Otago exercise program: recommended for all older adults or not?

Abstract

With great interest, we read the article of Jahanpeyma et al. entitled “Effects of the Otago exercise program on falls, balance and physical performance in older nursing home residents with high fall risk: a randomized controlled trial” [1]. To our knowledge, this is one of the first studies to implement the Otago Exercise Program (OEP) in a nursing home setting. The authors demonstrate a beneficial effect of 12 weeks OEP, compared to a walking intervention alone, on balance, physical performance, and fall incidence in 72 nursing home residents (> 65 years) [1]. Interestingly, in the same month, Lamb et al. published a large, cluster-randomized, controlled trial in 9803 community-dwelling older adults (> 70 years) in which the effects of OEP combined with fall prevention advice by mail were compared to fall prevention advice alone or a multifactorial fall prevention [2]. Implementing OEP did not result in a lower fracture incidence, compared to fall prevention advice by mail alone. This raises the question to the clinician: should we recommend OEP to all older adults or not? First, a key issue of the OEP—and for many, if not all, exercise and lifestyle interventions—is to define the right target population. Lamb et al. [2] used the home-based exercise protocol focussing on community-dwelling older adults, for whom OEP was initially designed and validated to prevent falls [3]. In contrast, Jahanpeyma et al. [1] targeted nursing home residents. Despite this deviation of target population, the intervention was successful in preventing falls in the study with nursing home residents and not in the study with community-dwelling older adults. This might be attributed to the difference in fall risk. Nursing home residents can generally be considered at increased risk of falling. In contrast, in the study of Lamb et al. less than half of the participants (4192/9803) participants were considered as subjects with increased risk of falls (based on a screening questionnaire). The difference in fall risk between both studies is more clearly depicted when comparing the frequency of previous falls at baseline: in the OEP intervention group of the community-dwelling population, only 986 out of 3211 (31%) had fallen in the previous year with a median of 0 falls (IQR:0–1) [2], whereas 32 out of 35 subjects (91.4%) in the intervention group of the nursing home residents reported a fall in the last three months with a mean of 1.94 ± 1.187 falls [1]. Second, the way in which OEP is implemented might play a determining role in the contradicting results. The original OEP protocol suggested a start-up period with four home visits by an OEP trainer in the first two months and afterwards followed by booster home visits every 6 months with motivational telephone calls between visits [3]. Lamb et al. aimed to deliver a minimum of seven supervised sessions over 6 months of which the participant had to be present in person for at least four sessions and the others could be performed by phone [2], whereas Jahanpeyma et al. supervised all OEP sessions in person during the first month (three times a week) and offered a weekly supervised session in person alternated by individual training without supervision in the second and third month of the trial, resulting in at least 20 contact moments per participant[1]. Moreover, supervised training sessions in the nursing home were performed in small groups (nine persons per group), whereas it is unclear in the paper of Lamb et al. if the supervised sessions in the community-dwellers were in a group or at home. These different environments might have contributed to the divergent conclusions of both studies. However, the intense workload with small groups and frequent contact moments in the nursing home study can rise questions * Jolan Dupont [email protected]