Background
People living with and beyond cancer are at risk of long-term problems including an increased risk of accidental falls. This is a result of the effect that the disease and the treatment can have on their body. Exercise reduces the rate and risk of falls in older people and is known to improve quality of life, tiredness and pain in people who have had cancer. It is not clear whether exercise can reduce the risk of falls in people living with and beyond cancer. This review was designed to determine the effect of exercise in reducing falls in people living with and beyond cancer.
Study characteristics
In July 2018, we searched for clinical trials about exercise to reduce falls in adults living with and beyond cancer. We found 11 studies of variable quality and size, including a total of 835 people, that compared exercise to usual care. Most of the studies were very small, four with fewer than 30 people. Only one study reported on accidental falls. All 11 studies reported on one or more measures that are risk factors for falling (e.g. strength, flexibility and balance).
Quality of the evidence
We rated the quality of the evidence from the studies using four levels: very low, low, moderate or high. Very low-quality evidence means that we are very uncertain about the results. High-quality evidence means that we are very confident in the results. The quality of the evidence was very low to low across all of the measures of interest. There were several weaknesses identified in the design of all studies including small numbers of participants. No study could prevent participants knowing their treatment and so there could have been bias.
Key findings
Only one study looked at the effect of exercise on accidental falls and found no difference in number of falls between people who exercised and people who did not (very low-quality evidence). Therefore, there were insufficient data for conclusions to be drawn regarding the effects of exercise on reducing accidental falls for people living with and beyond cancer. There was improvement in some factors that are known to affect falls; we found improvement in some measures of strength, flexibility and balance, although the overall quality of this evidence was very low to low.
There is a paucity of evidence for exercise training to reduce fall rates in people living with and beyond cancer. Exercise training may improve strength, flexibility and balance for people in this population, but the evidence is very low quality.
Current treatment modalities for cancer have been successful in achieving improved survivorship; however, they come with a number of long-term adverse effects. Accidental falls are a common and clinically significant adverse event in people living with and beyond cancer and rates are higher than in the rest of the population.
To assess the effects of prescribed or provided exercise for reducing accidental falls, and falls risk factors of strength, flexibility and balance, in people living with and beyond cancer.
We searched the following electronic databases from inception to 10 July 2018, with no restrictions: CENTRAL, MEDLINE, Embase, and seven other databases. We searched clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP) for ongoing trials, and reference lists of reviews and retrieved articles for additional studies.
We included all randomised controlled trials investigating exercise interventions versus no treatment, usual care or non-exercise interventions on falls incidence or falls risk factors in adults living with and beyond cancer (18 years of age or older at diagnosis). We excluded cross-over studies and studies in acute or inpatient hospice care.
At least two review authors independently completed data extraction for included papers. We used Covidence software to manage screening, data collection and extraction. We assessed evidence using GRADE and presented results in a 'Summary of findings' table.
Eleven studies (835 participants) compared exercise to usual care. No studies compared exercise with no treatment or non-exercise interventions. The quality of the evidence was very low for the primary outcome rates of falls, and very low to low for the secondary outcomes. We downgraded the evidence due to study limitations (risk of bias), and issues of imprecision due to small sample sizes, inconsistency and indirectness. All studies were at high risk of bias for blinding of participants and personnel due to inability to blind participants to an exercise intervention. Risk of bias was generally low or unclear for other categories.
There was generally little information on the important outcomes comparing exercise to usual care.
Rates of falls and number of fallers: one study (223 participants) measured accidental falls, but reported neither the rate of falls or the number of fallers; there was no difference in the number of falls between exercise and usual care (very low-quality evidence).
Strength: 10 studies (813 participants) reported on strength outcomes. Two analyses favoured exercise over usual care: quadriceps strength (2 studies, 72 participants; mean difference (MD) 8.99 kg, 95% confidence interval (CI) 1.29 to 16.70; low-quality evidence), and leg press (4 studies, 388 participants; MD 21.1 kg, 95% CI 8.47 to 33.74; low-quality evidence). In one analysis of the Sit-to-Stand Test, there was no difference between exercise and usual care (4 studies, 214 participants; standardised mean difference (SMD) –0.45, 95% CI –1.05 to 0.14; very low-quality evidence).
Flexibility: one study (21 participants) reported on flexibility for Sit-and-Reach Distance (MD 2.05 cm, 95% CI 0.59 to 3.51; very low-quality evidence).
Balance: five studies (350 participants) measured three different balance outcomes. Two analyses favoured exercise over usual care: postural balance (4 studies, 127 participants; standardised mean difference (SMD) 0.44, 95% CI 0.08 to 0.79; very low-quality evidence), and Backward Walk Test (2 studies, 280 participants; SMD –0.24, 95% CI –0.48 to –0.01; low-quality evidence). There was no difference between exercise and usual care for the Timed Up-and-Go Test (1 study, 15 participants; MD –0.35 seconds, 95% CI –1.47 to 0.77; low-quality evidence).
Number of people sustaining a fall-related fracture: the quality of the evidence for exercise reducing fall-related fractures was very low.
Adverse events: a single study (223 participants) noted some temporary muscle soreness on initiation of exercise or when there was an increase in the weight lifted. As no occurrence data were reported, we could not assess this variable further. No studies reported musculoskeletal injury. Analysis indicated that there was very low-quality evidence that exercise did not increase fatigue.