COMMUNITY

MEDICINE

JOURNAL
APPRAISA
L
Janelcris G. Enriquez
Community Clerk August 2014

Community-based Group
Exercise Improves
Balance and Reduces
Falls in At-risk Older
People
a randomized controlled trial

 OBJECTIVE:
To determine whether participation
in a weekly group exercise
programme with ancillary home
exercises over one year improves
balance, muscle strength, reaction
time, physical functioning, health
status and prevents falls in at-risk
community-dwelling older people.

DESIGN:
A randomized controlled trial

SETTING AND SUBJECTS

The subjects were drawn from
601 people aged 65 years and
older who attended one of 24
general practice clinics or two
acute hospital physiotherapy
departments in South Western
Sydney, Australia.

SETTING AND SUBJECTS

Screening assessments:
an inability to stand from a 45 cm
high chair in less than 2 seconds;
a need to step to maintain balance
when performing a near-tandem
balance test
inability to catch a rod dropped
from above the hand within 300
milliseconds.

INTERVENTION
Subjects
randomised
to
the
intervention arm attended a weekly
structured exercise group run in a
community setting. An accredited
exercise instructor trained to provide
the same programme led each class.
The class content was designed by a
physiotherapist to specifically address
physical falls risk factors.

INTERVENTION
Functional exercises
sit to stand practice
weight transference
reaching were an important part of
the group exercise.
There was a 10-minute cool down
where the participants performed
gentle stretches and then in a
seated
position
practiced
relaxation
and
controlled

RESULTS
At baseline both groups were well
matched in their physical performance,
health and activity levels.
At retest, the exercise group performed
significantly better than the controls in
three of six balance measures;.
Within the 12-month trial period, the
rate of falls in the intervention group
was 40% lower than that of the control
group (IRR=0.60, 95% CI 0.360.99).

CONCLUSION
These
findings
indicate
that
participation in a weekly group
exercise programme with ancillary
home exercises can improve balance
and reduce the rate of falling in atrisk
community
dwelling
older
people.

CRITICAL APPRAISAL

Primary Validity
Guidelines: (Yes/No)

Was the assignment of patients to

treatment randomized?

YES.

Were all patients who entered the trial properly

accounted for and attributed at its conclusion?

YES.

Were all patients who entered the trial properly

accounted for and attributed at its conclusion?

Yes, patients were properly

accounted, and attributed.

Was follow-up complete? Dropouts,

withdrawals
Yes, all patients that participated in
the study followed up throughout the
duration of the study.
There was 7 withdrawals from exercise
group while 6 on control group.

Were patients analyzed in the groups

to which they were randomized?

Yes, the participants were

analyzed within the groups
to which they are
randomized.

CRITICAL APPRAISAL

Secondary Validity
Guidelines

Were patients, their clinicians, and

study personnel blind to treatment?
Yes, Three assessors blind to
treatment status administered
the physical performance and
general health measure
assessments.

Were the groups similar at the start

of the trial?

Yes, the baseline

characteristics of each
group were similar at the
start of the trial.

Aside from the experimental intervention,

were the groups treated equally?

Yes, all patients received

the appropriate treatment.

IS THE STUDY VALID?

YES.
The primary validity guide
questions as well as the secondary
validity guide questions were
answered well.

OUTCOME
OUTCOME

EXERCISE GROUP
VS. CONTROL
GROUP

(+)

(-)

Treated(Y)

Y=a/(a+b)

Control(X)

X =c/(c+d)

Treated(Y)

83

Y= 83/(83+7) =
0.922

80

Y= 83/(83+7) =
0.922

Control(X)

RISK OF OUTCOME

Experimental Event Rate (EER)

A measure of how often a particular statistical
event (such as response to a drug) occurs within
the experimental group (non-control group) of an
experiment
In the treatment group, number of patients with
(+) outcome divided by total number of patients
No Pxs with outcome = __a__
Total no of patients
(a+b)
EER Exercise group 0.922

Control Event Rate (CER

A measure of how often a particular statistical
event (such as response to a drug) occurs within
thescientific control groupof an experiment.
In the control group, number of patients with (+)
outcome divided by total number of patients

No of PXs with outcome = __b__

Total no of patients
(b+d)
CER Control group 0.930

How large was

the treatment
effect?

Relative Risk or Risk

Ratio (RR)
the risk of the outcome occurring in
the intervention group compared
with the control group.
RR = EER/CER
RR (Exercise group vs. control group)
=
0.922/0.933 = 0.988

Absolute Risk Reduction

(ARR)
decrease inriskof a given activity (or
treatment) in relation to a control activity.
Risk of the outcome in the control group risk of
the outcome in the treatment group.
ARR (Exercise group vs. control group) =
CER-EER=
0.922-0.933 = 0.011
The absolute benefit of treatment is a 11%
reduction in the outcome for exercise group vs.
control group.

How large was the treatment

effect?
Take the inverse of the ARR which tells us the
number of patients that we'd need to treat with the
experimental therapy in order to prevent one
additional bad event.
Number Needed to treat (NNT) (exercise group
vs. control group) = 1 / ARR = 1/0.011 = 91
Therefore, we need to treat 91 patients for 60
months in order to prevent the occurrence of the risk
with exercise group vs. control group.

CAN THE RESULT BE APPLIED TO MY

PATIENT CARE?

YES.

WERE ALL CLINICALLY IMPORTANT

OUTCOMES CONSIDERED?

Yes, all relevant outcomes

were considered.