE, ScienceDirect and Web of

Science. Then, searching was also done in clinical trial registries for ongoing and unpublished

trials. There were results from Cochrane Controlled Register of Trials, WHO International

Clinical Trials Registry Platform, ClinicalTrials.gov, ISRCTN and Australian New Zealand Clinical

Trials Registry. Authors of ongoing trials found to be relevant by the abstract were contacted

for further details. Grey literature such as unpublished thesis and conference proceedings were

searched in Google Scholar, Scopus and ProQuest. Later, a hand search of relevant RCTs and

SRs from reference lists of studies and SRs was conducted, producing 4 relevant results.

Keywords including older adults, community-dwelling, telehealth and falls were used in

the search. Subject headings or MeSH terms were identified for each database. MeSH terms,

10
subject headings and keywords were combined for a comprehensive search of catalogued and

recent studies. Boolean operators ‘AND’ were used to combine terms, ‘OR’ to broaden terms

and ‘NOT’ to narrow terms. Proximity operators of up to 6 words were used. Verified filters

giving the best optimization of sensitivity and specificity were used to narrow the search to

RCTs only (Grewal, Kataria & Dhawan, 2016). The detailed search algorithm for all the

databases are presented in the Supplementary Table 1.

2.2 Eligibility criteria

The PICO (populations, interventions, comparator interventions and outcomes)

framework (Liberati et al., 2009) guided the selection of eligibility criteria. The target population

were older adults 50 years old and above, who experience normative aging, live independently

in communities or assisted living facilities. The definition of older adults varies across countries

due to the differences in life expectancy. WHO has accepted age 50 as a “realistic working

definition” for Africa, focusing on livelihood transitions and physical decline as an indicator of

ageing over chronological age alone (WHO, 2002). Therefore, a broader definition of older

adults is beneficial to interventions targeting fall prevention, since those who fall at a younger

age are more likely to fall again in the future (WHO, 2007). Those living in nursing homes or

long-term care facilities were excluded. Studies recruiting only older adults with Parkinson’s

disease were excluded as the review focus on older adults who experience normative aging.

Interventions included exergaming, exercise with virtual reality or interactive components,

education through mobile applications, posture and gait training with visual computer feedback,

home-based technology designed to reduce and detect falls, tele-rehabilitation, telehealth

11
coaching and counselling, computerized cognitive-behavioural training, activity-tracking fitness

devices and computerized balance training. Comparator interventions included standard

physiotherapy or exercise (with no gaming, virtual reality or interactive component), education

without the use of mobile applications (such as face-to-face counselling or educational leaflets),

standard care or no intervention. Studies required at least one of the following outcomes:

proportion of falls, fall efficacy, balance, lower extremity strength, cognitive function and

quality of life.

2.3 Selection process

In this review, the PRISMA flow diagram guided the selection process of studies (Liberati

et al., 2009). EndNote version X9.2 (Clarivate Analytics, 2018) data management software was

used in this review to manage the process of elimination of studies, e.g. remove the duplicated

studies which were searched from various databases. Two independent reviewers (JKYC and

JKEG) carried out the selection process. The identification step consisted of databases searching

and hand searches for studies. In the screening step, duplicates were identified and manually

removed. Titles and abstracts of studies not matching the review’s problem and intervention

were excluded. Next, full texts were downloaded. Studies with unsuitable population, controls

or comparators and outcomes were excluded. Finally, included studies were assessed on their

suitability for meta-analysis. Studies unsuitable for meta-analyses were retained for narrative

synthesis. The number of studies included and excluded at each step and the reasons for

exclusion are listed in the PRISMA diagram.

2.4 Quality assessment

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 Each RCT included in this study was assessed individually by two independent reviewers

(JKYC and JKEG) for risk of bias using the tool developed by the Cochrane Collaboration (Higgins

et al., 2011). A third reviewer (VXW) was consulted if there’s any disagreement between the

two reviewers. Consensus was achieved after the team discussion. The six domains were

assessed: random sequence generation (selection bias), allocation concealment (selection bias),

blinding of participants and personnel (performance bias), blinding of outcome assessment

(detection bias), incomplete outcome data (attrition bias), and selective outcome reporting

(reporting bias) (Higgins et al., 2011). Each domain was rated as ‘High’, ‘Low’ or ‘Unclear’, with

reasons to support each judgement and the evidence. The Cochrane Collaboration’s Review

Manager (RevMan) version 5.3 software (Review Manager, 2014) was used to organize the

assessment of individual risk and produce a summary table.

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE)

approach was used to summarize the quality of evidence of the studies analysed and strength

of recommendations (Schünemann et al., 2013). GRADEpro GDT software was used (Evidence

Prime, 2015). Each outcome was rated individually based on its strength in five domains and

importance. Importance was rated on a scale of 1 to 9, 1 being not important and 9 being

critical. The quality of each domain was ranked on a 4-point scale of ‘High’, ‘Moderate’, ‘Low’

and ‘Very low’. Recommendations based on the results were then generated accordingly

(Schünemann et al., 2013). Two authors independently rated individual risk of bias and GRADE

quality and compared the results. In the case of disagreements, they discussed with the third

author until 100% agreement was reached. Cohen’s Kappa (K) was calculated to determine the

13
degree of inter-rater agreement, where: Excellent: >0.75, Good: 0.60-0.74, Fair: 0.40-0.59, Poor:

<0.4 (Vevea, Zelinsky & Orwin, 2019).

2.5 Data extraction

A data collection form with specific and detailed items to fulfil review goals was

developed specifically for this study. The form extracted four categories of information: (1)

Basic information and publication details, (2) Sample characteristics, (3) Intervention

characteristics and (4) Outcome measurements. Full data extraction was carried out after

confirming the tool. Quantitative data extracted was entered into RevMan (Version 5.3).

2.6 Data synthesis

Review manager software (RevMan) was used for quantitative data synthesis. RevMan

is suitable for meta-analysis and graphical presentation of data to study effects of healthcare

interventions for reviews (The Cochrane Collaborative, 2014). Heterogeneity across the studies

was assessed with Chi-square and I2 statistics, and indicates poor consistency and overlap of

confidence intervals (CIs), and that the studies have low similarity. I2 considers both effect size,

magnitude and heterogeneity and is expressed as a percentage (Higgins et al., 2019). When

high heterogeneity was found, sensitivity and subgroup analysis were conducted. In sensitivity

analysis, different combinations of the studies were tested further. Studies were removed one

by one from the pool of the studies to compare the heterogeneity level before and after.

Studies increased heterogeneity and have poor similarity to other studies were excluded from

meta-analysis but would be reported narratively. Possible reasons for heterogeneity were

14
studied. Based on Cochrane’s guide on the Thresholds for the interpretation of I2, 0% to 40% -

might not be important; 30% to 60% - may represent moderate heterogeneity; 50% to 90% -

may represent substantial heterogeneity; 75% to 100% - may represent considerable

heterogeneity (Higgins et al., 2019). In subgroup analysis, studies with varying designs or factors

were identified. Heterogeneity was improved by extracting these studies into different groups

and conducting meta-analysis separately (Kim & Mallory, 2016).

3. Result

3.1 Study selection

A total of 1,702 records were gathered from various databases and four from hand

searching. After removing duplicates, 1,311 records remained. Screening by two independent

authors resulted in 1,017 records removed for not having key words in the title and another

175 records removed for not meeting the inclusion criteria after reading abstracts. Finally, 119

records with corresponding full texts were screened according to the eligibility criteria. Reasons

for exclusion are listed in full in the PRISMA diagram (Figure 1). Four authors with completed

but unpublished trials were contacted for preliminary data. Three authors responded but their

results were not available. Thirty-one articles met the eligibility criteria. Out of the 31 studies,

26 studies were included in the meta-analysis and 5 studies were used for narrative review.

(Insert Figure 1 here)

15
 3.2 Characteristics of included studies

This review included 31 studies and consisted of 4,877 older adults aged 50 and above.

Sample sizes ranged from 12 to 523 participants with a total of 4,613 across studies. The

average age of participants was 77.7 years (SD=8.4). Most studies delivered telehealth (n=14,

45.1%) (Barker et al., 2019; Bernocchi et al., 2019; Chang et al., 2011; Bjerk et al., 2019;

Clemson et al., 2012; Di Monaco et al., 2015; Haines et al., 2009; Hong etal., 2018; Light et al.,

2016; Imhof et al., 2012; Kolt et al., 2012; Kruse et al., 2010; Oliveira et al., 2019; Voukelatos et

al., 2015), followed by exergames (n=9, 29%) (Crandall & Shake, 2019; Eggenberger et al., 2015;

Gschwind et al., 2015; Padala et al., 2017; Mirelman et al., 2016; Schoene et al., 2013; Shake et

al., 2018; Szturm et al., 2011; Whyatt et al., 2015), cognitive games (n=3, 9.7%) (Barban et al.,

2017; Smith-Ray et al., 2014; van het Reve & de Bruin, 2014), NCBT (n=2, 6.5%) (Bao et al., 2018;

Hagedorn & Holm, 2010), smart home systems (n=2, 6.5%) (Tchalla et al., 2012; Tchalla et al.,

2013) and socialized training (n=1, 3.2%) (van het Reve et al., 2014).

The studies were conducted across 17 different countries: United States (n=8), Australia

(n=7), Italy (n=4), Switzerland (n=4), France (n=2), Germany (n=2), South Korea (n=2), Spain

(n=2), United Kingdom (n=2), Belgium (n=1), Canada (n=1), Greece (n=1), Israel (n=1),

Netherlands (n=1), New Zealand (n=1), Norway (n=1), and Serbia (n=1). Some studies were

conducted in multiple countries. Gschwind et al. (2015) conducted trials in three countries

(Australia, Germany and Spain), Barban et al. (2017) in four countries (Greece, Italy, Serbia and

Spain), and Mirelman et al. (2016) in five countries (Belgium, Israel, Italy, Netherlands and UK).

Characteristics of all studies included mean age, sample size, country of origin, intervention

type and outcome variables are summarized in Supplementary Table 2. In order to examine if e-

16
interventions are effective, careful consideration of the outcome assessment measures is

necessary.

3.3 Risk of Bias

Thirty one studies were assessed for the risk of bias. Risk of bias was graded low 74.7%

overall. Eleven studies had one component with high risk of bias (35.5%) (Supplementary Figure

1). The overall risk of bias inter-rater reliability (IRR) was excellent (K=0.776) (Vevea et al., 2019).

Twenty-four studies (77.4%) were rated as having low risk of bias for random sequence

generation. Eighteen studies (58.1%) were rated as having low risk of bias for allocation

concealment. Two studies (6.5%) were rated as high risk of bias as couples living in the same

household were allocated to the same study group. Thirty studies (96.7%) were rated as having

low risk of bias for blinding of participants. These studies also mentioned precautions taken to

retain blinding, such as keeping study groups separated. Twenty-eight (90.3%) were rated as

having low risk of bias for blinding outcome assessment. Most used blinded research assistants

to measure the outcomes. Twenty-four studies (77.4%) were rated as having low risk of bias for

incomplete outcome data. These studies had either no attrition, less than 10% attrition with or

without intention-to-treat analysis (ITT) or less than 20% attrition with ITT. Fifteen studies

(48.4%) were rated as having low risk of bias for selective reporting. These studies reported

outcomes in full or partially with other measures published elsewhere. Another fifteen studies

(48.4%) were rated as unclear as protocols or clinical trial registrations could not be identified

for cross-checking.

3.4 Effectiveness of e-interventions on Fall, Neuromuscular Function, Quality of Life

17
 3.4.1 Effect of e-interventions on Proportion of fallers (PF)

Eleven studies reported the PF, hence, 2,500 participants were included in the meta-

analysis (Figure 2). The number of falls is a self-reported measure where individuals or family

members declare any falls that occurred over the monitored period. Lower risk ratios indicated

decreased PF. The effect of e-interventions in reducing the proportion of fallers in intervention

groups was statistically significant (z=3.68, p<0.0002), with a medium effect size (RR=0.79),

favouring e-interventions to traditional interventions, as determined by the random-effects

method. E-interventions reduced fall risk by 21%. Risk ratios ranged from 0.51 (Tchalla et al.,

2013) to 1.10 (Oliveira et al., 2019). Heterogeneity tests suggested moderate heterogeneity

across the studies (I2=44%, Chi2=19.49, p=0.05) (Figure 2). The moderate heterogeneity could

be caused by the various types of e-interventions, hence, subgroup analysis was recommended.

3.4.1.1 Effect of e-intervention types on proportion of fallers

A subgroup analysis was conducted to examine the effect of e-intervention types on the

proportion of fallers. E-interventions included Telehealth & Exercise (n=7), telehealth only (n=2),

and smart home system (n=2). There was no significant subgroup difference in risk ratio (chi2 =

5.45, p=0.07) across the three groups. All three e-interventions showed risk reductions, T&E

(RR=0.84) and telehealth only (RR=0.80) demonstrating less reduction than smart home

systems (RR=0.58). There was low heterogeneity for both T&E (I2=26%, Chi2=9.44, p=0.22) and

smart home systems (I2=0%, Chi2=0.46, p=0.50) (Figure 2).

(Insert Figure 2 here)

18
 3.4.2 Effect of e-interventions on Balance

Balance consists of different types (static/dynamic) and was measured in a variety of

ways. As most of the included studies used the Berg Balance Scale (BBS) as a common measure

of balance, hence, balance is measured by BBS in this review. Ten studies (with 653 participants)

reported balance using BBS score, which were pooled in meta-analysis using a random-effect

model. The BBS is a 14-item objective measure used to assess static balance and fall risk for

older adults (Berg, Wood-Dauphinee, Williams & Gayton, 1989). Intervention groups had better

balance, as indicated by higher BBS scores. The effect of e-interventions in improving BBS

scores in intervention groups was statistically significant (z=2.24, p=0.03), with a small effect

size (SMD=0.28), favouring e-interventions. Effect sizes ranged from -0.64 (Szturm et al., 2011)

to 1.42 (Chang, Huang & Jung, 2011). Heterogeneity tests suggested moderate heterogeneity

across the studies (I2=49%, Chi2=17.77, p=0.04) (Figure 3).

3.4.2.1 Effect of e-intervention types on balance

A subgroup analysis was conducted to examine the effect of e-intervention types on

balance (BBS score). E-interventions groups were T&E (n=5), NCBT (n=1), exergame (n=3) and

cognitive gaming (n=1). Subgroup differences were not significant (I2=0%, Chi2=1.31, p=0.73).

Statistical significance was not found for BBS score improvement in NCBT (z=0.26, p=0.79),

exergame (z=0.53, p=0.60) and cognitive game (z=0.10, p=0.92), whereas only T&E

interventions showed statistically significant improvements in balance (z=2.18, p=0.03). Effect

sizes for all groups were small (telehealth: SMD=0.38, NCBT: SMD=0.10, exergame: SMD=0.18

19
and cognitive game: SMD=0.03). Heterogeneity remained high for both T&E (I2=57%, Chi2=9.20,

p=0.06) and exergames (I2=71%, Chi2=6.86, p=0.03) (Figure 3).

(Insert Figure 3 here)

3.4.3 Effect of e-interventions on Lower extremity strength (LES)

Six studies reported post-intervention Short Physical Performance Battery (SPPB) scores

were included in the meta-analysis of 702 participants. The SPPB is a 3-part objective measure

of LES (Guralnik et al., 1994). Higher SPPB scores indicated better LES. The effect of e-

interventions in improving SPPB scores in intervention groups was not statistically significant

(z=0.67, p=0.50), with a small effect size (SMD=0.05), as determined by the random-effects

method. Effect sizes ranged from -0.10 (Eggenberger et al., 2015) to 0.62 (Crandall & Shake,

2016). Heterogeneity tests suggested homogeneity across the studies (I2=0%, Chi2=2.69, p=0.91)

(Figure 4).

3.4.3.1 Effect of e-intervention types on LES

A subgroup analysis was conducted to see the effect of e-intervention type on LES. E-

interventions including T&E (n=1), socialized training (n=1), exergame (n=3), and cognitive game

(n=1). The subgroup differences were insignificant (I2=0%, Chi2=1.63, p=0.65) (Figure 4). Except

T&E (SMD=-0.07), the meta-analysis result of the rest subgroups still favoured interventions,

including socialized training (SMD=0.12), exergame (SMD=0.12) and cognitive game (SMD=0.15).

There was low heterogeneity for all four e-interventions.

(Insert Figure 4 here)

20
 Shake, Crandall, Mathews, Falls and Dispennette (2018) reported the mean and

standard deviation of each component of the SPPB. Only the four-metre walk (z=5.74,

p<0.00001) and repeated chair stands (z=7.84, p<0.00001) were statistically significant and

favoured the e-interventions. Voukelatos et al. (2015) reported the median and interquartile

range of their SPPB scores. This result was excluded from the meta-analysis as we were not able

to extract the data or contact the authors. Mirelman et al. (2016) reported the least mean

square difference. Only time effects between the intervention and controls groups showed

statistical significance (p<0.0001). Group effects were not statistically significant (p=0.078).

3.4.4 Effect of e-interventions on Fall efficacy

Six studies reported post-intervention Activities-Specific Balance Confidence Scale (ABC)

scores were included in the meta-analysis of 429 participants. ABC is a 16-item subjective self-

reported measure assessing confidence in performing ambulatory activities without falling

(Powell & Myers, 1995). The effect of e-interventions in improving ABC scores in intervention

groups was statistically significant (z=2.84, p=0.005), with a small effect size (SMD=0.29),

favouring the e-interventions, as determined by the random-effects method (Figure 5).

Intervention groups had better fall efficacy, as indicated by higher scores. Effect sizes ranged

from -0.46 (Bao et al., 2018) to 0.63 (Chang et al., 2011). Heterogeneity tests suggested

homogeneity across the studies (I2=0%, Chi2=5.06, p=0.54). Padala et al. (2017) also reported

their mean change from the baseline at eight weeks. The mean difference (3.5 [-4.2-11.2])

between the intervention and control groups at eight weeks was not statistically significant

(p=0.36).

21
 (Insert Figure 5 here)

3.4.5 Effect of e-interventions on Cognitive function

In total, three studies reported cognitive function in a meta-analysis of 329 participants.

Trail Making Test (TMT) is a 2-part test of cognitive function, TMT A and B. The time taken for

each test indicates the fluid intelligence, with faster speeds indicating better cognitive

performance (Salthouse, 2011). Executive function is indicated by the difference in time taken

between TMT B and A because of the need for cognitive flexibility to switch between

alphanumeric patterns (Kortte, Horner & Windham, 2002). The effect of e-intervention in

improving cognitive function was statistically insignificant (z=0.13, p=0.89), with a small effect

size (SMD=-0.01). Heterogeneity test suggested homogeneity across the studies (I2=0%,

Chi2=3.75, p=0.44). Two studies reported TMT A in a meta-analysis of 297 participants. The

effect of e-interventions in improving TMT A scores in intervention groups was statistically

insignificant (z=0.10, p=0.92), with a small effect size (SMD=0.01), as determined by the

random-effects method. Better cognition was indicated by lower TMT A scores. Effect sizes

ranged from -0.04 (van het Reve & de Bruin, 2014) to 0.06 (Gschwind et al., 2015).

Heterogeneity tests suggested homogeneity across the studies (I2=0%, Chi2=0,17, p=0.68)

(Supplementary Figure 2).

Two studies reported TMT B in a meta-analysis of 297 participants. The effect of e-

interventions in improving TMT B scores in intervention groups was statistically insignificant

(z=0.28, p=0.78), with a small effect size (SMD=0.03), as determined by the random-effects

method (Supplementary Figure 2). Better cognition was indicated by lower scores. Effect sizes

22
ranged from -0.02 (van het Reve & de Bruin, 2014) to 0.09 (Gschwind et al., 2015).

Heterogeneity tests suggested homogeneity across the studies (I2=0%, Chi2=0.23, p=0.63).

Schoene et al. (2013) reported TMT B-A for 32 participants. The effect of e-interventions

in improving TMT B-A in intervention groups was statistically insignificant (z=1.81, p=0.07), with

a relative larger effect size (SMD=-0.66), as determined by the random-effects method

(Supplementary Figure 2). Better cognition was indicated by lower TMT A scores. Barban et al.

(2017) reported F-test results for TMT B-A in 408 participants. Only time effects between

cognitive and non-cognitive groups showed statistical significance (F=15.247, p<0.001). Group,

interaction and follow-up minus interaction effects were not statistically significant.

3.4.6 Effect of e-interventions on Health-related quality of life

Two measurements, EuroQol-5 Dimension (EQ-5D) and EuroQol Visual Analogue Scale

(EQ VAS), were used to measure Health-related quality of life (HRQOL) (EuroQol Research

Foundation, 2019). Five studies reported post-intervention EQ-5D scores in the meta-analysis of

791 participants. The effect of e-interventions in improving EQ-5D scores in intervention groups

was not statistically significant (z=0.77, p=0.44), with a small effect size (SMD=0.08), as

determined by the random-effects method (Supplementary Figure 3). Better HRQOL was

indicated by higher scores. Effect sizes ranged from -0.11 (Haines et al., 2009) to 0.43

(Bernocchi et al., 2019). Heterogeneity tests suggested moderate heterogeneity across the

studies (I2=45%, Chi2=9.09, p=0.11).

Four studies reported post-intervention EQ VAS scores in the meta-analysis of 693

participants. The effect of e-interventions in improving EQ VAS scores in intervention groups

23
was statistically insignificant (z=1.51, p=0.13), with relatively larger effect size (SMD=0.16), as

determined by the random-effects method (Supplementary Figure 3). Better HRQOL was

indicated by higher scores. Effect sizes ranged from -0.07 (Clemson et al., 2012) to 0.45

(Clemson et al., 2012). Heterogeneity tests suggested moderate heterogeneity across the

studies (I2=40%, Chi2=6.72, p=0.15).

3.5 Quality of evidence

Publication bias was assessed using the funnel plot for outcomes with more than 10

studies (Sterne et al., 2011). The funnel plots for proportion of fallers (Supplementary Figure 4)

and balance (Supplementary Figure 5) were symmetrical and equally distributed about the

summary estimate suggesting that there was an absence of publication bias. The overall quality

of evidence was assessed using the GRADE framework (Supplementary Table 2). The quality of

evidence for executive function assessed by TMT B-A and HRQOL assessed by EQ VAS was rated

high. The quality of evidence for proportion of fallers and HRQOL assessed by EQ-5D was rated

moderate due to inconsistency issues. The quality of evidence for LES assessed by SPPB and

cognitive measures (TMT A and B) were rated moderate due to high risk of bias across studies.

The quality of evidence for fall efficacy was rated moderate due to imprecision. The quality of

evidence for balance was rated low due to inconsistency and imprecision. The GRADE Quality of

Evidence of the studies are presented in Supplementary Table 3.

4 Discussion

4.1 Discussion on the findings

24
 This review investigated the effectiveness of e-interventions on proportion of fallers,

balance, lower extremity strength, fall efficacy, cognitive function, and quality of life among

community-dwelling older adults. Six types of e-interventions were reviewed: telehealth,

exergames, cognitive games training, NCBT, smart home systems and socialized training. In this

review, telehealth significantly improved fall outcomes in decreasing fall risk by 21% compared

to controls. The fall risk ratio was 0.83, which was higher than that of previous non-e-

intervention exercise reviews (RR=0.78) (Hamed, Bohm, Mersmann & Arampatzis, 2018).

Despite non-significant finding in the T&E subgroup, both Telehealth only and T&E produced

large effect size and helped to reduce the fall risk. In Telehealth only and T&E interventions,

the feedback and encouragement by the healthcare professionals might promote adherence to

home exercise. Thus, Telehealth only and T&E interventions improved lower extremity strength

and reduced falls. The smart home system provided smaller effect size. Nevertheless, the

sensor-detected nightlight path provided night time visibility, and hence, ensure safety and

reduce the risk of fall.

Our findings suggested T&E significantly improved balance as measured by BBE among

elderly individuals. Cadore, Rodríguez-Mañas, Sinclair and Izquierdo (2013)’s review on exercise

interventions showed similar improvements on balance. Furthermore, T&E showed similar

reductions in fall risk as compared to exercise interventions without telehealth (Hamed et al.,

2018), suggesting that T&E has good evidence of reducing falls and improving balance, and

should be considered due to their ability to increase user support and adherence (Baez et al.,

2017). Moreover, T&E significantly improved confidence in performing ambulatory activities

without falling, but only had a small effect size. Exercise, particularly resistance training, has

25
shown to be able to improve balance confidence, with comparable effect size (Liu-Ambrose,

Khan, Eng, Lord & McKay, 2004). This increase in confidence could also be attributed to the

professional advice and motivation from telephone calls received by participants and their

sense of accomplishment (Baez et al., 2017; Liu-Ambrose et al., 2004). The results suggest that

both exercise and motivational support are important to building up the level of confidence,

which in turn decreases falls (Hatch et al., 2003).

T&E did not significantly improve lower extremity strength. However, these studies used

walking exercise over strength-building exercises, which Cadore et al. (2013) proposed as

having insufficient effect on muscle strength. Studies emphasizing strength-building showed

better increase in balance (Granacher, Gollhofer, Hortobágyi, Kressig & Muehlbauer, 2013). This

suggests that strength-building exercises should be recommended in T&E for better balance.

T&E did not significantly improve HRQOL and had a small effect size. Limited studies reporting

these outcomes could affect statistical significance and power. Moreover, studies on effect of

exercise on global HRQOL of older adults have shown mixed results (Kelley, Kelley, Hootman &

Jones, 2009). More recent studies suggest that exercise improves physical aspects of HRQOL

more than global HRQOL, which EQ-5D and EQ VAS lacks sensitivity in measuring (Gusi,

Hernandez-Mocholi & Olivares, 2015). This suggests that T&E would not be as effective in

improving global HRQOL.

Our review suggested that Exergames reduced the proportion of fallers as compared to

control groups. These positive findings might due to the simultaneous cognitive and motor

training which might improve both lower extremity strength and executive function, and was

critical in preventing falls (Cadore et al., 2013; Lauenroth, Ioannidis & Teichmann, 2016).

26
Furthermore, Exergames produced better cognitive function, but not statistically significant.

These findings were supported by Stojan & Voelcker-Rehage (2019), who found that cognitive

demand of physical activity was indeed increased by the executive function demands of gaming,

but the variety of exergames could not account for a significant improvement in cognitive tests.

Moreover, Exergames improved lower extremity strength, except in Shake et al. (2018) where

the standing scores were slightly lower than the control group despite improvements in the

score. This could be due to the intervention group scores being significantly lower at baseline.

The physical activity components most likely contributed to the increase in LES through

strength training (Cadore et al., 2013), which in turn led to reduced falls amongst exergame

interventions.

On the contrary, Exergames did not significantly improve balance as measured by BBS.

Nevertheless, a systematic literature review reported that majority of the exergames improved

balance (66.6%) when compared with usual care (Choi, Guo, Kang & Xiong, 2017). Exergames

were less likely to show significant improvements when compared with other active controls.

Schoene et al. (2014) showed that balance board training was able to consistently improve

balance. However, since only 33% of the exergame studies reporting BBS utilized balance board

training, this may account for the insignificant results. Similar to other studies, in Schoene et al.

(2014), exergames were unable to conclusively improve fall efficacy as measured by ABC scale.

One possible reason for non-significance in our review was the various subtypes of exergames

of which it was not possible to determine most effective type.

Cognitive game training significantly improved within-group cognitive function as

reflected by TMT scores in all included studies in our review. However, the between-group TMT

27
improvements were not statistically significant. This insignificance was expected since motor

training alone (as the control) can also increase global cognitive function (Lauenroth et al.,

2016). However, cognitive training remains advantageous due to the specific improvements in

executive function demonstrated by the better performance in TMT (van het Reve & de Bruin,

2014). Despite lacking statistical significance and power, cognitive games were likewise helpful

in bettering balance, LES and fall outcomes due to their contribution towards improving

simultaneous motor and executive functions (Lauenroth et al., 2016). A meta-analysis

suggested that cognitive behaviour therapy-based interventions using cognitive restructuring,

motivational interviewing, or goalsetting as components of a complex biopsychosocial

intervention program have favourable effects in reducing fear of falling among community‐

dwelling older adults who are at risk of fall (Chua et al., 2019).

NCBTs improved balance and fall efficacy in the intervention groups, but without

statistical significance or power. Lajoie (2004) found balance and fall efficacy scores to be

improved, but the latter improvement was significant. NCBT decreased the amount of attention

needed to correct posture, retraining the brain to automatically maintain balance, thereby

improving BBS score (Lajoie, 2004). Enhanced performance in balance, then psychologically

improves confidence in activity (Hatch et al., 2013).

All studies on the effectiveness of smart home systems showed a statistically significant

reduction in the proportion of fallers (RR=0.58). This reduction mainly stemmed from the

system’s ability to reduce falls at night by improving awareness of surroundings and improving

night-time vision (Tchalla et al., 2012). In fact, most smart home systems were able to produce

positive fall outcomes (66.6%) (Liu, Stroulia, Nikolaidis, Miguel-Cruz & Rios Rincon, 2016). Falls

28
were reduced in the study on the smart home systems that reported direct fall outcomes

(Brownsell & Hawley, 2004). The limited number of studies reporting smart home system effect

on fall-related outcomes restricts generalization, but the studies show promising evidence of

effectiveness.

Socialized training produced slightly better lower extremity strength than individual

training but not statistically significant. Martin et al. (2013), which studied group-based

physiotherapy, found improvements in functional mobility scores. Baez et al (2017) found that

social groups showed increase LES. This improvement was correlated to increased persistence

and enjoyment, proving that socializing training indeed encouraged participants to train harder

and more frequent, thereby increasing LES (Baez et al., 2017). This suggests socialized training,

even online, can reduce fall risk.

E-interventions in general were able to reduce the proportion of fallers. Both T&E and

smart home systems significantly lowered the fall occurrence. Nevertheless, the length of the

interventions should be considered as fall prevention interventions 6 months or longer is more

effective in reducing both fall risk and rate compared to interventions with shorter duration

(Finnegan, Seers & Bruce, 2019). E-interventions improved balance, and closer examination

showed that only T&E brought about significant changes. In addition, e-interventions

significantly improved fall efficacy. Notably, the effect sizes of balance and fall efficacy are small

may not be generalizable. Overall, e-interventions were not able to significantly improve lower

extremity strength, cognitive function or HRQOL. The results could be attributed to the limited

number of studies reporting such outcomes.

29
 E-interventions shows good evidence of effectiveness, with the added advantage of a

community- or home-based setting. The advantage of e-interventions over existing

unsupervised home-based exercise programmes is the ability to boost patient care support and

adherence, thereby decreasing fall risk (Hamed et al., 2018; Baez et al., 2017). Moreover, e-

interventions increases cost-effectiveness for patients by reducing travelling costs, consultation

fees and loss of income from taking medical leave with no or little difference to health

outcomes. After break-even from the initial set-up costs, telehealth is effective in cost-saving

for healthcare institutions (Buvik et al., 2019).

4.2 Strength and limitations

This review filled in a gap in existing literature by assessing the effectiveness of

various types of e-interventions for the prevention of falls in community-dwelling older adults.

By evaluating the strengths and limitations of each type of intervention, healthcare providers

and policymakers looking to implement e-interventions will have an overview of the pros and

cons of each type and make an informed decision to choose the most appropriate e-

intervention in their context (Garg, Hackam & Tonello, 2008). In addition to qualitative

perspectives, this study also provides a new quantitative perspective by the conduction of a

meta-analyses which has not yet been conducted for e-interventions on falls in older adults.

This review is not without limitations. This review included many studies (n=16) at trial

level and had small sample sizes of less than 50 participants in each study group. As such, the

results had smaller effect sizes and may not be representative of larger populations. The

reviewers acknowledge that many factors influence fall risk, such as ethnicity, health status and

30
socioeconomic status affecting the rate of falls (WHO, 2007). Majority of the studies are

conducted on healthy older adults, most of which were Caucasian and from developed

countries. Thus, the results may not be replicable in other countries with different ethnic and

economic backgrounds. Furthermore, all included studies used only BBS to measure balance,

and thus findings from this review cannot be generalised to other measures of balance. In

addition, the details of balance and strength training, and specific programs were not described

in the review and could have varied significantly between studies. In the review, only three

studies reported cognitive function and were included in the meta-analysis. The cognitive

function in the included studies was based on one measure, the trail-making test, which did not

reflect the cognitive function comprehensively. The result on cognitive function was

inconclusive, and further studies are recommended to evaluate the effect of e-interventions on

cognitive function. The review excluded older adults with Parkinson's diseases, as they would

have different presentations in gait and balancing, hence the mechanisms for fall prevention

would be different. Future study could consider to investigate the effects of e-intervention on

fall prevention for older adults with neurological conditions, such as Parkinson's diseases, post-

stroke or Huntington's diseases.

4.3 Implications for practice and research

Besides adding statistical value to existing studies on e-interventions, the review

provides evidences that e-interventions are suitable alternative to face-to-face interventions.

This review has also identified strengths of e-interventions that will be beneficial to direct the

implementation of fall prevention interventions for community-dwelling older adults. Firstly,

telehealth can be an effective tool for fall prevention and improving balance but should be

31
combined with exercise regimens and safety training (e.g. home environment assessment) for

better results. These exercise regimens should include strength and balance training

components and be implemented for longer periods of 6 months or more. Secondly, cognitive-

motor training in the form of exergames or separate training motor and cognition training

sessions can improve fall outcomes and balance. Cognitive training should focus on improving

executive functions and can include dual-task training. These exergames should also be

implemented for longer periods for better results. Lastly, smart home systems can improve fall-

related outcomes and safety for older adults and can be feasibly implemented in more well-

developed countries. Future work is needed on smart home systems and Artificial Intelligence

to forecast falls.

5 Conclusion

This review examined the best available evidence of the effectiveness of various e-

interventions in preventing falls in community-dwelling older adults. Six fall-related outcomes

were investigated. Limited studies were found for four out of six types of interventions. E-

interventions were able to improve four of the six fall-related outcomes. E-interventions

significantly reduced fall risk. Balance and fall efficacy scores were significantly improved by e-

interventions, barring small effect sizes. E-interventions were not able to significantly improve

lower extremity strength, cognitive function or health-related quality of life. Of the

interventions evaluated, T&E and smart home systems showed the best evidence of

effectiveness and should be strongly considered by healthcare professionals and policymakers

seeking to implement e-interventions for the older adults in their communities. If future studies

32
are guided by the recommendations from this review, the e-interventions can be refined, and

the full potential of e-interventions can be explored and utilized for successful prevention of

falls in older adults.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships
that could have appeared to influence the work reported in this paper.

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41
 Records identified through database searching
Identification

Cochrane (n = 149), PubMed (n = 407),

EMBASE (n = 139), CINAHL (n = 24),
ScienceDirect (n = 167), Scopus (n = 252), Additional records identified
MedLine (n = 248), PsycINFO (n = 112), Web of through manual search
Science (n = 44), Google Scholar (n = 17), (n = 4)
ProQuest (n = 143), Total (n = 1702)

Records after duplicates removed (n = 1311)

Records excluded for

inappropriate title (n = 1017),
Screening

inappropriate intervention (n = 35),

inappropriate outcome (n = 6),
systematic review (n = 28),
Records screened by title and conference abstract (n = 27),
abstract (n = 1311) fall detection (n = 7),
newspaper article (n = 16),
other language (n = 5),
trial/protocol only (n = 51),
Total (n = 1192)

Full-text articles assessed for Full-text articles excluded for

eligibility comment (n = 1),
conference abstract (n = 2),
Eligibility

(n = 119)
inappropriate outcome (n = 15),
inappropriate intervention (n = 3),
inappropriate population (n = 2),
inappropriate setting (n = 3),
Studies included in non/quasi-experimental design (n = 13),
qualitative synthesis non-English language (n = 1),
(n = 31) ongoing trial/protocol only (n = 37),
product design/development (n = 5),
text unavailable (n = 1),
>10 years ago (n = 5).
Total (n = 88)
Studies included in
Included

quantitative synthesis (meta-

analysis)
(n = 26)

Fig. 1. PRISMA Flow Diagram

42
Fig. 2. Forest Plot of the effect of e-interventions on Proportion of fallers

43
Fig. 3. Forest Plot of the effect of e-intervention types on balance

44
Fig. 4. Forest Plot of the effect of e-interventions on lower extremity strength

45
Fig. 5. Forest Plot of the effect of e-interventions on fall efficacy

46