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Phys. Ther. Korea 2021; 28(1): 1-12

Published online February 20, 2021

https://doi.org/10.12674/ptk.2021.28.1.1

© Korean Research Society of Physical Therapy

The Literature Review on the Effectiveness of Fall-related Hip Fracture Prevention Programs

Se-young Lee , PT, BPT, Seung-su Kim , PT, BPT, Kitaek Lim , PT, BPT, Woochol Joseph Choi , PT, PhD

Injury Prevention and Biomechanics Laboratory, Department of Physical Therapy, Yonsei University, Wonju, Korea

Correspondence to: Woochol Joseph Choi
E-mail: wcjchoi@yonsei.ac.kr
https://orcid.org/0000-0002-6623-3806

Received: January 11, 2021; Revised: January 26, 2021; Accepted: January 27, 2021

While efforts have been made to address fall-related injuries in older adults, the problem is unsolved to date. The purpose of this review is to provide a guideline for fall and injury prevention programs in older adults, based on evidence generated over the past 30 years. Research articles published between 1990 and 2020 have been searched on PubMed, using keywords, including but not limited to, falls, hip fracture, injuries, intervention, older adults, prevention, hip protector, vitamin D, safe landing strategy, and exercise. Total of 98 articles have been found and categorized into five intervention areas: exercise program, hip protector, safe landing strategy, vitamin D intake, and compliant flooring. Furthermore, the articles have been rated based on their study design: class 1, randomized controlled trials; class 2, nonrandomized controlled trials; class 3, experimental studies; class 4, all other studies. Exercise programs have shown to decrease the risk of fall, and associated injuries. Hip protectors, safe landing strategy, and vitamin D intake were effective in reducing a risk and incidence of hip fracture during a fall. Furthermore, compliant flooring has also decreased hip fracture risk without affecting balance. An integrated approach combining exercise program, wearing a hip protector, teaching safe landing strategies, scheduled vitamin D intake, and compliant flooring installation, is suggested to address fall-related injuries in older adults.

Keywords: Exercise, Falls, Hip fracture, Intervention, Older adults, Prevention

노인 낙상을 줄이기 위해 많은 노력이 있었음에도 불구하고 지난 10여년간 노인의 넘어짐으로 인한 사망률은 지속적으로 증가했고, 2030년까지 시간당 7명의 사망률을 예측하고 있다[1]. 연구결과를 바탕으로 여러 중재법이 제시되어 오고 있음에도 불구하고, 노인 낙상 문제가 쉽게 해결되지 않는 이유는 증가하는 노인 인구에 있기도 하지만, 왜 넘어지고, 어떤 넘어짐이 골절을 유발하는지에 대한 불명확한 이해가 이유이기도 하다. 실제로 1%–2%의 노인의 넘어짐만이, 생명을 위협하는 고관절 골절을 일으키는데[2], 왜 그런지에 대한 명확한 이해는 부족한 실정이다. 다행히도 연구자들의 노력으로 골절 위험도에 영향을 미치는 10여 가지의 생체역학적 요인들이 확인되었고, 이를 바탕으로 중재법들이 제안되어 오고 있지만, 완전한 이해를 위해서는 지속적인 연구가 필요한 실정이다.

본 리뷰의 목적은, 현재까지 제시된 증거 기반 노인 넘어짐 및 고관절 골절 예방프로그램의 효과를 고찰하고, 노인 낙상예방을 위한 통합적인 중재법의 방향성을 제시함에 있다. 이를 위해, 현재까지 알려진 노인 낙상 예방 중재 방법을 운동프로그램(i.e., 균형능력증진, 근력강화, 지구력강화 등), 고관절 보호대의 사용, 안전하게 넘어지는 전략 (i.e., 구르기, 엉덩이와 무릎이 동시에 바닥에 닿기 등), 비타민 D 섭취, 그리고 충격 흡수 매트 등 5가지 영역으로 나누고, 각 영역별로 현재까지 출판된 논문을 정리하여 고찰하였다.

1. 논문 검색 및 분류 방법

1990년부터 2020년까지 출판된 논문들이 PubMed를 통해 검색되었다. 사용된 키워드로는 Falls, hip fracture, injuries, intervention, older adults, prevention, hip protector, vitamin D, safe landing strategy, exercise 등을 포함했다. 검색 결과, 308개의 영어 논문이 검색되었으나, 종설 논문과 초록 및 원문 확인이 불가한 원저 논문, 그리고 Journal Citation Report에 색인되어 있지 않은 논문을 제외하여 총 117편의 논문이 확인되었다. Physical Therapy Korea 종설 논문 참고문헌 개수 제한에 따라 journal impact factor percentile 하위 19개의 논문을 제외하고, 총 98편의 논문이 운동프로그램(44편), 고관절 보호대(28편), 안전하게 넘어지는 전략(13편), 비타민 D 섭취(9편), 그리고 충격 흡수 매트(6편) 등 5가지 영역으로 나뉘어 고찰되었다(Table 1). 또한, 연구 논문 결과의 영향력을 구분하기 위해, 연구 디자인에 따라 다음의 네 개의 등급으로 나누어 고찰하였다. 1등급, 무작위대조실험연구(randomized controlled trials); 2등급, 대조실험연구(non-randomized controlled trials); 3등급, 대조군 없는 실험 연구(experimental studies); 4등급, 1, 2, 3등급에 속하지 않은 모든 유형의 연구(i.e., case study 등).

Table 1 . The number of articles included in this review.

InterventionsClass of evidenceaTotal

1234
Exercise programs3328144
Hip protector1459028
Safe landing strategy049013
Vitamin D intake81009
Compliant flooring12306

aClass 1: randomized controlled trials. Class 2: non-randomized controlled trials. Class 3: experimental studies with no control group. Class 4: studies not belonging to Class 1, 2, and 3 (i.e., case study)..


1. 운동프로그램

노인의 균형 능력 증진을 통한 낙상예방을 위한 운동중재는 다양한 연구에서 검증되었으며, 연구들의 결과 변수에 따라 정적 균형, 동적 균형, 통합 균형(정적 균형과 통합 균형을 함께 확인하는 결과변수), 설문지, 넘어짐 또는 골절 횟수로 나누어 고찰되었다.

1) 정적 균형

압력 중심점의 궤도(trajectory of center of pressure)를 통해 균형 증진이 확인된 운동은 갑작스러운 속도 변화 훈련(unexpected perturbations training), 다감각 훈련(multisensory training), 시각 유도 무게 이동(visually guided weight-shifting), 보수와 스위스볼(Bosu and Swiss ball), 그룹 운동(group exercise) 등이 있었다(Table 2) [3-14]. 기능적 팔 뻗기 검사를 통해 균형 능력 증진이 확인된 운동은 태극권(Tai Chi), 흉부골반 보조 운동(thoracopelvic assisted movement) 등이 있었다. 한발 서기 검사를 통해 균형 증진을 확인한 운동은 그룹 운동(group exercise)이 있었다. 그 외 컴퓨터 게임을 적용하여 균형을 잃은 횟수를 통해 균형 능력 증진을 확인하였으며, 그룹 운동을 적용하여 균형감각조절임상검사를 통해 균형 능력 증진을 확인하였다.

Table 2 . Effect of exercise on static balance.

ArticlesClass of evidenceInterventionsOutcomesImprove
Kurz et al., 2016 [3]1Unexpected perturbation trainingCOPYes
Alfieri et al., 2012 [4]1Multisensory trainingCOPYes
Hatzitaki et al., 2009 [5]1Visually guided weight-shiftingCOPYes
Li et al., 2004 [6]1Tai ChiFRTYes
Cyarto et al., 2008 [7]1Group exerciseOLSYes
Szturm et al., 2011 [8]1Interactive computer gameLoss of balanceYes
Barnett et al., 2003 [9]1Group exerciseCOPYes
Jorgensen et al., 2013 [10]1Nintendo WiiCOPNo
Martínez-Amat et al., 2013 [11]2Bosu and Swiss ballCOPYes
Bulat et al., 2007 [12]3Group exercise1. COP2. CTSIB1. Yes2. Yes
Springer et al., 2018 [13]3Thoracopelvic assisted movementFRTYes
Sung et al., 2018 [14]4Tai ChiFRTYes

COP, center of pressure; FRT, functional reach test; OLS, one leg standing test; CTSIB, clinical test of sensory integration on balance..


2) 동적 균형

보행 속도 확인을 통해 균형 증진을 확인한 운동중재에는 노르딕 보행(Nordic walking), 흔들의자 가정기반운동(home-based rocking chair exercise), 강렬한 운동(intensive exercise), 시각 보조 트레드밀(projected visual context treadmill), 장기간 강화 및 균형 훈련(long-term strength and balance training), 넘어짐 예방 프로그램(fall prevention program), 흉부골반 보조 운동(thoracopelvic assisted movement), 태극권(Tai Chi), 이중 작업 훈련(dual-task training)이 있었다(Table 3) [15-23]. 보행 변수들을 통해 균형 증진을 확인한 운동은 이중 작업 훈련(dual-task training)이 있었다. 동적 보행 지수를 통해 균형 증진을 확인한 운동은 이중 작업 훈련(dual-task training), 태극권(Tai Chi), 물리치료중재(physical therapeutic intervention)가 있었다. 보행 중 총 이동거리를 통해 균형 증진을 확인한 운동은 수정된 오타고 운동 프로그램(modified Otago exercise program)이 있었다.

Table 3 . Effect of exercise on dynamic balance.

ArticlesClass of evidenceInterventionsOutcomesImprove
Gomeñuka et al., 2019 [15]1Nordic walkingGait speedYes
Niemelä et al., 2011 [16]1Home-based rocking-chair exerciseGait speedYes
Oh et al., 2012 [17]1Intensive exerciseGait speedYes
van Ooijen et al., 2016 [18]1Projected visual context treadmillGait speedYes
Li et al., 2004 [6]1Tai ChiDynamic gait indexYes
Wolf et al., 2001 [19]1Physical therapeutic interventionDynamic Gait IndexYes
Conradsson and Halvarsson, 2019 [20]1Dual-task balance trainingGait parametersYes
Barnett et al., 2003 [9]1Group exerciseGait speedNo
Springer et al., 2018 [13]3Thoracopelvic assisted movementGait speedYes
Li, 2014 [21]3Tai ChiGait speedYes
Dorfman et al., 2014 [22]3Dual-task training1. Gait speed2. Dynamic gait index1. Yes2. Yes
Renfro et al., 2016 [23]3Modified Otago exercise programTotal walk distanceYes

3) 통합 균형

정적 및 동적 균형을 함께 측정할 수 있는 임상균형측정 도구는 버그균형척도(Berg Balance scale, BBS), 일어서서 걷기검사(Timed Up and Go, TUG), 실행지향움직임 평가(Tinetti Performance Oriented Mobility Assessment, POMA), 플러턴 어드밴스드 균형척도(Fullernton Advanced Balance Scale), 의자에서 일어나기(Chair stand test), 8-foot up-and-go test, 수정된 운동수행검사(Physical Performance Test), 간편신체기능검사(Short Physical Performance Battery, SPPB) 등 다양했는데, 이러한 임상균형측정 도구를 이용해 균형 능력 증진을 확인한 운동은 더욱더 다양했다(Table 4) [24-36].

Table 4 . Effect of exercise on balance (studies using clinical balance measurement tools).

ArticlesClass of evidenceInterventionsOutcomesImprove
Binder et al., 2002 [24]1Intensive exercise trainingPerformance testYes
Cyarto et al., 2008 [7]1Group-based resistance and balancetraining8-foot up-and-go testYes
Frih et al., 2018 [25]1Combined exercise1. TUG2. Tinetti3. BBS1. Yes2. Yes3. Yes
Irandoust et al., 2019 [26]1Aquatic exerciseTinettiYes
Jorgensen et al., 2013 [10]1Nintendo Wii1. TUG2. Chair stand test1. Yes2. Yes
Lai et al., 2013 [27]1Video game with exercise1. BBS2. TUG1. Yes2. Yes
Leiros-Rodríguez and García-Soidan,2014 [28]1Balance training1. BBS2. TUG1. Yes2. Yes
Li et al., 2004 [6]1Tai ChiBBSYes
Li et al., 2018 [29]1Biofeedback balance training withfunctional electrical stimulationBBSYes
Mihailov and Popa, 2010 [30]1Long term exercise1. Tinetti2. TUG1. Yes2. Yes
Niemelä et al., 2011 [16]1Home-based rocking-chair exerciseBBSYes
Pollock et al., 2012 [31]1Whole body vibration with strengthand balance exerciseTUGYes
Pooranawatthanakul andFoongchomcheay, 2015 [32]1Video game (Wii)-based exercise1. BBS2. Fullerton1. Yes2. Yes
Steadman et al., 2003 [33]1Enhanced balance trainingBBSYes
Wolf et al., 2001 [19]1Balance trainingBBSYes
Zhang et al., 2014 [34]1Whole body vibrationTUGYes
Szturm et al., 2011 [8]1Interactive computer game exercise1. BBS2. TUG1. Yes2. No
Hale et al., 2012 [35]1Water based exerciseTUGNo
Sherrington et al., 2020 [36]1Recovery exercise after fractureSPPBNo
Martínez-Amat et al., 2013 [11]2Proprioception training1. BBS2. Tinetti1. Yes2. Yes
Bulat et al., 2007 [12]3Functional balance trainingBBSYes
Dorfman et al., 2014 [22]3Dual tasking on treadmillBBSYes
Li, 2014 [21]3Tai ChiTUGYes
Springer et al., 2018 [13]3Thoracopelvic assisted movement trainingTUGYes

4) 설문지

넘어짐 효능감 척도(fall efficacy scale)를 통해 균형 증진을 확인한 운동은 닌텐도 위(Nintendo Wii), 태극권(Tai Chi), 상호작용 비디오 게임(interactive video game), 기능적 전기 자극을 통한 시각 되먹임 기반 훈련(visual feedback based training with functional electric stimulation), 가정기반 운동 프로그램(home-based exercise program), 전신 진동(whole body vibration)이 있었다(Table 5) [37-43]. 행동특이적 균형 자신감 척도(activities-specific Balance Confidence Scale)를 통해 균형 증진을 확인한 운동은 지구력 저항 운동(endurance-resistance exercise), 니즈메겐 넘어짐 예방 프로그램(Nijmegen fall prevention program), 상호작용 컴퓨터 게임(interactive computer game), 전신 진동(whole body vibration)이 있었다. 두려움 척도(fear of falling)를 통해 균형 증진을 확인한 운동은 시각 보조 트레드밀(projected visual context treadmill), 기능적 순환 훈련(functional circuit training), 시각적 되먹임 균형 훈련(visual feedback based balance training), 태극권(Tai Chi)이 있었다.

Table 5 . Effect of exercise on balance (studies using questionnaires).

ArticlesClass of evidenceInterventionsOutcomesImprove
Frih et al., 2018 [25]1Endurance-resistance exerciseABCYes
Smulders et al., 2010 [37]1Nijmegen fall prevention programABCYes
Szturm et al., 2011 [8]1Interactive computer gameABCYes
Zhang et al., 2014 [34]1Whole body vibrationABCYes
Jorgensen et al., 2013 [10]1Nintendo WiiFESYes
Lai et al., 2013 [27]1Interactive video gameFESYes
Li et al., 2018 [29]1Visual feedback-based training with functionalelectric stimulationFESYes
Pollock et al., 2012 [31]1Whole body vibrationFESYes
van Ooijen et al., 2016 [18]1Projected visual context treadmillFear of fallingYes
Giné-Garriga et al., 2013 [38]1Functional circuit trainingFear of fallingYes
Sihvonen et al., 2004 [39]1Visual feedback-based balance trainingFear of fallingYes
Wolf et al., 1996 [40]1Tai ChiFear of fallingYes
Zeeuwe et al., 2006 [41]1Tai ChiFear of fallingYes
Cyarto et al., 2008 [7]1Group exerciseABCNo
Hale et al., 2012 [35]1Water-based exerciseABCNo
Kurz et al., 2016 [3]1Unexpected perturbations trainingFESNo
Barnett et al., 2003 [9]1Group exerciseFear of fallingNo
Wolf et al., 2001 [19]1Physical therapeutic interventionFear of fallingNo
Miller et al., 2010 [42]3Home-based exercise programFESYes
Groen et al., 2010 [43]3Martial artsFear of fallingYes

ABC, activities-specific balance confidence scale; FES, fall efficacy scale..


5) 넘어짐 및 골절 횟수

넘어짐 횟수(number of falls) 및 골절 횟수(fracture incidence)를 통해 낙상예방 효과를 확인한 운동은 가정 기반 운동(home based exercise), 가상 현실을 이용한 균형 운동(balance exercise with using virtual reality), 기능적 전기 자극을 함께 사용한 시각 되먹임 기반 힘판 훈련(visual feedback-based force platform training with functional electrical stimulation), 칼슘-비타민 보충제 복용과 함께한 운동(exercise with calcium and vitamin supplement), 시각 보조 트레드밀 (treadmill training with projected visual context), RESTORE 치료(RESTORE intervention) 등이 있었다(Table 6) [44-46].

Table 6 . Effect of exercise on fall and fracture incidence.

ArticlesClass of evidenceInterventionsOutcomesImprove
Campbell et al., 1997 [44]1Home based exerciseFall incidenceYes
Duque et al., 2013 [45]1Balance exercise using Virtual RealityFall incidenceYes
Li et al., 2018 [29]1Visual feedback-based force platform trainingwith functional electrical stimulation1. Fall incidence2. Fracture incidence1. Yes2. Yes
Sihvonen et al., 2004 [39]1Biofeedback balance trainingFall incidenceYes
Swanenburg et al., 2007 [46]1Exercise with calcium and vitamin supplementFall incidenceYes
van Ooijen et al., 2016 [18]1Treadmill training with projected visual contextFall incidenceNo
Sherrington et al., 2020 [36]1RESTORE interventionFall incidenceNo


2. 고관절 보호대

노인의 넘어질 때 발생하는 고관절 골절예방을 위한 고관절 보호대 효과를 검증한 연구에서 사용된 결과 변수로는 골절 발생률(hip fracture incidence), 넘어짐 및 부상에 대한 두려움(fear of fall and injury risk), 충격힘 등이 있었다. 넘어지는 상황에서 고관절 보호대가 잘 착용되어 있으면, 대퇴골에 가해지는 충격힘을 상당히 줄어서, 골절 발생률을 줄일 수 있었을 뿐 아니라, 넘어짐 및 부상에 대한 두려움도 상당히 감소됨을 확인할 수 있었다(Table 7) [47-74].

Table 7 . Effect of a hip protector on fall-related hip fracture risk.

ArticlesClass of evidenceInterventionsOutcomesImprove
Bentzen et al., 2008 [47]1Hip protectorHip fracture incidenceYes
Cameron et al., 2000 [48]1Hip protectorFear of fall and injury riskYes
Kannus et al., 2000 [49]1Hip protectorHip fracture incidenceYes
Koike et al., 2009 [50]1Hip protectorHip fracture incidenceYes
Lauritzen et al., 1993 [51]1Hip protectorHip fracture incidenceYes
Meyer et al., 2003 [52]1Hip protectorHip fracture incidenceYes
Cameron et al., 2011 [53]1Hip protector1. Fear of fall and injury risk2. Hip fracture incidence1. No2. No
Cameron et al., 2011 [54]1Hip protectorFear of fall and injury riskNo
Cameron et al., 2003 [55]1Hip protector1. Fear of fall and injury risk2. Hip fracture incidence1. No2. No
Birks et al., 2004 [56]1Hip protectorHip fracture incidenceNo
Kiel et al., 2007 [57]1Hip protectorHip fracture incidenceNo
O'Halloran et al., 2004 [58]1Hip protectorHip fracture incidenceNo
van Schoor et al., 2003 [59]1Hip protectorHip fracture incidenceNo
Birks et al., 2003 [60]1Hip protectorHip fracture incidenceNo
Harada et al., 2001 [61]2Hip protectorHip fracture incidenceYes
Garfinkel et al., 2008 [62]2Hip protectorHip fracture incidenceYes
Juby, 2009 [63]2Hip protectorHip fracture incidenceYes
Korall et al., 2019 [64]2Hip protectorHip fracture incidenceYes
Woo et al., 2003 [65]2Hip protectorHip fracture incidenceYes
Bentzen et al., 2008 [66]3Hip protectorHip fracture incidenceYes
Forsén et al., 2003 [67]3Hip protectorHip fracture incidenceYes
Honkanen et al., 2005 [68]3Hip protectorHip fracture incidenceYes
O'Halloran et al., 2007 [69]3Hip protectorHip fracture incidenceNo
Laing et al., 2011 [70]3Hip protectorHip impact forceYes
Laing and Robinovitch, 2008 [71]3Hip protectorHip impact forceYes
Laing and Robinovitch, 2008 [72]3Hip protectorHip impact forceYes
Choi et al., 2010 [73]3Hip protectorHip impact forceYes
Choi et al., 2010 [74]3Hip protectorHip impact forceYes


3. 안전하게 넘어지는 전략

넘어지는 방법에 따라 엉덩이가 바닥에 닿을 때 대퇴골에 가해지는 충격힘을 줄여 고관절 골절 위험도를 크게 낮출 수 있었는데, 안전한 넘어짐 전략은 넘어질 때 고관절 근 수축(hip muscle contraction), 무술(martial arts), 충격 시 몸통 및 무릎의 위치(trunk and knee position), 골반 충격 각도(pelvis impact angle), 팔 위치(arm configuration) 등이 있었다(Table 8) [75-86]. 특히 무술(martial arts), 목 근육 활성도(neck muscle activation) 등은 충격 속도를 줄여 골절 위험을 크게 낮추었다. 대퇴경부에 발생하는 스트레스 또는 축방향 힘을 줄인 전략은 고관절 벌림근력(hip abductor muscle forces), 충격 시 무릎의 위치(knee boundary conditions), 골반 충격 각도(pelvis impact angle)이 있었다.

Table 8 . Effect of safe landing strategies on fall-related hip fracture risk.

ArticlesClass of evidenceInterventionsOutcomesImprove
Martel et al., 2018 [75]2Hip muscle contractionHip impact forceYes
Pretty et al., 2017 [76]2Hip muscle contractionHip impact forceYes
Groen et al., 2007 [77]2Martial arts1. Hip impact force2. Hip impact velocity1. Yes2. Yes
Weerdesteyn et al., 2008 [78]2Martial arts1. Hip impact force2. Hip impact velocity1. Yes2. Yes
Robinovitch et al., 1997 [79]3Trunk positionHip impact forceYes
van der Zijden et al., 2012 [80]3Martial artsHip impact forceYes
Lim and Choi, 2020 [81]3Knee boundary conditionHip impact forceYes
Choi et al., 2010 [73]3Pelvis impact angleHip impact forceYes
DeGoede and Ashton-Miller, 2002 [82]3Arm configurationHip impact forceYes
Choi et al., 2017 [83]3Neck muscle activationHip impact velocityYes
Lo and Ashton-Miller, 2008 [84]3Segment movementHip impact forceYes
Choi et al., 2015 [85]3Hip abductor muscle forces,Knee boundary conditions1. Femoral neck stress2. Femoral neck force1. Yes2. Yes
Choi and Robinovitch, 2018 [86]3Pelvis impact angle1. Femoral neck stress2. Femoral neck force1. Yes2. Yes


4. 비타민 D 섭취

비타민 D 섭취가 낙상 예방에 미치는 효과를 검증한 연구들은 넘어짐 및 부상률(fall and injury rate), 넘어짐 위험률(fall risk), 균형 능력(balance), 자세불안정성(posture instability) 등의 결과 변수를 사용하였다. 비타민 D 섭취는 노인의 넘어짐 및 부상률뿐만 아니라 균형능력이 증진되어 넘어짐 위험률을 효과적으로 감소시켰다(Table 9) [87-94].

Table 9 . Effect of vitamin D intake on fall-related hip fracture risk.

ArticlesClass of evidenceInterventionsOutcomesImprove
Uusi-Rasi et al., 2015 [87]1Vitamin D (800 IU)Fall and injury rateYes
Bischoff-Ferrari et al., 2016 [88]1Vitamin DFall and injury rateYes
Smith et al., 2017 [89]1Vitamin D (4,000–4,800 IU)Fall and injury rateYes
Bogaerts et al., 2011 [90]1Vitamin D with squat1. Fall and injury rate2. Balance1. Yes2. Yes
Swanenburg et al., 2007 [46]1Vitamin D with protein, balance exercise1. Fall risk2. Balance1. Yes2. Yes
Bischoff-Ferrari et al., 2006 [91]1Vitamin D and calciumFall riskYes
Law et al., 2006 [92]1Vitamin DFall and injury rateNo
Sanders et al., 2010 [93]1Vitamin DFall and injury rateNo
Boersma et al., 2012 [94]2Vitamin DPostural instabilityYes


5. 충격 흡수 매트

노인 낙상 위험도는 바닥재에 따라 큰 영향을 받았는데, 고무 재질의 충격 흡수 매트는 균형에 나쁜 영향을 미치지 않으면서, 넘어질 때 발생하는 충격힘을 줄임으로써, 넘어짐 및 골절 위험도를 크게 낮추었다(Table 10) [95-100].

Table 10 . Effect of compliant flooring on fall-related hip fracture risk.

ArticlesClass of evidenceInterventionsOutcomesImprove
Mackey et al., 2019 [95]1Compliant (low-stiffness) flooringFall and injury riskNo
Simpson et al., 2004 [96]2Wooden carpeted floorsFall and injuryYes
Laing and Robinovitch, 2009 [97]2Smart Cell (low- stiffness)Hip impactYes
Gustavsson et al., 2018 [98]3Compliant (low-stiffness) flooringFall and injury riskYes
Wright and Laing, 2011 [99]3Smart Cell and SofTileFemur peak forceYes
Gustavsson et al., 2015 [100]3Impact absorbing flooringFall and injury riskYes

1. 운동프로그램

태극권, 전신 진동을 이용한 운동 그리고 닌텐도 위를 활용한 운동프로그램은 다른 운동들과 비교하였을 때, 많은 수의 논문들이 출판되었으며 대부분 무작위 대조군 실험을 통해 정적, 동적, 그리고 통합 균형 및 넘어짐 효능감과 두려움에 대해 효과가 있음을 밝혔으므로, 본 문헌 고찰에서는 해당 운동들을 권장한다.

그 외에, 낙상 횟수의 감소에 영향이 있었던 7개의 운동들은 대부분 무작위 대조군 실험을 통해 효과를 증명하였다. 하지만, 7개의 연구 중, 고관절 골절 횟수를 결과 변수로 포함시킨 연구는 1개에 불과했다. 골절예방을 위한 운동프로그램의 확실한 효과를 확인하기 위해 더 많은 연구가 필요해 보인다.

2. 고관절 보호대

임상 연구 결과에 따라 고관절 보호대의 고관절 골절 예방 효과에 대해 긍정적으로 보기도 하고 부정적으로 보기도 했다. 그러나 생체역학 연구에서는 넘어질 때 올바르게 착용된 고관절 보호대는 충격힘을 최대 50%까지 줄일 수 있어 고관절 골절 예방에 큰 도움이 된다고 보고한다. 이는, 고관절 보호대의 처방뿐 아니라, 실제로 잘 착용하고 있는지에 대한 확인 및 교육이 중요함을 말해 준다. 따라서, 노인 본인뿐 아니라 관련 보건의료 인력들은 고관절 보호대의 적절한 사용을 교육 및 모니터링 할 필요가 있다.

3. 안전하게 넘어지는 전략

안전한 넘어짐 전략은 넘어짐으로 인한 심각한 손상을 예방하기 위하여 중요하다. 본 문헌 고찰에서 제시된 연구들로 제안된 전략들은 대부분 넘어지는 동안 고관절과 머리에 가해지는 충격에 대하여 초점이 맞춰져 있었다. 안전한 전략의 정도를 논하기 위해서 연구들에서는 보통 충격힘(impact force)와 충격 속도(impact velocity) 그리고 뼈에 가해지는 스트레스와 축 방향 힘(stresses and axial forces)을 결과변수로 사용하였으며, 제시된 전략은 무술 동작을 하는 것(martial arts), 다른 방향으로 골반에 충격이 가도록 넘어지는 것(pelvis impact angle), 신체 분절의 위치를 바꿔 넘어지는 것(segment movement), 넘어지는 동안 근 수축을 하는 것(muscle activation during a fall)이 있었으며, 제시된 방법 모두 효과가 있다고 보고되었다. 그러나, 본 연구에서는 넘어지는 동안 노인에게 미칠 영향을 알고자 하였으나, 대부분의 연구가 젊은 대상자에게 넘어짐 전략을 적용하거나, 고관절 충격 시뮬레이터를 이용하여 노인의 뼈에 가해질 충격을 예측하였다. 노인에게 직접적으로 실험을 진행할 수 없었던 것은 실험 간 발생할 가능성이 있는 문제(예를 들면, 골절 및 타박상)를 마주하지 않기 위해서였으나, Groen 등[43]은 실제 노인을 대상으로 무술 훈련이 충격힘을 8%까지 줄일 수 있다는 것을 보고하였다.

4. 비타민 D 섭취

노쇠한 노인(비타민 D의 결핍이 있는 노인)의 넘어짐과 부상률을 예방하기 위해 비타민 D의 섭취가 권장됐고, 고용량 비타민 D (800 IU) 이상의 섭취는 넘어짐 및 부상으로부터 본인을 보호할 수 있었다. 낙상예방프로그램에 규칙적인 비타민 D 섭취 포함, 혹은 국가 복지 사업으로 고위험군 노인에게 비타민 D 보급 등을 통한 적극적인 대응은 노인 낙상 문제를 해결하는 데 도움이 될 것이다. 뿐만 아니라, 비타민 D 섭취와 병행하여 칼슘 섭취 및 운동을 실행하면 낙상 예방에 더 효과적인 것으로 보인다.

5. 충격 흡수 매트

충격 흡수 매트는 노인의 넘어짐 및 부상 위험률을 증가시키지 않는다고 하였다. 이는 일부 낮은 강성의 표면이 균형 유지 및 균형 회복 능력을 손상시켜 낙상 위험을 증가시킬 수 있다는 우려를 불식시키는 연구 결과이다[97]. 오히려, 넘어질 때 발생하는 충격힘을 최대 50%까지 줄여, 골절 위험률을 줄이게 된다. 충격 흡수 매트는 균형과 안정성에 영향을 미치지 않음과 동시에 낙상 시 발생하는 엉덩이 충격힘을 크게 줄이므로, 낙상 고위험군이 많이 모여 있는 시설 내에 설치되어야 하는 바닥재로 평가된다.

6. 본 문헌 고찰의 제한점

본 연구의 제한점은 많은 데이터베이스 중에서 하나의 데이터베이스(PubMed)만 사용되었다는 것이다. PubMed는 의학분야에서 가장 흔하게 사용되는 데이터베이스이기 때문에 본 문헌 고찰 결과에 사실성이 보장된다고 할 수 있지만, 다른 데이터베이스를 통해 획득되는 증거들 또한 함께 고려해 보아야 한다.

7. 고찰 결과 요약

노인 낙상예방을 위한 통합적인 중재법의 방향성을 제시하기 위해, 현재까지 제시된 증거 기반 노인 넘어짐 및 고관절 골절 예방프로그램의 효과를 고찰하였다. 위에서 고찰한 바와 같이, 노인 낙상 예방을 위한 다섯 가지 중재방법은 연구방법에 따라 영향력의 차이는 있었지만, 모두 효과적이었다. 상기 고찰 결과는 효과적인 노인 낙상 예방 프로그램을 개발하는 데 도움을 줄 것이다.

This study was supported by the “Brain Korea 21 FOUR Project”, the Korean Research Foundation for Department of Physical Therapy in the Graduate School of Yonsei University.

No potential conflict of interest relevant to this article was reported.

Conceptualization: WJC. Data curation: SL, SK, KL. Formal analysis: SL, SK, KL. Investigation: SL, SK, KL. Methodology: SL, SK, KL, WJC. Project administration: WJC. Resources: WJC. Supervision: WJC. Writing - original draft: SL, SK, KL, WJC. Writing - review & editing: WJC.

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