Research in context
Evidence before this study
We searched PubMed and the Cochrane Database for relevant articles published from Jan 1, 1980, to Dec 31, 2015. We used the keywords “falls”, “prevention training”, “aging”, “older adults”, and “Parkinson's disease”. We found several reviews and meta-analyses. Many intervention programmes based on reported multiple risk factors have been proposed and assessed. However, despite extensive knowledge about fall risk, no consensus exists as to the most effective or optimum treatment approach. To date, the effect of common treatment approaches on fall risk tends to be small and the reported changes are mainly focused on motor aspects with limited long-term retention. Furthermore, most trials have compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls, showing the need for studies with an active control comparison. A paucity of studies targeting participants with cognitive deficits was also noted. Additionally, recent work on the role of the central nervous system in mobility calls for multimodal interventions that target multiple pathways simultaneously, using an adaptive and individually tailored treatment in an enjoyable and challenging environment to increase adherence and maintenance.
Added value of this study
To our knowledge, this study describes the largest randomised controlled trial to investigate use of a multimodal, motor-cognitive training approach with a virtual reality component for the reduction of falls in older adults. Advantages of this approach include the fact that it provides training in a more engaging, stimulating, and enriched environment than does traditional rehabilitation, gives feedback about performance to the participant to enable the learning of new motor strategies of movement, and simultaneously addresses motor and cognitive aspects of fall risk that are crucial to safe ambulation. We compared our multimodal approach with an active comparison intervention (a matched treadmill training programme) but without the virtual reality component, to better estimate the added effect of the virtual reality system. Our results showed that treadmill training alone and treadmill training with virtual reality both reduced the risk of falls. Furthermore, the approach with a virtual reality component reduced fall rate and fall risk to a greater degree than did the active control comparison group.
Implications of all available evidence
Falls are widespread and common among older adults. However, ample evidence suggests that fall rates and risk can be reduced, even among older adults with an especially high risk of falls, such as people with Parkinson's disease. Multimodal approaches that target motor and cognitive function might have added value on top of that from an intervention that focuses on motor control alone. Our results suggest that interventions that combine technology, mobility training, and cognitive remediation to reduce the risk of falls and enhance mobility can reduce fall rates and fall risk among the elderly, even among those with chronic disease and cognitive deficits. Targeting of both the cognitive aspects of safe ambulation and mobility aspects through treadmill training is feasible, with little added cost compared with treadmill training alone, and with high levels of compliance, even in patients with neurodegenerative diseases and other high-risk populations. A game-like approach based on virtual reality seems to be able to engage subjects, motivate compliance, and reduce fall rates.