Skip to content

USPSTF: Exercise Best for Preventing Falls – updated recommendations from the U.S. Preventive Services Task Force (USPSTF)

by Jeff Minerd, Contributing Writer, MedPage Today 

Examples of effective exercise interventions evaluated in the clinical trials included supervised individual and group exercise classes, physical therapy, functional training, resistance training, and endurance training. The majority of trials, however, included group exercise classes.

Fall Prevention

Exercise is most effective for preventing falls in at-risk older adults, whereas vitamin D is not effective for this purpose ("D" statement), according to updated recommendations from the U.S. Preventive Services Task Force (USPSTF).

Moreover, the task force did not support vitamin D for preventing fractures in adults -- recommending against supplementation up to 400 IU/day in most post-menopausal women ("D" statement) and finding insufficient evidence to judge the benefit-risk balance with higher doses. The USPSTF had reached the same conclusions in 2013.

Multifactorial interventions for fall prevention tailored to individual patients -- which could include exercise, cognitive behavioral therapy, education, environmental modification, and other components -- are moderately effective, said the group of USPSTF researchers led by Janelle Guirguis-Blake, MD, of the University of Washington in Tacoma.

A systematic review of 62 randomized clinical trials found that exercise significantly reduced the risk for experiencing a fall (relative risk 0.89, 95% CI 0.81 to 0.97) and injurious falls (RR 0.81, 95% CI 0.73 to 0.90). Multifactorial interventions significantly reduced fall risk (RR 0.79, 95% CI 0.68 to 0.91) but not fall-related morbidities, the researchers reported in JAMA.

The evidence for vitamin D supplements was mixed. One trial reported significantly lower fall risk, and another trial of high-dose supplements reported significantly higher risk, but the majority of trials reported nonsignificant results.

"The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older (D recommendation). These recommendations apply to community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency," the task force wrote.

Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. In 2014, nearly 29% of community-dwelling adults 65 and older reported falling, for a total of 29 million falls. Of these, more than one-third necessitated medical treatment or restricted activity. There were an estimated 33,000 fall-related deaths in 2015, according to the report.

"Given this large burden of morbidity and the complexity of falls in older adults, it is important to determine which fall prevention interventions targeting modifiable fall risk factors (e.g., balance and gait abnormalities, environmental factors, medication adverse effects) are effective," the report said.

Examples of effective exercise interventions evaluated in the clinical trials included supervised individual and group exercise classes, physical therapy, functional training, resistance training, and endurance training. The majority of trials, however, included group exercise classes.

Primary care physicians can identify older adults at risk for falls with a few key risk factors. "A pragmatic approach to identifying persons at high risk for falls, consistent with the enrollment criteria for intervention trials, would be to assess for a history of falls or for problems in physical functioning and limited mobility. Clinicians could also use assessments of gait and mobility, such as the Timed Up and Go test," the authors wrote.

In an accompanying editorial, David Reuben, MD, of the University of California Los Angeles, said the exercise recommendations may not be as simple to implement as they seem. "At first blush, these recommendations seem to be straightforward deductions based on the evidence and should be easy for clinicians to follow. However, further evaluation shows how complicated the issues truly are," he said.

"In contrast with other USPSTF recommendations for screening (e.g., breast cancer, osteoporosis) that rely on a one-time action by clinicians ... these preventive services also require ongoing action by patients. Therefore, they rely on adherence and raise the question as to whether efficacy (outcomes under ideal conditions) or effectiveness (outcomes under usual conditions) should be the basis of the recommendations," Reuben said.

Vitamin D for Preventing Fractures

Advocates of vitamin D will likely be disappointed with the USPSTF's decision to leave in place its 2013 judgment about such supplements for fracture prevention -- saying, in effect, that 5 years of additional research still hasn't proven a benefit.

A systematic review of 11 randomized clinical trials, led by Leila Kahwati, MD, of RTI International in Research Triangle Park, N.C., and also published in JAMA, found that while vitamin D decreased total fracture incidence (absolute risk difference -2.26%, 95% CI -4.53% to 0.00%) it had no significant effect on hip fractures (ARD -0.01%, 95% CI -0.80% to 0.78%).

Furthermore, the review found that the combination of vitamin D and calcium had no significant effect on total fracture incidence (ARD -0.35%, 95% CI -1.02% to 0.31%) or hip fractures (ARD -0.14%, 95% CI -0.34% to 0.07%), the researchers said.

For men and premenopausal women, the task force concluded "that the current evidence is insufficient to assess the balance of the benefits and harms of vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in community-dwelling, asymptomatic men and premenopausal women."

For post-menopausal women, the USPSTF in 2013 and again in the new update recommended against supplements up to 400 IU/day for vitamin D and 1,000 mg/day for calcium for purposes of fracture prevention, and found insufficient evidence to recommend for or against these supplements at higher doses.

The task force noted, however, that the recommendations do not apply to those with a history of osteoporotic fractures, those with osteoporosis or vitamin D deficiency, or those at increased risk for falls.