The rehabilitation programme prevented falls partly by getting people off controlled analgesics

Design

secondary and mediation analysis of a randomised controlled trial, follow-up at 6 and 12 months

Population

435 older people with painful neurogenic claudication; 34% on at least one controlled pain medication at baseline

Primary outcome

change in pain medication use, and mediators of the trial's 12-month falls reduction

Effect

controlled medication use at 6 months OR 0.62 (95% CI 0.40 to 0.96), narrowing by 12 months; the six-month reduction was a notable mediator of falls prevention

The BOOST trial randomised 435 older people with painful neurogenic claudication to a physical and psychological group intervention or best practice advice, and previously reported improved walking and fewer falls at twelve months. This secondary and mediation analysis asked how the falls reduction happened.

At baseline, 63 per cent were taking at least one pain medication and 34 per cent at least one controlled medication. At six months, the group intervention had reduced controlled medication use against best practice advice (OR 0.62, 95% CI 0.40 to 0.96) — though the difference had narrowed by twelve months. The benefit in pain itself was modest. The mediation analysis found several contributors to the twelve-month falls reduction, with the reduction in controlled analgesics over the first six months standing out among them.

That reframes what the programme is doing. A falls intervention that works by building strength and confidence is one thing; one that works substantially by getting people off opioids and gabapentinoids is a different proposition, because that mechanism is available to any clinician with a drug chart and is not confined to people who can attend a group programme. The narrowing by twelve months is the warning attached: the medication reduction was not sustained, and the authors say the intervention needs refining to hold it. In practice that means the deprescribing conversation has to be repeated, not held once during rehabilitation and assumed to have taken.

• Make analgesic review an explicit component of any falls programme, not an aside
• Target controlled analgesics specifically — opioids, gabapentinoids, benzodiazepines
• Start the reduction within the first six months of rehabilitation, when it worked here
• Plan to revisit it — the difference had narrowed by twelve months
• Do not expect large pain gains; the benefit in pain itself was modest

Why it matters

It identifies the part of a rehabilitation programme that any clinician can deliver without the programme.

Don't overread it

A secondary mediation analysis, not a trial of deprescribing — it cannot show that reducing controlled analgesics on its own prevents falls.

The statistics, in plain English

An odds ratio of 0.62 with a confidence interval reaching 0.96 only just excludes no effect, so the size of the medication reduction is uncertain even though its direction is clear. Mediation analysis is inferential rather than experimental: it shows the falls benefit travelled along with the medication change, which is consistent with the medication causing it but does not prove it, since both could follow from improved function.

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