Evaluation of participation restriction in trials of exercise interventions to prevent falls in older people: A systematic review and meta-analysis.

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Participation, as defined by the International Classification of Functioning, Disability and Health, reflects the societal consequences of health conditions. Despite being a key component of functioning and an important goal of rehabilitation, participation is not measured consistently in ageing research. Falls are a major public health problem. Fortunately, well-designed exercise interventions have been shown to reduce falls in older people. To date, evaluation of these interventions has focused on rate of falls, impairment of body function and performance of tasks. The consequence of falls prevention programs on functioning at a societal level have not been evaluated. Increased understanding of how falls prevention interventions affect participation may provide opportunities to enhance outcomes for people at risk of falling. The objectives of this study are to: - Evaluate the extent to which measurement of participation has been reported in trials of fall prevention interventions with an exercise component. - Determine whether exercise interventions targeting falls increase ICF participation in older people. We will undertake a systematic review with meta-analysis of randomised controlled trials of interventions including exercise that aimed to reduce falls in older people in the community, aged care facilities or hospital. Studies will be extracted from the Cochrane Review of interventions for preventing falls in older people living in the community(1) and the Cochrane Review of interventions for preventing falls in older people in nursing care facilities and hospitals.(2) We will re-run the search strategies used in these Cochrane Reviews in Medline, EMBASE, AMED, PsychINFO, CINAHL and CENTRAL. The original Cochrane Reviews searched CINAHL via the Ovid platform. As this is no longer available, CINAHL will be accessed via EBESCO. The searches will run from the final date searched by Gillespie et al(1) and Cameron et al,(2) to May 2010. Language restrictions will not be applied. Measurement instruments used in the trials will be linked to the ICF then assessed against instrument classification criteria, to determine whether they measure participation. Trials with published participation data at baseline and at least one follow-up time-point will be included in the meta-analysis. In order to minimise bias, the following methods will be used: - Study selection. One author will independently examine the titles, abstracts and keywords to identify potentially relevant trials from the search results. Full text reports will be obtained for all potentially eligible studies. Based on the full text reports, two authors will independently decide on study inclusion. Differences will be resolved by discussion or, if necessary, arbitrated by an independent third author. Details of discussions will be kept. - Data extraction. Data regarding trial characteristics and estimates of effect of the intervention will be extracted from the included trials by one author and checked by a second author. Disagreement will be resolved by discussion or, if necessary, arbitration by third author. - Duplicate publication bias will be avoided by comparing author names, sample sizes, interventions and outcomes. - Publication bias will be assessed using Egger’s test and observation of the funnel plot. - Assessment of bias of included studies. Two authors will independently assess risk of bias using the Cochrane risk of bias tool, outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Bias will be considered from the study level (assessment of sequence generation and adequacy of allocation concealment) and also the outcome level (evaluation of the methods used to measure the participation outcome in each study: blinding of outcome assessors, completeness of participation data and selective reporting of participation data). Any disagreement will be resolved by consensus or third-party arbitration. (1) Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009(2):CD007146. (2) Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010(1):CD005465.