Falls are common in people with idiopathic Parkinson's disease (PD) and fall related injuries can be associated with immobility and reduced quality of life. Many people with PD experience difficulties walking and balancing as the disease progresses and this can compromise their ability to participate in work, family, community and social activities [1
]. Previous research suggests that more than half of people who are diagnosed with PD experience one or more falls in a given 12 month period, compared to 30% of older adults who live in the community [3
]. The extent to which falls in people with PD are related to hypokinesia, dyskinesa, postural instability, rigidity, weakness, cognitive impairment or medication remains unclear. The associated burden of disease arising from falls and immobility can impact adversely on individuals, their families, the healthcare system and society.
At the present time there is no known cure for idiopathic PD. Pharmacological therapy currently provides the most effective symptomatic treatment for many movement disorders [9
]. Nevertheless freezing of gait, postural instability and hypokinesia have only a limited or short-lived response to PD medication in many individuals [10
]. As the disease progresses, PD medications are adjusted in response to changes in symptoms [11
]. Despite the best medical management, motor fluctuations and movement disorders can recur due to progressive cell loss in the substantia nigra pars compacta in the brainstem and disruption to neural connections to the frontal lobes, cerebellum and other regions of the brain [12
]. For these reasons, pharmacological management is often augmented by physical therapy and falls education [13
There are two main approaches to physical rehabilitation for people with PD. Movement strategy training (MST) teaches individuals how to cope with their movement disorders by using attention, cues, environmental adaptation, part practice and mental rehearsal [14
]. Rather than regulating well learned movements automatically through the defective basal ganglia circuitry, MST aims to train people to use the frontal cortex in the initiation and execution of movements and functional activities. Motor performance is optimised by breaking down complex movement sequences into small parts and by teaching people to focus their attention on each part prior to "whole" task practice [13
]. Mental rehearsal of forthcoming movements, focussing on the movement while it is occurring and the use of visual or auditory cues to guide motor performance are additional strategies [13
]. Other "tricks" include performing the movement in a different way (e.g., running or dance steps instead of walking) and using different intent (e.g., thinking about getting to the fridge to get the milk rather than thinking of trying to walk).
The other key approach to improving movement in people with PD is progressive resistance strength training (PST) [16
]. People with PD can become weak and de-conditioned due to inactivity, disuse and reduced physical activity associated with hypokinesia and ageing [17
]. There is preliminary evidence that PST might improve muscle strength [18
] with associated improvements in balance [21
] and walking [18
] in some people. The extent to which PST prevents falls in people with PD remains unclear.
Education packages that provide advice about the predictors of falls and how to prevent them are also thought to be effective in reducing falls, either as a single intervention or as part of a multifaceted treatment package [23
]. Although a range of approaches and methods of delivery have been used, these packages generally aim to increase awareness of a person's risk of, and risk factors for, falling, as well as to help them identify and access resources to undertake appropriate interventions.
The primary aim of the current study is to conduct the first large scale community based trial to investigate if outpatient physical therapy programs comprising either (i) MST combined with falls education or (ii) PST combined with falls education are more effective than a control group that receives a generic "life-skills" program that does not contain any information or advice about gait, balance, falls, exercise or mobility. We hypothesise that participation in physical therapy directed to either MST or PST combined with falls education will reduce falls relative to participation in the control group. Participation in an active therapy group is also predicted to provide significant improvements in mobility and quality of life, which are not expected to occur for the control group. The anticipated reduction in falls rate in the therapy groups is likely to be accompanied by cost benefits, as we have described in an earlier paper [27