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Effectiveness of Intervention Programs in Preventing Falls - A Systematic Review of Recent 10 Years and Meta-Analysis
Effectiveness of Intervention Programs in Preventing Falls - A Systematic Review of Recent 10 Years and Meta-Analysis
Effectiveness of Intervention Programs in Preventing Falls - A Systematic Review of Recent 10 Years and Meta-Analysis
e21
JAMDA
journal homepage: www.jamda.com
Original Study
a b s t r a c t
Keywords: Objective: To examine the reported effectiveness of fall-prevention programs for older adults by
Falls reviewing randomized controlled trials from 2000 to 2009.
prevention programs
Design: Systematic review and meta-analysis of randomized controlled trials.
meta-analysis
older adults
Data Sources: A systematic literature search of articles was conducted using 5 electronic databases
(Medline, PubMed, PsycINFO, CINAHL, and RefWorks), including articles describing interventions
designed to prevent falls, in English with full text availability, from 2000 through 2009.
Review Methods: Of a potential 227 studies, we identified 17 randomized controlled trials with a duration
of intervention of at least 5 months of follow-up. Inclusion and exclusion criteria were used to assess the
methodological qualities of the studies. We excluded unidentified study design, quasi-experimental
studies, and/or studies that were nonspecific regarding inclusion criteria.
Data Extraction: Primary outcome measures were number of falls and fall rate. Methodological quality
assessment included internal and external validity, reporting, and power. Data were extracted inde-
pendently by 2 investigators and analyzed using a random-effects model. We analyzed the effectiveness
of these fall intervention programs using their risk ratios (RR) in 2 single-intervention versus 15
multifactorial intervention trials, 3 nursing homes versus 14 community randomized controlled trials,
and 8 Model 1 (initial intervention with subsequent follow up) versus 9 Model II (ongoing intervention
throughout the follow-up) studies.
Results: The combined RR for the number of falls among 17 studies was 0.855 (z ¼ e2.168; p ¼ .030; 95%
CI ¼ 0.742e0.985; Q ¼ 196.204, df ¼ 16, P ¼ .000, I2 ¼ 91.845), demonstrating that fall-prevention
programs across the studies were effective by reducing fall rates by 14%, but with substantial hetero-
geneity. Subgroup analysis indicated that there was a significant fall reduction of 14% in multifactorial
intervention (RR ¼ 0.856, z ¼ e2.039, P ¼ .041) with no variation between multifactorial and single-
intervention groups (Q ¼ 0.002, P ¼ .961), 55% in the nursing home setting (RR ¼ 0.453, z ¼ e9.366,
P ¼ .000) with significant variation between nursing home and community groups (Q ¼ 62.788, P ¼
.000), and no significant effect was gained by dividing studies into either in Model I or II. Sensitivity
analysis found homogeneity (Q ¼ 18.582, df ¼ 12, P ¼ .099, I2 ¼ 35.423) across studies with a 9% overall
fall reduction (RR ¼ 0.906, 95% CI ¼ 0.853e0.963, z ¼ e3.179, P ¼ .001), including a fall-reduction rate of
10% in multifactorial intervention (RR ¼ 0.904, z ¼ e3.036, P ¼ .002), 9% in community (RR ¼ 0.909, z ¼
e3.179, P ¼ .001), and 12% in Model I (RR ¼ 0.876, z ¼ e3.534, P ¼ .000) with no variations among all the
groups. Meta regression suggested that the model fit explained 68.6% of the relevant variance.
Conclusions: The meta-sensitivity analysis indicates that randomized controlled trials of fall-prevention
programs conducted within the past 10 years (2000e2009) are effective in overall reduction of fall
rates of 9% with a reduction of fall rates of 10% in multifactorial interventions, 9% in community settings,
and 12% in Model I interventions (initial intervention efforts and then subsequent follow-up).
Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
Falls are the leading cause of injury deaths among older adults
The authors declare no conflicts of interest. and the leading cause of hospital admissions for trauma in this age
* Address correspondence to Myunghan Choi, PhD, MPH, APRN-BC, College of
group.1,2 Direct medical cost estimates totaled $19.2 billion for fatal
Nursing & Health Innovation, Arizona State University, 500 N. Third Street, Phoenix,
AZ 85004. and nonfatal injuries in the United States in 2000.3,4 Earlier studies
E-mail address: Myunghan.choi@asu.edu (M. Choi). have suggested that fall-related injuries could be prevented with
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
doi:10.1016/j.jamda.2011.04.022
M. Choi, M. Hector / JAMDA 13 (2012) 188.e13e188.e21 188.e14
either multifactorial or individualized intervention.5,6 In 2003, studies were reviewed by the primary author (M.C.). We excluded
Gillespie et al6 reported that multifactorial-intervention programs studies of fall-prevention programs for children (n ¼ 27). The
and single-intervention programs of muscle strengthening and primary search (completed from July 2009 to March 2010) gener-
balance retraining were likely to be effective. Gates et al’s5 meta- ated a total of 227 studies: 22 studies from CINAHL, 62 studies from
analysis of multifactorial interventions in 2008 found little Medline, 37 studies from PsycInfo, 64 studies from PubMed, and 42
evidence in support. from RefWorks. Among these, we excluded studies that did not
Previous research has identified that fall-intervention programs report fall-intervention programs or effectiveness of the program
were effective when focusing on a multidisciplinary team inter- (n ¼ 151), those that identified unclear intervention follow-up or
vention.7e10,19 Single-intervention programs were effective when were quasi-experimental in design (n ¼ 40), those that included
focusing on a certain exercise program, when implementing men or women only (n ¼ 15), or those that were studies where
a specific home safety assessment, providing a high dose of vitamin postintervention follow-up was impractical (n ¼ 4). Of the 227
D supplementation, and so forth.11e15 Community intervention publications that met the criteria for meta-analysis, 17 studies
programs were effective when focusing on a comprehensive at- remained (Figure 1).
home assessment, individualized risk reductions, and/or educa-
tion programs used to prevent falls.10,16e20 In 2004, Chang et al7 Quality Assessment
concluded that a multifactorial fall-risk assessment and manage-
ment program was the most effective intervention, and that a single Each of these 17 studies was classified independently using the
intervention program of exercise also had a beneficial effect. Downs and Black Checklist for Measuring Study Quality (DB
Despite these and many other intervention programs, fall- checklist).25 The DB checklist included a total of 27 items including
related injuries among older adults in general seem to have five subcategories: 10 items for reporting, three items for external
further decreased only slightly. Several meta-analysis studies based validity, seven items for internal validity, six items for selection
on fall-related studies from the 1990s and 2000s including bias, and one item for power. All items were measured one for “Yes”
randomized controlled trials (RCTs) and quasi-experimental studies or 0 for “No” or “Unable to determine.” Inter-rater reliabilities were
reported disparate conclusions.5,7 assessed to examine the extent of consensus on use of the scale
between two completely blinded raters.25 After the completion of
Purpose the quality assessment by each individual, the two raters presented
their own quality assessment. Because the data are categorical and
Several meta-analysis studies reported the effectiveness of fall- raters are two, the consensus was examined using Cohen’s Kappa as
prevention programs focusing on the previous decade (1990s to an inter-rater reliability measure.26 The Cohen’s Kappa was calcu-
early 2000) for older adults.7,8,12,20e23 Since then, a variety of fall- lated using a 3 3 table and number of agreement in five categories
intervention programs have been developed and implemented on the 17 studies. Five categories included reporting (n ¼ 10),
either in communities or nursing homes for frail older adults. external validity (n ¼ 3), internal validity (n ¼ 7), selection bias (n ¼
However, there is no recent meta-analysis indicating that newly 6), and power (n ¼ 1) (see DB checklist). The number of agreements
developed intervention programs are any more or less reliably in each category was entered in PASW (Version 18) (Predictive
effective in preventing falls for older adults. Our analysis was an Analytics Software, Armonk, NY) with total count weighted. The
attempt to derive scientific evidence of the effectiveness of fall- Cohen’s Kappa (K) in 5 categories indicated that the agreement of
prevention programs and to make recommendations to health quality assessment was moderate in power (K ¼ 0.556; P ¼ .002),
care providers about the effectiveness of fall-intervention substantial in reporting (K ¼ 0.796; P ¼ .000) and internal validity
programs. (K ¼ 0.797; P ¼ .000), and outstanding in external validity (K ¼
0.850; P ¼ .000) and selection bias (K ¼ 0.830; P ¼ .000). The overall
Methods Cohen’s Kappa was 0.782 (P ¼.000), demonstrating the agreement
between 2 raters was substantial. In addition to the DB checklist,
Identification of Studies we also assessed the evidence-based, minimum set of recommen-
dations for reporting RCTs per Consolidated Standards of Reporting
A thorough search of the scientific and medical literature was Trials (CONSORT). Six studies adhered to CONSORT guidelines by
conducted using major biomedical electronic databases: Medline, reporting intention to treat.10,14,27e30 Only one study reported
PubMed, PsycINFO, CINAHL, and RefWorks. This rigorous literature allocation concealment.17 After the completion of quality assess-
examination selected articles in peer-reviewed journals published ment, each individual study’s variables were selected and entered
in the English language, with full-text availability, targeting both in the Comprehensive Meta-Analysis software (CMA, Englewood,
men and women, in RCTs, with primary outcome measures as NJ) by the first author (M.C.), with said descriptors of each study
either the number of falls or the fall rate, with fall-intervention assigning it as either a high- or low-quality performance (Figure 2).
follow-up of a minimum of 5 months, and published from 2000
to 2009. We excluded articles with unidentified study design, Statistical Methods
cohort studies, case-control studies, quasi-experimental studies,
quasi-randomized controlled studies, and community studies We used a random-effects model to determine the variance
conducted in environments where essential postintervention associated with each of the sources of variation influencing the fall-
follow-up was impractical.24 intervention programs. The random-effects model is more plau-
There were 33 studies duplicated across databases that were sible than the fixed effect model and has the benefit of reducing the
excluded. The key words used were the combination of falls, heterogeneity of sources.31 The outcome measure used for the
recurrent falls, fall-prevention programs, interventions, programs, combined effect size was a risk ratio (RR) to estimate the overall
injuries, older adults, RCTs, and/or long term care facilities. A total combined fall-reduction rate. The estimated RR of falls between
of 17,325 studies were generated from the 5 electronic databases. groups was computed, along with its variance and a standard error
Studies with titles and abstracts unlikely to be relevant were of the RR, to yield a summary effect as the best approach consistent
excluded (n ¼ 15,419) followed by exclusion of studies that did not with the primary outcome measures used in these studies. Statis-
identify an RCT (n ¼ 1619). A total of 287 potentially relevant tical heterogeneity was quantified using I2 and Q statistics. I2 is the
188.e15 M. Choi, M. Hector / JAMDA 13 (2012) 188.e13e188.e21
Titles and abstracts were a discernible difference between studies conducted where the
reviewed via electronic search
(n = 17,325)
intervention was accomplished and results were then monitored
Titles and abstracts unlikely to be relevant were (Model I) versus studies in which the intervention continued
excluded
(n = 15,419)
throughout the measured period (Model II). Sensitivity analyses
Studies that did not identify RCT were excluded were performed to assess the effect of excluding the trials for which
(n = 1,619)
studies showed high standardized random residual errors. Stan-
Potentially relevant studies
were reviewed dardized residual errors were calculated based on observed value
(n = 287) minus predicted value divided by the square root of the residual
Studies that included children falls were excluded
(n = 27) mean square. Publication bias was assessed using a funnel plot
Studies duplicated were excluded analysis.32 Mean effect was computed for this bias. Meta-regression
(n = 33)
Potentially relevant studies using mixed effects regression with unrestricted maximum likeli-
were reviewed hood was conducted to assess the degree of dispersion remaining
(n = 227)
Studies that did not report fall intervention or after sampling error variance.31 Proportion of total variance
effectiveness of the program were excluded explained by the model was calculated using T2total and T2unexplained.
(n = 151)
Studies that identified unclear intervention period or Comprehensive Meta-Analysis software (CMA, Version 2.2) was
did not meet the intervention period, and quasi used to synthesize the effectiveness of fall-intervention programs
experimental design studies were excluded
(n = 40) provided by the individual studies. Sensitivity analysis, a funnel
Studies that did not include both men and women plot analysis, and meta-regression were also performed using the
were excluded
(n = 15) CMA.
Study name Type Intervention Model Setting Statistics for each study Risk ratio and 95% CI
Risk Lower Upper
ratio limit limit Z-Value p-Value
Berggren Multi 1.000 Com 0.761 0.573 1.009 -1.896 0.058
Broe Single 2.000 NH 0.494 0.202 1.206 -1.548 0.122
Campbell Single 2.000 Com 1.000 0.778 1.285 -0.003 0.998
Clemson Multi 1.000 Com 0.828 0.614 1.118 -1.232 0.218
Davison Multi 2.000 Com 0.936 0.883 0.992 -2.237 0.025
Day Multi 1.000 Com 0.667 0.494 0.900 -2.647 0.008
Elley Multi 2.000 Com 1.096 0.932 1.288 1.106 0.269
Hendriks Multi 1.000 Com 1.017 0.671 1.542 0.080 0.936
Lightbody Multi 1.000 Com 0.853 0.792 0.919 -4.171 0.000
Lord Multi 2.000 Com 1.028 0.830 1.274 0.255 0.799
Mahoney Multi 1.000 Com 0.854 0.690 1.058 -1.440 0.150
Neyens Multi 2.000 NH 0.431 0.334 0.555 -6.500 0.000
Rapp Multi 2.000 NH 0.461 0.413 0.515 -13.675 0.000
Spice Multi 1.000 Com 0.899 0.811 0.998 -2.004 0.045
van Hasstregt Multi 2.000 Com 1.118 0.728 1.718 0.509 0.611
Vind Multi 1.000 Com 1.089 0.906 1.309 0.911 0.363
Whitehead Multi 2.000 Com 2.063 1.255 3.389 2.856 0.004
0.855 0.742 0.985 -2.168 0.030
0.1 0.2 0.5 1 2 5 10
age of 79.2. One study29 reported the mean age of the participants the continuum of intervention (as a proxy for intervention inten-
was older than 70 and we treated this as a mean age of 70. sity). If an intervention was made in the beginning of a study and
not throughout the study, it was treated as a Model I. If the inter-
Type of Intervention vention was continued throughout the study, it was treated as
a Model II. For instance, we treated studies reported as 2-hour
Single or multifactorial intervention in each study indicated sessions for 7 weeks,14 2 visits at 4 months and 12 months,17
actual program management. In a study13 reported to be a multi- 4-week intervention,19 2 home visits,37 intervention approxi-
faceted intervention, we used only a single component (eg, home mately continued 2.5 months,28 weekly exercise for 15 weeks,29
safety) of the multifaceted intervention to meet our inclusion and 1-stop multidisciplinary clinic30 as Model I studies. The
criteria and treated it as a single intervention. Each individual study follow-up period after intervention was also tabulated but not
might include any of several types of intervention strategies that included for analysis (Table 1). Most studies reported detailed
were conducted with the goal of fall prevention. Two studies used follow-up intervention periods and also used terms “intervention”
single intervention programs.13,15 Multifactorial intervention and “follow-up” interchangeably.
programs included a comprehensive medical exam, occupational
therapy assessment, activities of daily living, home environmental Pooled Results
and behavioral assessment, cognition assessment, gait stability,
medication review, staff training, and education for residents. The combined effect size based on RR and 95% confidence
Multifactorial team approaches included more than one staff intervals (CI) were calculated for each individual study and for the
member, including physicians, nurses, physical therapists, occu- overall 17 studies. The combined effect size of RR for the 17 studies
pational therapists, social workers, and/or other trained health care was 0.855 (z ¼ e2.168; P ¼.030; 95% CI ¼ 0.742e0.985). The overall
professionals. For example, individualized intervention programs results indicate that the interventions across the studies were
used in one study focused on counseling sessions after initial effective by demonstrating a 14% reduction in falls (Figure 2),
assessment followed by individualized exercises aimed at implying that 1 fall of 7 is possibly preventable with an
improving strength, coordination, and balance by trained accredi- intervention.
ted fitness instructors twice weekly was treated as a multifactorial
intervention.33 A total of 15 studies used multifactorial interven- Subgroup Analyses
tions using multidisciplinary team approaches.
We found, however, that there was clear evidence of heteroge-
Setting of Intervention neity across the findings of the pooled results (Q ¼ 196.204; df ¼
16; P ¼ .000; I2 ¼ 91.845). Therefore, we attempted to analyze the
One study’s intervention was applied in the hospital before reasons for the variance by conducting group comparisons across
patient discharge but evaluated over 1 year of follow-up in the the studies. We conducted 3 different group analyses stratified by
community. We treated this study as a community intervention.17 (1) type of intervention: 2 studies for single interventions versus 15
One study sample recruited from community-dwelling individ- studies for multifactorial interventions; (2) type of setting: 3
uals who attended the emergency department of the university studies in nursing homes and 14 studies in the community; and (3)
hospital was treated as a community intervention because inter- intensity of intervention: 8 studies for Model I and 9 studies for
vention was home based.28 Three studies were conducted in Model II. The subgroup analysis of all 17 studies demonstrated as
nursing homes.10,15,34 A total of 14 studies were conducted target- follows: a significant 14% fall reduction in multifactorial interven-
ing community-dwelling residents. One study was a nurse-led tions (RR ¼ 0.856; z ¼ e2.039; 95% CI ¼ 0.737e0.994; P ¼ .041) with
intervention,19 and 5 studies used home-based intervention no study variations between the groups (Q ¼ 0.002; df ¼ 1; P ¼
programs.18,19,28,35,36 .961); an inconceivable 54% fall reduction in nursing homes (RR ¼
0.453; z ¼ e9.366; 95% CI ¼ 0.384e0.535; P ¼ .000) with study
Intensity of Intervention variations between the groups (Q ¼ 62.788; df ¼ 1; P ¼ .000); and
no significant fall reduction was identified in either Model I or II.
Our initial intention was to determine the effectiveness of a fall-
prevention program between intervention periods shorter than Sensitivity Analyses
6 months versus longer than 12 months. Twelve studies used
shorter than 6-month interventions, and 14 studies used 12 months A sensitivity analysis is crucial in determining how robust the
or more of follow-up interventions. There were no other inter- findings were.31 We were interested in how the findings would
vention periods reported, such as 8 months or 9 months. There was shift if we determined results deleting high standardized random
a great deal of variability in terms used (intervention period/ residuals. Four of the 17 studies showed large standard residuals
duration, data collection period, follow-up period/duration) across ranging from e2.42 to 2.46. These studies were also identified as
the studies. For example, Elley et al18 reported that the exercise outliers whose effects were substantially different from others.
intervention was delivered for 1 year during home visits at weeks 1, According to Borenstein et al,31 sensitivity analysis can be used “to
2, 4, and 8, and after 6 months. However, no interventions were investigate whether the conclusions would differ across a range of
reported after 6 months. We treated this study intervention period plausible imputed values.” We removed these 4 studies one at
as 6 months. Another study10 purporting a 12-month trial in a time from the analysis to determine the change of overall effect
nursing homes reported that the intervention was 12 months with size until the homogeneity across the studies was determined. The
12 months of follow-up, which counts as a total of 24 months. combined effect size of RR of 13 studies after excluding 4
Because the entire trial was 12 months, the intervention and studies10,18,34,38 was 0.906 (z ¼ e3.179; P ¼ .001), with 95% CI of
follow-up occurred at the same time. Furthermore, specific inter- 0.853e0.963, demonstrating there was an overall significant fall-
vention periods were not always reported. As an inference from this reduction rate (9%) across the studies (Figure 3). These remaining
fact, we thought it optimal to dichotomize interventions to Model I 13 studies were found to be homogeneous (Q ¼ 18.582; df ¼ 12; P ¼
or II to determine the effectiveness of fall-prevention programs. .099; I2 ¼ 35.423), demonstrating that there was no variation across
We, therefore, divided all studies into Model I or II depending on the studies.
188.e17
Table 1
Studies Included in Meta-Analysis
First Author Year Control Intervention Intervention Intervention Setting Mean Intervention Programs
n n Period/Follow- Model Age
up, mo
1. Berggren17 2008 97 102 1/12 I C 81 Two visits at 4 months and 12 months focusing on comprehensive geriatric assessment of in-hospital
patients after hip fracture, calcium 1000 mg with vitamin D 800 IU, rehab program, home training programs (M)
2. Broe15 2007 25 23 5/5 II NH 89 Simple vitamin D supplement with different doses in 4 groups for 5 months (S)
3. Campbell13 2005 196 97 1/12 II C 84 Two-day home safety alone program focusing on muscle strengthening and balance retraining for elderly with
severe visual impairments (S)
4. Clemson14,* 2004 153 157 2/14 I C 76 Two-hour session for 7 weeks focusing on lower limb balance and strengthening exercise, improving home and
community environmental and behavioral safety, making adaptations to low vision, and medication review (M)
27,*
5. Davison 2005 154 159 12/12 II C 77 Follow-up every 4 weeks over 12 months with multifactorial intervention focusing on comprehensive cardio,
n, sample size; C, community; NH, nursing home; H, hospital; OT, occupational therapy; FAI, Frenchay Activity Index; ED, emergency department; ECG, electrocardiogram; BP, blood pressure; M, multifactorial intervention;
S, single intervention; MMSE, Mini-Mental State Examination; GDS, Geriatric Depression Scale.
*
Indicates intention-to-treat analysis reported in each study.
M. Choi, M. Hector / JAMDA 13 (2012) 188.e13e188.e21 188.e18
Study name Type Intervention Model Setting Statistics for each study Risk ratio and 95% CI
Risk Lower Upper
ratio limit limit Z-Value p-Value
Berggren Multi 1.000 Com 0.761 0.573 1.009 -1.896 0.058
Broe Single 2.000 NH 0.494 0.202 1.206 -1.548 0.122
Campbell Single 2.000 Com 1.000 0.778 1.285 -0.003 0.998
Clemson Multi 1.000 Com 0.828 0.614 1.118 -1.232 0.218
Davison Multi 2.000 Com 0.936 0.883 0.992 -2.237 0.025
Day Multi 1.000 Com 0.667 0.494 0.900 -2.647 0.008
Hendriks Multi 1.000 Com 1.017 0.671 1.542 0.080 0.936
Lightbody Multi 1.000 Com 0.853 0.792 0.919 -4.171 0.000
Lord Multi 2.000 Com 1.028 0.830 1.274 0.255 0.799
Mahoney Multi 1.000 Com 0.854 0.690 1.058 -1.440 0.150
Spice Multi 1.000 Com 0.899 0.811 0.998 -2.004 0.045
Vind Multi 1.000 Com 1.089 0.906 1.309 0.911 0.363
van Hasstregt Multi 2.000 Com 1.118 0.728 1.718 0.509 0.611
0.906 0.853 0.963 -3.179 0.001
0.1 0.2 0.5 1 2 5 10
0.1
Standard Error
0.2
0.3
0.4
0.5
0.62
0.44
0.26
-0.10
-0.28
-0.46
-0.64
-0.82
-1.00
-11.20 29.84 70.88 111.92 152.96 194.00 235.04 276.08 317.12 358.16 399.20
Sample size
There is little disagreement that RCTs are the most rigorously hanging fruit” of falls preventiondbed, chair, and personal alarms;
designed scientific experimental studies in testing such questions hip protection devices; lowered beds; mats on the floor; and
as these 17 trials on fall prevention attempt to address. Yet, in meticulous training of attendants to pay attention to all of these to
fall-intervention RCT studies, blinding the control group to such the extent that they are of benefitdhave already been incorporated
prevalent ambient sources of information about evolving into a necessarily practical prevention program.
practices and assistive equipment is nearly impossible. None
of the studies reported blinding. Unlike blinding, studies
with allocation concealment reported to reduce selection bias Implications for Clinical Practice
and protect the randomization were few. It is for these and
undoubtedly many more known or unknown reasons that it Implementing intervention programs preventing falls for older
becomes so difficultdbordering on the heroicdto do essential fall- adults seems to be plausible and highly desirable, but the overall
intervention research studies. Therefore, it is difficult to examine the effectiveness of intervention programs are not supported strongly
literature in aggregate and derive an intervention, or set of inter- by significant statistical results. The following are recommenda-
ventions, that truly seems to lend itself to recommendations that tions for health care providers to attempt to reduce fall rates in
providers can efficiently incorporate into their practice. their clinical practice: (1) identify an individual’s risk factors for
falls; (2) determine predisposing and precipitating factors if the
Limitation patient has a history of falls, and intervene accordingly; (3)
provide intervention programs and management focusing on
We found significant differences among the studies included lower-extremity balance and strengthening; (4) consider
in our meta-analysis. Owing to their small number, one potential psychological factors such as fear of falling and self-imposed
problem might be estimating the between-study variance, which restriction of activity;10 and (5) classify injuries when they do
might in turn have an influence on common effect sizes. Several occur based on the International Classification of Diseases (10th
potential limitations of this meta-analysis need to be addressed. revision, classification system).40
The limitation of a search based on electronic databases might
lead to an overestimation or underestimation of effect sizes. We
also consider that one significant limitation of the existing References
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Available at: http://www.cdc.gov/Injury/Publications/FactBook. Accessed
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