This was the first large trial to evaluate the effectiveness of a home based exercise and strategy programme for people with PD who repeatedly fall. Findings from the trial showed a consistent trend of reduced rates of falls and injurious falls among participants in the exercise programme but the differences were not significant. However, rates of near falls and repeat near falling among those in the exercise group were significantly less than those in the control group.
The trend in fall reduction suggests that individuals in the exercise group may have benefited from the exercises in the programme and from following the strategies for safe functional mobility by allowing them to use appropriate balance reactions to save themselves, avoiding near fall situations and minimising the severity of fall injuries. Such benefits have been found by other researchers who have evaluated exercise programmes for reducing falls among the general older population.7,8,9,10,11
Few researchers have reported on near falls which are occasions when an individual manages to save him/herself from falling to a lower level. Following an exercise and awareness programme for older individuals (over 50 years) from the general population, Steinberg et al15
reported a significant reduction in falls and near falls. The findings from the present study and from Steinberg's suggest that individuals may have improved balance control, adaptive saving reactions and the effective use of fall prevention strategies as a result of the intervention programmes, and were able to save themselves from some but not all postural disturbances. Steinberg et al
also suggested that as near falls can be considered a precursor to falls, reducing near falls is an important contribution to falls prevention.
Why these strategies failed to produce a significant reduction in fall frequency among the PD population is not totally clear. One possible explanation is that we were unable to recruit our target of 200 subjects. On average, subjects in the study had suffered from PD for 8–9 years, experienced multiple falls, multiple pathologies and took multiple medications. It became evident that changing the movement patterns and behaviour of some subjects in the group who fell daily was extremely challenging. It is possible that single fallers and those with less severe disease severity may be more receptive to changing their movement patterns and behaviour through exercise programmes and training. The results of a subgroup analysis of fall frequency according to disease severity reinforced this point as subjects with less disease severity (Hoehn and Yahr grades 2–3) demonstrated a trend of reduced rates of repeat falling in the exercise group at 8 weeks (p
0.128) and at 6 months (p
0.046); a corresponding reduction was not consistently maintained for those with more severe disease (Hoehn and Yahr grade 4). The lack of effect of the intervention on most of the secondary outcomes was surprising but not totally dissimilar to the findings of other researchers9,10
who, despite demonstrating a reduction in fall rate, found a lack of effect on a number of outcomes, including muscle strengthening. This could be explained by the difficulty in assessing muscle strength in the home, but also supports the possibility that the beneficial effect of the intervention was as much related to education and greater confidence as to physical change.11
Trial limitations include the increasing numbers of control subjects who accessed rehabilitation outside of the trial by 6 months, in preference to waiting for advice at the end of the trial. At baseline there were approximately equal numbers of people in the exercise and control groups (24% and 22%, respectively) receiving rehabilitation. These percentages reflect those reported nationally26
and indicate how few people in the UK have PD rehabilitation. By 6 months, 34% of the control group were participating in extra rehabilitation compared with 25% in the exercise group. Involvement in the trial may have raised the interest of participants in fall management and despite being encouraged not to alter their management and being told they would receive advice at the end of the trial, many control subjects chose to seek rehabilitation. To have stated “no involvement in rehabilitation for 6 months”, as an inclusion criterion, we believe would have negatively influenced recruitment and posed ethical problems.
Although we had only one treating physiotherapist in the trial, considerable care was taken to ensure that the intervention programme in the trial reflected evidence based practice: the package of progressive exercises was compiled from the literature and from expert views. The content of each individualised programme and the frequency of practice were carefully documented. Treatment sessions generally lasted for 6 weeks but those with a severe progressive condition may have benefited from more prolonged intervention. Additional support to encourage continued adherence to exercises and strategies following a period of contact with the physiotherapist may also have proved helpful. We chose instead to adopt a pragmatic approach and modelled our intervention within the constraints likely to be experienced in routine practice. The exercise programme developed for the trial was safe when delivered by a physiotherapist; no individual fell while doing their exercises.
Self‐report of fall events remains a vital source of information about people living in the community. Prospective (use of monthly diaries) and retrospective recall are both self‐reported, and both methods were used in this trial, but with differing periods of recall.27
In line with other researchers, we favoured the use of prospective monthly diaries during the trial period10
but as participants were unknown to us prior to recruitment, retrospective recall of fall events (through a face to face questionnaire developed in a previous study28
) was essential for identifying those who met the inclusion criteria (two or more previous falls) and for characterising the sample at baseline. Interestingly, Mackenzie et al27
propose that retrospective recall is likely to be less accurate than prospective because of under reporting which suggests that in reality, the fall frequency among a community sample of people with PD may be even higher than the values we have reported.