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The purpose of this perspective article is to describe the use of a physiological profile approach to falls risk assessment and prevention that has been developed by the Falls and Balance Research Group of the Prince of Wales Medical Research Institute, Sydney, Australia. The profile's use for people with a variety of factors that put them at risk for falls is discussed. The Physiological Profile Assessment (PPA) involves a series of simple tests of vision, peripheral sensation, muscle force, reaction time, and postural sway. The tests can be administered quickly, and all equipment needed is portable. The results can be used to differentiate people who are at risk for falls (“fallers”) from people who are not at risk for falls (“nonfallers”). A computer program using data from the PPA can be used to assess an individual's performance in relation to a normative database so that deficits can be targeted for intervention. The PPA provides valid and reliable measurements that can be used for assessing falls risk and evaluating the effectiveness of interventions and is suitable for use in a range of physical therapy and health care settings.

Hip fracture guidelines recommend early mobilisation, multidisciplinary care, physiotherapy and fall prevention interventions. This study documents mobilisation practices and physiotherapy interventions provided post-hip fracture in six countries. Physiotherapists from orthopaedic wards in Denmark, Australia, Spain, Brazil, Norway and Ireland provided information regarding mobilisation and physiotherapy for 10 consecutive hip fracture patients (>60 years), between 2014 and 2018. Physiotherapists (n = 107) entered data on 426 patients. Two-thirds of patients (283, 66%) attempted standing 0-1 days after surgery (range: 0% of patients in Spain to 92% in Norway). Fewer patients (199, 47%) attempted walking on day 0-1 (range: 0% Spain/Brazil to 69% Norway). Physiotherapy to mobilise every weekday was provided to 356 patients (84%, range: 60% Ireland to 100% Spain). On weekends, physiotherapy to mobilise was limited (175, 40%, range: 0% Spain to 81% Brazil) but 298 patients (70%) mobilised with non-physiotherapy staff (range: 0% Spain to 96% Denmark/Ireland). Physiotherapy treatments included mobility, gait training, and range-of-motion exercises. Referral to fall prevention interventions was low (93, 22%, range: 0% Spain to 76% Ireland). Stronger compliance with guideline recommendations on early mobilising, weekend mobilising and referral to fall prevention interventions post hip-fracture is needed in some countries.Implications for rehabilitation This study provides a snapshot of mobilisation and physiotherapy practice for hip fracture patients in six countries. The results suggest a need to improve systems and approaches in some countries to enhance compliance with recommendations specifically relating to: • early attempts at standing and walking post-surgery. • opportunities to mobilise on weekends (with physiotherapist and/or other staff). • broader range of multidisciplinary care e.g., geriatric review, occupational therapy and nutrition advice. • use of standardised tests by physiotherapists post-surgery. • referral to fall prevention interventions. This study provides a snapshot of mobilisation and physiotherapy practice for hip fracture patients in six countries. The results suggest a need to improve systems and approaches in some countries to enhance compliance with recommendations specifically relating to: • early attempts at standing and walking post-surgery. • opportunities to mobilise on weekends (with physiotherapist and/or other staff). • broader range of multidisciplinary care e.g., geriatric review, occupational therapy and nutrition advice. • use of standardised tests by physiotherapists post-surgery. • referral to fall prevention interventions.

To evaluate the effect of walking promotion strategies on physical activity, pain, and function in people with musculoskeletal disorders.Intervention systematic review with meta-analysis.We performed the searches in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Physiotherapy Evidence Database (PEDro) from inception to August 2019.We included randomized controlled trials evaluating interventions that promote walking in people with musculoskeletal disorders.We used the PEDro scale for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. We expressed pooled effects for between-group differences as mean differences or standardized mean differences and 95% confidence intervals, or as risk ratios and 95% confidence intervals, using random-effects meta-analyses.Twelve eligible trials (n = 1456 participants) were identified. There was moderate- to very low-quality evidence of no difference in physical activity levels for walking promotion interventions when compared to minimal interventions, and a significant effect favoring walking promotion when compared with usual care in the short term. There was moderate-quality evidence that walking promotion was modestly effective for reducing pain and improving function compared with minimal intervention and usual care. There was no difference in pain and function for walking promotion compared to supervised exercise. Walking promotion was not associated with different rates of adverse events compared to control conditions.Strategies to promote walking did not increase physical activity in people with musculoskeletal disorders. Walking promotion was associated with small improvements in pain and function compared to minimal intervention and usual care.

Background Disability and falls are common following fall-related lower limb and pelvic fractures. Objective To evaluate the impact of an exercise self-management intervention on mobility-related disability and falls after lower limb or pelvic fracture. Design Randomized controlled trial. Participants Three hundred thirty-six community dwellers aged 60+ years within 2 years of lower limb or pelvic fracture recruited from hospitals and community advertising. Interventions RESTORE (Recovery Exercises and STepping On afteR fracturE) intervention (individualized, physiotherapist-prescribed home program of weight-bearing balance and strength exercises, fall prevention advice) versus usual care. Main Measures Primary outcomes were mobility-related disability and rate of falls. Key Results Primary outcomes were available for 80% of randomized participants. There were no significant between-group differences in mobility-related disability at 12 months measured by (a) Short Physical Performance Battery (continuous version, baseline-adjusted between-group difference 0.08, 95% CI − 0.01 to 0.17, p = 0.08, n = 273); (b) Activity Measure Post Acute Care score (0.18, 95% CI − 2.89 to 3.26, p = 0.91, n = 270); (c) Late Life Disability Instrument (1.37, 95% CI − 2.56 to 5.32, p = 0.49, n = 273); or in rate of falls over the 12-month study period (incidence rate ratio 0.96, 95% CI 0.69 to 1.34, n = 336, p = 0.83). Between-group differences favoring the intervention group were evident in some secondary outcomes: balance and mobility, fall risk (Physiological Profile Assessment tool), physical activity, mood, health and community outings, but these should be interpreted with caution due to risk of chance findings from multiple analyses. Conclusions No statistically significant intervention impacts on mobility-related disability and falls were detected, but benefits were seen for secondary measures of balance and mobility, fall risk, physical activity, mood, health, and community outings. Trial Registration Australian New Zealand Clinical Trials Registry: ACTRN12610000805077

Background Intervention trials promoting physical activity among older people frequently report low and unrepresentative recruitment. Better understanding of reasons for participation can help improve recruitment. This study explored why participants enrolled in the Coaching for Healthy Ageing (CHAnGE) trial, including how their decision was influenced by recruitment strategies. CHAnGE was a cluster randomised controlled trial testing the effectiveness of a healthy ageing program targeting inactivity and falls. Seventy-two groups of people aged 60+ were recruited from community organisations via informal presentations by the health coaches. Methods We conducted a secondary thematic analysis of interview data from our wider qualitative evaluation in which 32 purposively sampled trial participants took part in semi-structured interviews about their experiences of CHAnGE. Data relating to recruitment and participation were analysed inductively to identify themes, then a coding framework comprising the core constructs from self-determination theory—autonomy, competence and relatedness—was used to explore if and how this theory fit with and helped to explain our data. Results Recruitment presentations promoted the CHAnGE intervention well in terms of addressing value expectations of structured support, different forms of accountability, credibility, achievability and, for some, a potential to enhance social relationships. Participation was motivated by the desire for improved health and decelerated ageing, altruism and curiosity. These factors related strongly to self-determination concepts of autonomy, competence and relatedness, but the intervention’s demonstrated potential to support self-determination needs could be conveyed more effectively. Conclusions Findings suggest that recruitment could have greater reach using: 1. Strengths-based messaging focusing on holistic gains, 2. Participant stories that highlight positive experiences, and 3. Peer support and information sharing to leverage altruism and curiosity. These theory-informed improvements will be used to increase participation in future trials, including people in hard-to-recruit groups. They may also inform other physical activity trials and community programs.

Objectives and importance of study: Exercise prevents falls among community-dwelling older adults. Therefore, it is crucial that health and exercise professionals have the knowledge and skills to prescribe appropriate fall prevention exercise. This study evaluated the effect of a fall prevention education program, compared with a waitlist control group, on health and exercise professionals’ fall prevention knowledge and behaviour, and their confidence to prescribe fall prevention exercises for older people. Study type: Randomised controlled trial. Methods: Participants were 200 health and exercise professionals recruited in New South Wales (NSW), Australia. The intervention group participated in a 1-day face-to-face education workshop on exercise to prevent falls in older age. The waitlist control group received the education intervention after completion of the 3-month follow-up. Primary outcomes were self-reported fall prevention knowledge, and change in prescribing behaviour for fall prevention exercise. Secondary outcomes were: confidence to prescribe fall prevention exercise; proportion of people aged 60 years and older seen in the past month who were prescribed fall prevention exercise; and proportion of fall prevention exercises prescribed in the past month that were evidence based. Data were analysed using analysis of covariance models for continuously scored outcomes and the differences in proportions between groups (relative risk [RR]). Results: The intervention significantly improved knowledge (between-group difference [BGD] 0.27 points out of a possible 6; 95% confidence interval [CI] 0.03, 0.51; p = 0.03), perceived clinical behaviour (RR 5.58; 95% CI 3.25, 9.59; p < 0.001), confidence (BGD 1.02/10 points; 95% CI 0.65, 1.39; p < 0.001) and the proportion of evidence-based exercise prescribed, in both the number of exercises (BGD 0.36; 95% CI 0.03, 0.68; p = 0.03) and percentage of participants who prescribed at least 2 hours/week of fall prevention exercise (RR 1.53; 95% CI 1.08, 2.15; p = 0.015). Conclusion: The education workshop significantly improved participants’ knowledge, confidence and behaviour regarding fall prevention exercise prescription.

Background and Objectives Frequent participation in physical activity (PA) has benefits across the lifespan but is particularly important for older adults. PA levels are either measured by objective or self-reported survey methods. Objective PA measurement is used to increase accuracy. This systematic review investigated the effect of physical activity-based interventions on objectively measured PA levels among community-dwelling adults aged 60 years and older. Research Design and Methods Literature searches were conducted in five electronic databases and four clinical trial registries. Randomized controlled trials investigating the effect of physical activity–based interventions on objectively measured PA levels (e.g., accelerometers or pedometers) in community-dwelling adults aged 60 years and older compared with no/minimal intervention were considered eligible. Data were pooled using the most conservative estimates reported from each study using the standardized mean difference (SMD). Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the overall quality of the evidence. Results Fourteen published trials and 3 ongoing trials were identified. There were significant effects favoring physical activity–based interventions compared with minimal intervention at short-term (less than or equal to 3 months) (SMD: 0.30, 95% CI: 0.17 to 0.43) and intermediate-term (more than 3 months and less than 12 months; SMD: 0.27, 95% CI: 0.06 to 0.49) follow-ups. The quality of evidence was moderate according to GRADE (downgraded for risk of bias). Discussion and Implications Our findings suggest that physical activity–based interventions may increase objectively measured PA levels in community-dwelling older adults. Further studies are still needed to identify the optimal dose, intensity, and mode of delivery of physical activity–based interventions.

Background Recent investigations suggest that obesity may be associated with an increased risk of falls; however, this theory has yet to be definitively confirmed. This systematic review and meta-analysis examined the strength of the association between obesity and falls, multiple falls, fall-related injuries, and fall-related fractures among older adults. Methods MEDLINE, Embase, CINAHL, PsycINFO, SPORTDiscus, LILACS, and Web of Science databases were searched to identify observational studies that assessed the association between obesity and fall-related outcomes in participants aged 60 years and older. Two independent reviewers performed data extraction and quality assessment. Relative risks and 95% confidence intervals (CI) were pooled using random effect meta-analyses. Results Thirty-one studies including a total of 1,758,694 participants were selected from 7,815 references. Pooled estimates showed that obese older adults have an increased risk of falls compared with nonobese counterparts (24 studies; relative risk: 1.16; 95% CI: 1.07–1.26; I2: 90%). Obesity was also associated with an increased risk of multiple falls (four studies; relative risk: 1.18; 95% CI: 1.08–1.29; I2: 0%). There was no evidence, however, of an association between obesity and fall-related injuries (seven studies; relative risk: 1.04; 95% CI: 0.92–1.18; I2: 65%). Fall-related fractures were reported in only one study, which demonstrated a lower risk of hip fracture with obesity (odds ratio: 0.65; 95% CI: 0.63–0.68). Conclusions Obesity increases the risk of falls and multiple falls in people aged 60 years and older; however, there is insufficient evidence of an association with fall-related injuries or fractures. Prevention and treatment of obesity may play a role in preventing falls in older age.

Background Low back pain is one of the most prevalent musculoskeletal conditions and the highest contributor to disability in the world. It is characterized by frequent relapses leading to additional care-seeking. Engagement in leisure physical activity is associated with lower recurrences and better prognosis and potentially reduced care-seeking. Our aim was to investigate the feasibility and preliminary efficacy of a patient-centred physical activity intervention, supported by health coaching and mobile health, to reduce care-seeking, pain and disability in patients with chronic low back pain after treatment discharge. Methods We conducted a pilot randomised controlled trial with blinded outcome assessment. Sixty-eight participants were recruited from four public outpatient physiotherapy departments and the general community in Sydney. The intervention group received a physical activity information booklet, plus one face-to-face and 12 telephone-based health coaching sessions. The intervention was supported by an internet-based application and an activity tracker (Fitbit). Control group (standard care) received the physical activity information booklet and advice to stay active. Feasibility measures included recruitment rate, intervention compliance, data completeness, and participant satisfaction. Primary outcomes were care-seeking, pain levels and activity limitation. Outcomes were assessed at baseline, 6-month follow-up and weekly for 6 months. Results Ninety potential participants were invited over 15 months, with 68 agreeing to take part (75%). Overall, 903 weekly questionnaires were answered by participants from a total of 1107 sent (89%). Participants were largely satisfied with the intervention (mean = 8.7 out of 10 on satisfaction scale). Intervention group participants had a 38% reduced rate of care-seeking (Incidence Rate Ratio (IRR): 0.62, 95% CI: 0.32 to 1.18, p = 0.14, using multilevel mixed-effects Poisson regression analysis) compared to standard care, although none of the estimates was statistically significant. No between groups differences were found for pain levels or activity limitation. Conclusion The health coaching physical activity approach trialed here is feasible and well accepted by participants and may reduce care-seeking in patients with low back pain after treatment discharge, although further evaluation with an adequately powered trial is needed. Trial registration Australian and New Zealand Trial Registry ACTRN12615000189527. Registered prospectively on 26–02–2015. Electronic supplementary material The online version of this article (10.1186/s12891-019-2454-y) contains supplementary material, which is available to authorized users.

Questions: In people aged ≥ 60 years, does a combined physical activity and fall prevention intervention affect physical activity and mobility-related goal attainment? Does the combined intervention also improve fall rates, daily steps, the proportion of people meeting the physical activity guidelines, quality of life, mood, fear of falling, and mobility limitation? Design: Randomised trial with concealed allocation, intention-to-treat analysis and assessor blinding. Participants: One hundred and thirty-one people living in the community and aged ≥ 60 years. Interventions: The experimental group received one physiotherapist visit, fortnightly telephone-based health coaching, a pedometer, tailored fall prevention advice, and a fall prevention brochure. The control group received the same fall prevention brochure. Outcome measures: Primary outcomes were mobility goal attainment (Goal Attainment Scale) and objectively measured physical activity (accelerometer counts per minute) at 6 and 12 months. Secondary outcomes were falls, other physical activity measures, quality of life, fear of falling, mood, and mobility. Results: Participants had a mean age of 71 years (SD 6.5) and 31 (24%) had fallen in the past year. The experimental group reported significantly better mobility goal attainment at 6 months compared to controls (OR 2.0, 95% CI 1.1 to 3.7) but this was not maintained at 12 months (OR 1.1, 95% CI 0.6 to 2.1). Physical activity counts were not significantly different between groups at 6 months (MD 13 counts/minute, 95% CI −98 to 124) or 12 months (MD 56 counts/minute, 95% CI −14 to 125). There were no significant between-group differences in the secondary outcomes. Conclusion: A combined physical activity and fall prevention intervention was associated with significantly higher mobility goal attainment at 6 months. There was no significant impact on physical activity but future investigation in a larger trial is warranted. Trial registration: ACTRN12614000016639. Key words: Randomised controlled trial, Exercise, Accidental falls, Goals, Aged

Background This statistical analysis plan details the Coaching for Healthy AGEing (CHAnGE) trial analysis methodology. Objective To investigate the effect of a combined physical activity and fall prevention program on physical activity and falls compared to a healthy eating among people aged 60 years and over. Methods The CHAnGE trial is a pragmatic parallel-group cluster-randomised controlled trial with allocation concealment and blinded assessors. Clusters are allocated to either (1) a physical activity and fall prevention intervention or (2) to a healthy eating intervention. The primary outcomes are: objectively measured physical activity at 12 months post-randomisation, and self-reported falls throughout the 12-month trial period. Secondary outcomes include the proportion of participants reporting a fall, the proportion of participants meeting the Australian physical activity guidelines, body mass index, eating habits, mobility goal attainment, mobility-related confidence, quality of life, fear of falling, risk-taking behaviour, mood, well-being, self-reported physical activity, disability, and use of health and community services. Analysis We will follow the intention-to-treat principle. All analysis will allow for cluster randomisation using a generalised estimating equation approach. The between-group difference in the number of falls per person-year will be analysed using negative binomial regression models. For the continuously scored primary and secondary outcome measures, linear regression models adjusted for corresponding baseline scores will assess the effect of group allocation. Analyses will take into account cluster randomisation and will be adjusted for baseline scores. A subgroup analysis will assess differential effects of the intervention by baseline physical activity levels and history of falls.

Background To inform implementation and future research, this scoping review investigates the volume of evidence for physical activity interventions among adults aged 60+. Our research questions are: (1) what is the evidence regarding interventions designed to increase total physical activity in adults aged 60+ years, in accordance with three of the four strategic objectives of GAPPA (active societies, active environments, active people); (2) what is the current evidence regarding the effectiveness of physical activity programmes and services designed for older adults?; and (3) What are the evidence gaps requiring further research? Methods We searched PEDro, MEDLINE, CINAHL and Cochrane from 1 January 2010 to 1 November 2020 for systematic reviews and meta-analyses of physical activity interventions in adults aged 60+. We identified interventions designed to: (1) increase physical activity; and (2) deliver physical activity programmes and services in home, community or outpatient settings. We extracted and coded data from eligible reviews according to our proposed framework informed by TIDieR, Prevention of Falls Network Europe (PROFANE), and WHO’s International Classification of Functioning, Disability and Health (ICF). We classified the overall findings as positive, negative or inconclusive. Results We identified 39 reviews of interventions to increase physical activity and 342 reviews of programmes/services for older adults. Interventions were predominantly structured exercise programmes, including balance strength/resistance training, and physical recreation, such as yoga and tai chi. There were few reviews of health promotion/coaching and health professional education/referral, and none of sport, workplace, sociocultural or environmental interventions. Fewer reported outcomes of total physical activity, social participation and quality of life/well-being. We noted insufficient coverage in diverse and disadvantaged samples and low-middle income countries. Conclusions There is a modest but growing volume of evidence regarding interventions designed to increase total physical activity in older adults, although more interventional studies with long term follow-up are needed, particularly for GAPPA 1. Active Societies and GAPPA 2. Active Environments. By comparison, there is abundant evidence for GAPPA 3. specific programmes and services, but coverage of sport and workplace interventions, and diverse samples and settings is lacking. Comprehensive reviews of individual studies are now needed as well as research targeting neglected outcomes, populations and settings.

Objective: The Stepping On program has been shown to prevent falls among community-dwelling people in a research setting and was implemented statewide by the New South Wales (NSW) Ministry of Health in 2008. This study measured ongoing fall prevention strategies and behaviours undertaken by Stepping On participants during the 6 months after program completion. Secondary objectives were to document participant satisfaction with the program, and to identify motivators for, and barriers to, fall prevention behaviour and uptake of the strategy. Methods: We conducted a pre–post prospective study among Stepping On program participants, with 6-month follow-up. Participants commenced Stepping On in 2015 and 2016 in 15 Local Health Districts across NSW. A study-specific survey was completed at baseline and 6 months after completion of Stepping On. Measures were current self-reported fall prevention strategies and behaviours; the Falls Behavioural (FaB) Scale; the Incidental and Planned Exercise Questionnaire (IPEQ); and motivators for, and barriers to, uptake of fall prevention strategies and behaviours. Results: Baseline questionnaires were completed by 458 participants (mean age 77; standard deviation [SD] 6.7; 76% female). Both baseline and follow-up surveys were completed by 291 participants (64%; mean age 78; SD 6.9; 76% female). Program satisfaction was high – 251 participants (86%) completed the whole program, 284 (98%) said it increased their awareness of falls, and 284 (98%) would recommend Stepping On to others. There were statistically significant increases in the proportion of participants who reported doing regular balance and strength exercise (74% vs 24%; p < 0.0001), and using safe walking strategies (78% vs 51%; p < 0.0001) at follow-up compared with baseline. There was also a significant improvement in the FaB Scale, indicating less risk-taking behaviour (mean increase 0.15 out of 4; 95% confidence interval [CI] 0.12, 0.19; p < 0.0001), and an increase in IPEQ-reported structured exercise (mean increase 2.0 hours per week; 95% CI 1.6, 2.5; p < 0.0001). The main motivators for, and barriers to, uptake of structured exercise included participants’ health, availability and access to local programs, and the amount of time available to take part. Conclusion: This study demonstrates the appeal of the Stepping On program, and its positive impact on fall prevention behaviours among adults in the community aged 65 years and older. It is important to note the study limitations – namely, the self-reported nature of the measures used and the large amount of missing data.

ISSUE ADDRESSED: The COVID-19 pandemic and associated social distancing regulations have disproportionally impacted the health of older adults. Lifestyle interventions targeting physical activity, diet and fostering social connection may help to alleviate the potential negative health consequences. This study aimed to determine the feasibility and preliminary effectiveness of delivering an online group lifestyle intervention for older adults during the COVID-19 pandemic. METHODS: Adults aged 60+, living in Australia were recruited to a single-arm feasibility study of a 6-week program delivered via a private Facebook group between June-August 2020. Facilitators provided motivation and education on weekly topics including goal setting and reducing sedentary behaviour in the form of Facebook posts and group video calls. Primary outcomes included feasibility and acceptability and secondary outcomes included psychological distress, quality of life (AQoL-6D), functioning, loneliness and physical activity (PA) with assessments conducted at baseline, post-intervention and 4-week follow-up. RESULTS: N = 11 participants were recruited and n = 10 (91%) completed the post-assessment questionnaires. High acceptability was observed and exploratory analysis from pre-post intervention found evidence of an effect on secondary outcomes. CONCLUSIONS: A mental health informed lifestyle program delivered online via Facebook appears feasible and well-accepted among older adults and may help to prevent some of the consequences of inactivity and social isolation associated with the pandemic. SO WHAT?: Online lifestyle interventions appear safe and may provide a scalable, cost-effective strategy for protecting the physical and mental health of older adults during the COVID-19 pandemic.

Realist evaluation offers a valuable way to understand how interventions function and thus how they can be improved and locally adapted. Consequently, realist evaluation is increasingly conducted in parallel with intervention trials. It comprises a clear philosophical foundation and view of causality, pragmatic mixed data collection methods, and a theory-driven approach in which hypothesised program theories are tested and refined. However, detailed methods for data analysis are seldom well-described in realist studies and no clear method for analysing and presenting realist evaluation data has yet emerged. In this methodological paper we use the worked example of our realist process evaluation of the SAGE yoga trial to illustrate an applied process of data analysis and presentation of findings. We show how we drew on other realist studies for ideas, provide examples of six key tasks involved in conducting a realist process evaluation (including coding data and structuring results) and describe strategies that did not work and our rationale for rejecting them. This detailed account of the decisions and methods that worked for us is intended to provide a practical and informed point of departure for researchers conducting a realist evaluation.

IntroductionFalls in older adults are associated with increased healthcare costs. Falls may be prevented or minimised with multifactorial interventions including exercise and behavioural modification. Objectives and ApproachTo describe the reach of the scale-up of Stepping On, a fall prevention program targeting community-dwellers aged 65 years and older in NSW, Australia; and fall-related ambulance service use and fall-related hospitalisations after scale-up. Routinely-collected data on program reach, fall-related ambulance usage and fall-related hospital admissions in NSW residents aged ≥65 years between 2009 and 2015 were compared within Statistical Local Areas prior to and following implementation of Stepping On using multilevel models. ResultsFrom 2009 to 2014 the program was delivered in 1,077 sites to 10,096 people with an average (SD) age of 81.0 (7.2) years. Rates of fall-related ambulance use and hospital admissions per 100-person-years were 1-2 in people aged 66-74, 4-5 in people aged 75-84 and 12-13 in people aged ≥85. These rates increased over time (p

Funder: Public Health Agency of Canada, Funder: Government of Norway, BACKGROUND: In July, 2019, the World Health Organization (WHO) commenced work to update the 2010 Global Recommendations on Physical Activity for Health and established a Guideline Development Group (GDG) comprising expert public health scientists and practitioners to inform the drafting of the 2020 Guidelines on Physical Activity and Sedentary Behavior. The overall task of the GDG was to review the scientific evidence and provide expert advice to the WHO on the amount of physical activity and sedentary behavior associated with optimal health in children and adolescents, adults, older adults (> 64 years), and also specifically in pregnant and postpartum women and people living with chronic conditions or disabilities. METHODS: The GDG reviewed the available evidence specific to each sub-population using systematic protocols and in doing so, identified a number of gaps in the existing literature. These proposed research gaps were discussed and verified by expert consensus among the entire GDG. RESULTS: Evidence gaps across population sub-groups included a lack of information on: 1) the precise shape of the dose-response curve between physical activity and/or sedentary behavior and several of the health outcomes studied; 2) the health benefits of light-intensity physical activity and of breaking up sedentary time with light-intensity activity; 3) differences in the health effects of different types and domains of physical activity (leisure-time; occupational; transportation; household; education) and of sedentary behavior (occupational; screen time; television viewing); and 4) the joint association between physical activity and sedentary time with health outcomes across the life course. In addition, we acknowledge the need to conduct more population-based studies in low- and middle-income countries and in people living with disabilities and/or chronic disease, and to identify how various sociodemographic factors (age, sex, race/ethnicity, socioeconomic status) modify the health effects of physical activity, in order to address global health disparities. CONCLUSIONS: Although the 2020 WHO Guidelines for Physical Activity and Sedentary Behavior were informed by the most up-to-date research on the health effects of physical activity and sedentary time, there is still substantial work to be done in advancing the global physical activity agenda.

IntroductionFalls significantly reduce independence and quality of life in older age. Balance-specific exercise prevents falls in people aged 60+ years. Yoga is growing in popularity and can provide a high challenge to balance; however, the effect of yoga on falls has not been evaluated. This trial aims to establish the effect on falls of a yoga exercise programme compared with a yoga relaxation programme in community-dwellers aged 60+ years.Method and AnalysisThis randomised controlled trial will involve 560 community-dwelling people aged 60+ years. Participants will be randomised to either: (1) the Successful AGEing (SAGE) yoga exercise programme or (2) a yoga relaxation programme. Primary outcome is rate of falls in the 12 months post randomisation. Secondary outcomes include mental well-being, physical activity, health-related quality of life, balance self-confidence, physical function, pain, goal attainment and sleep quality at 12 months after randomisation. The number of falls per person-year will be analysed using negative binomial regression models to estimate between-group difference in fall rates. Generalised linear models will assess the effect of group allocation on the continuously scored secondary outcomes, adjusting for baseline scores. An economic analysis will compare the cost-effectiveness and cost-utility of the two yoga programmes.Ethics and disseminationProtocol was approved by the Human Research Ethics Committee at The University of Sydney, Australia (approval 2019/604). Trial results will be disseminated via peer-reviewed articles, conference presentations, lay summaries.Trial registration numberThe protocol for this trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001183178).

ISSUE ADDRESSED We describe the reach of the scale-up of Stepping On, a fall prevention program targeting community-dwellers aged ≥65 years in NSW, along with fall-related ambulance service use and fall-related hospitalisations after scale-up. METHODS Data on program provision were received from Local Health Districts. Routinely collected fall-related ambulance usage and hospital admissions in NSW residents aged ≥65 years between 2009 and 2015 were compared within Statistical Local Areas prior to and following the implementation of Stepping On using multilevel models. RESULTS Between 2009 and 2014 the program was delivered in 1077 sites to 10 096 older adults. Rates of fall-related ambulance use and hospital admissions per 100-person-years were 1-2 in people aged 66-74, 4-5 in people aged 75-84 and 12-13 in people aged ≥85. These rates increased over time (P

Background Older people’s participation in structured exercise programs to improve balance and mobility is low. Senior Dance is an alternative option, as it may provide a safe and fun way of targeting balance. Objective The aim was to investigate the effect of Senior Dance on balance, mobility, and cognitive function compared with a control intervention. Design The study was a randomized controlled trial. Setting/Patients Eighty-two community-dwelling older people aged 60 years or over and cognitively intact were recruited in Brazil. Intervention Participants were randomly allocated to 2 groups: Dance plus education (intervention group) and education alone (control group). The Senior Dance program consisted of 12 weeks of twice-weekly group-based dance classes. Participants in both groups attended a single 1-hour educational session on prevention of falls. Measurements The primary outcome was single-leg stance with eyes closed. Secondary outcomes were timed sit-to-stand test, standing balance test, timed 4-m walk, and cognitive function tests, for example, Trail Making Test and Montreal Cognitive Assessment. Results Of the 82 participants randomized, 71 (87%) completed the 12-week follow-up. Single-leg stance with eyes closed (primary outcome) improved in the Senior Dance group (mean difference [MD] = 2.3 seconds, 95% confidence interval [CI] = 1.1 to 3.6) compared with the control group at follow-up. Senior Dance group performed better in the standing balance tests (MD = 3.7 seconds, 95% CI = 0.6 to 6.8) and were faster in the sit-to-stand test (MD = − 3.1 seconds, 95% CI = −4.8 to −1.4) and 4-m walk test (MD = −0.6 seconds, 95% CI = −1.0 to −0.1). There were no significant between-group differences for cognitive function tests. Limitations Participants and therapists were not blinded. Conclusion Senior Dance was effective in improving balance and mobility but not cognitive function in community-dwelling older people.

Objectives Obesity is associated with an increased risk of falls in older women; however, it is not certain how body fat distribution affects this relationship. This study examined the association between android and gynoid obesity and the incidence of falls in women aged 60 years and over. Study design Participants were recruited from the community in Brasilia, Brazil. At baseline, participants underwent obesity screening using dual-energy x-ray absorptiometry. Participants identified as obese (body fat percentage >42 %) were classified as android or gynoid type, based on the median of the android-gynoid fat percent ratio (0.99). Incident falls were recorded at the end of the 18-month follow-up period via participant recall. Chi-square test and modified Poisson regression were used to examine the association between obesity and falls. Results A total of 246 participants were recruited and 204 completed the follow-up. The gynoid obese group had a larger proportion of fallers (n = 27, 41 %) than the android obese (n = 17, 24 %) and non-obese (n = 12, 18 %) groups (p = .009). Compared with non-obese women, participants with gynoid obesity were more likely to experience a fall (RR: 2.09, 95 %CI: 1.13–3.87). The risk of falling did not differ between non-obese participants and those with android obesity (RR: 1.26, 95 %CI: 0.64–2.50). Conclusions Gynoid obesity is associated with an increased risk of falls in women aged 60 years and over. Screening for body fat distribution as a supplement to other risk factors for falls may help to identify older adults at a greater risk of falling and to prompt early implementation of fall prevention programs.

IntroductionMobility limitation is common and often results from neurological and musculoskeletal health conditions, ageing and/or physical inactivity. In consultation with consumers, clinicians and policymakers, we have developed two affordable and scalable intervention packages designed to enhance physical activity for adults with self-reported mobility limitations. Both are based on behaviour change theories and involve tailored advice from physiotherapists.Methods and analysisThis pragmatic hybrid effectiveness-implementation type 1 randomised control trial (n=600) will be undertaken among adults with self-reported mobility limitations. It aims to estimate the effects on physical activity of: (1) an enhanced 6-month intervention package (one face-to-face physiotherapy assessment, tailored physical activity plan, physical activity phone coaching from a physiotherapist, informational/motivational resources and activity monitors) compared with a less intensive 6-month intervention package (single session of tailored phone advice from a physiotherapist, tailored physical activity plan, unidirectional text messages, informational/motivational resources); (2) the enhanced intervention package compared with no intervention (6-month waiting list control group); and (3) the less intensive intervention package compared with no intervention (waiting list control group). The primary outcome will be average steps per day, measured with the StepWatch Activity Monitor over a 1-week period, 6 months after randomisation. Secondary outcomes include other physical activity measures, measures of health and functioning, individualised mobility goal attainment, mental well-being, quality of life, rate of falls, health utilisation and intervention evaluation. The hybrid effectiveness-implementation design (type 1) will be used to enable the collection of secondary implementation outcomes at the same time as the primary effectiveness outcome. An economic analysis will estimate the cost-effectiveness and cost-utility of the interventions compared with no intervention and to each other.Ethics and disseminationEthical approval has been obtained by Sydney Local Health District, Royal Prince Alfred Zone. Dissemination will be via publications, conferences, newsletters, talks and meetings with health managers.Trial registration numberACTRN12618001983291.

Objectives: Healthy ageing has been unattainable for many of Australia’s First Nation people, driven by an earlier onset of chronic disease when compared to the general Australian population. Our objective was to examine the perspectives of Australian First Nation people about healthy ageing. Methods: We used a conversational method to gather knowledge from older First Nation people from established communities in New South Wales, Australia. Discussions were audio recorded and transcribed and analysed using an Indigenous research standpoint methodology. Eight yarning circles were held in six locations with 76 participants aged 45 years and over. Results: Key issues around healthy ageing were identified; particularly, what the impact of chronic disease means to individuals. Study participants reported that healthy ageing is essential to continue to share knowledge of their history and culture. Conclusion: This article highlights the need for culturally appropriate healthy ageing programs addressing issues related to chronic disease among First Nation communities. Implications for public health: Research into what constitutes healthy ageing for older First Nation people is necessary for the development of culturally appropriate chronic disease interventions.

Objective health-related quality of life (HRQOL) and mental well-being are associated with healthy ageing. Physical activity positively impacts both HRQOL and mental well-being. Yoga is a physical activity that can be modified to suits the needs of older people and is growing in popularity. We conducted a systematic review with meta-analysis to determine the impact of yoga-based exercise on HRQOL and mental well-being in people aged 60+. Methods searches were conducted for relevant trials in the following electronic databases; MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine Database, PsycINFO and the Physiotherapy Evidence Database (PEDro) from inception to January 2017. Trials that evaluated the effect of physical yoga on HRQOL and/or on mental well-being in people aged 60+ years were included. Data on HRQOL and mental well-being were extracted. Standardised mean differences and 95% confidence intervals (CI) were calculated using random effects models. Methodological quality of trials was assessed using the PEDro scale. Results twelve trials of high methodological quality (mean PEDro score 6.1), totalling 752 participants, were identified and provided data for the meta-analysis. Yoga produced a medium effect on HRQOL (Hedges' g = 0.51, 95% CI 0.25-0.76, 12 trials) and a small effect on mental well-being (Hedges' g = 0.38, 95% CI 0.15-0.62, 12 trials). Conclusion yoga interventions resulted in small to moderate improvements in both HRQOL and mental well-being in people aged 60+ years. Further, research is needed to determine the optimal dose of yoga to maximise health impact. Prospero registration number (CRD42016052458).

Made available in DSpace on 2018-12-11T16:51:20Z (GMT). No. of bitstreams: 0 Previous issue date: 2018-01-15 Background: Physical activity plays an important role in the management of chronic low back pain (LBP). Engaging in an active lifestyle is associated with a better prognosis. Nevertheless, there is evidence to suggest that patients with chronic LBP are less likely to meet recommended physical activity levels. Furthermore, while exercise therapy has been endorsed by recent clinical practice guidelines, evidence from systematic reviews suggests that its effect on pain and disability are at best moderate and not sustained over time. A limitation of current exercises programmes for chronic LBP is that these programmes are not designed to change patients' behaviour toward an active lifestyle. Therefore, we will investigate the short- and long-term efficacy of a multimodal intervention, consisting of supervised exercises, health coaching and use of an activity monitor (i.e. Fitbit Flex) compared to supervised exercises plus sham coaching and a sham activity monitor on physical activity levels, pain intensity and disability, in patients with chronic, nonspecific LBP. Methods: This study will be a two-group, single-blind, randomised controlled trial. One hundred and sixty adults with chronic, nonspecific LBP will be recruited. Participants allocated to both groups will receive a group exercise programme. In addition, the intervention group will receive health coaching sessions (i.e. assisting the participants to achieve their physical activity goals) and an activity monitor (i.e. Fitbit Flex). The participants allocated to the control group will receive sham health coaching (i.e. encouraged to talk about their LBP or other problems, but without any therapeutic advice from the physiotherapist) and a sham activity monitor. Outcome measures will be assessed at baseline and at 3, 6 and 12 months post randomisation. The primary outcomes will be physical activity, measured objectively with an accelerometer, as well as pain intensity and disability at 3 months post randomisation. Secondary outcomes will be physical activity, pain intensity and disability at 6 and 12 months post randomisation as well as other self-report measures of physical activity and sedentary behaviour, depression, quality of life, pain self-efficacy and weight-related outcomes at 3, 6, and 12 months post randomisation. Discussion: This study is significant as it will be the first study to investigate whether a multimodal intervention designed to increase physical activity levels reduces pain and disability, and increases physical activity levels compared to a control intervention in patients with chronic LBP. Faculty of Science and Technology Sao Paulo State University (UNESP) Department of Physical Therapy School of Public Health Sydney Medical School University of Sydney Institute for Musculoskeletal Health Sydney Local Health District Pain Management Research Institute University of Sydney at Royal North Shore Hospital Faculty of Science and Technology Sao Paulo State University (UNESP) Departament of Physical Education Universidade Federal de Minas Gerais (UFMG) Departament of Physical Therapy Faculty of Science and Technology Sao Paulo State University (UNESP) Department of Physical Therapy Faculty of Science and Technology Sao Paulo State University (UNESP) Departament of Physical Education

Purpose This study aims to test the effect of an information and support intervention on physical activity (PA) in women aged 50+ years. Design Randomized wait-list controlled trial. Setting Sydney, Australia. Sample 126 female university and health service employees, aged 50+. Intervention Information session, activity tracker, regular motivational emails. Measures Proportion achieving ≥ 10,000 steps/day (primary outcome), daily step count, proportion meeting 150 mins/week of moderate to vigorous PA (MVPA), self-reported PA. Analysis Odds-ratios and general linear regression models. Results At 3 months, the intervention group reported significantly more vigorous PA (1.04 hours, 95% CI 0.24 to 1.85, P = .01, measured by IPAQ), were more likely to achieve 300 mins/week of MVPA (OR = 1.98, 95% CI 0.89 to 4.36, P = .09, measured by Actigraph) than the control wait-list group, and reported adopting PA promotion strategies (technology = 31/58% or goal-setting = 39/74%). No significant between-group differences in the primary outcome were detected (1.39, 95% CI 0.61 to 3.18, P = .44). Conclusions This low-dose intervention significantly increased self-reported vigorous PA time and non-significantly increased the proportion of people achieving 300 mins/week of MVPA but did not significantly increase the proportion of participants achieving 10,000 steps/day. Relatively small effects may be important at a population level given the minimal resources needed to deliver this intervention.

Objectives: To test the external validity of 4 approaches to fall prediction in a rehabilitation setting (Predict_FIRST, Ontario Modified STRATIFY (OMS), physiotherapists’ judgement of fall risk (PT_Risk), and falls in the past year (Past_Falls)), and to develop and test the validity of a simpler tool for fall prediction in rehabilitation (Predict_CM2). Participants: A total of 300 consecutively-admitted rehabilitation inpatients. Methods: Prospective inception cohort study. Falls during the rehabilitation stay were monitored. Potential predictors were extracted from medical records. Results: Forty-one patients (14%) fell during their rehabilitation stay. The external validity, area under the receiver operating characteristic curve (AUC), for predicting future fallers was: 0.71 (95% confidence interval (95% CI): 0.61–0.81) for OMS (Total_Score); 0.66 (95% CI: 0.57–0.74) for Predict_FIRST; 0.65 (95% CI 0.57–0.73) for PT_Risk; and 0.52 for Past_Falls (95% CI: 0.46–0.60). A simple 3-item tool (Predict_CM2) was developed from the most predictive individual items (impaired mobility/transfer ability, impaired cognition, and male sex). The accuracy of Predict_CM2 was 0.73 (95% CI: 0.66–0.81), comparable to OMS (Total_Score) (p = 0.52), significantly better than Predict_FIRST (p = 0.04), and Past_Falls (p

Objective To examine associations between fall risk factors identified previously in other populations and falls among Aboriginal people aged 60 years and older, living in New South Wales, Australia. Methods Interviews were conducted with older Aboriginal people in five urban and regional communities. Associations between past falls and 22 fall predictor variables were examined using linear and multiple regression analyses. Results Of the 336 participants, 80 people (24%) reported at least one fall in the past year, and 34 (10%) reported two or more falls. Participants had an increased fall risk if they were female; used three or more medications; had arthritis, macular degeneration, depression, history of stroke; were unable to do their own housework; or were unable to do their own shopping. Conclusion Falls were experienced by one-quarter of study participants. Fall risk factors identified for older Aboriginal people appear to be similar to those identified in the general population. Understanding of fall risk factors may assist with the development of appropriate and effective community-led fall prevention programs.

Objective To identify predictors and impact of adherence to a multifactorial fall-prevention program on falls and health service utilisation. Methods Randomised controlled trial with a priori subgroup analysis within intervention group according to adherence. Participants were community dwelling, (≥65 years), not transported to hospital following fall-related paramedic care. The Attitudes to Falls-Related Interventions Scale (AFRIS) was completed at baseline, adherence levels were measured (three-point scale) at six months, and falls and health service utilisation were recorded for 12 months. Multivariate logistic regression and area under the curve were calculated with 95% confidence interval (CI). Results Attitudes to Falls-Related Interventions Scale scores (n = 85) were independent of baseline characteristics. At six months, 39 (46%) participants reported full adherence. Independent predictors of adherence were positive AFRIS (OR 4.10, 95% CI 1.48-11.39) and receiving 3+ recommendations (OR 3.36, 95% CI 1.26-9.00). Adherers experienced fewer falls (IRR 0.53, 95% CI 0.45-0.80) and fall-related health service use (emergency department presentations IRR 0.37, 95% CI 0.17-0.82) compared to non-adherers. Conclusion Older adults who adhere to recommendations benefit, regardless of fall-risk profile.

Background Fall related injury is an emerging issue for older Indigenous people worldwide, yet few targeted fall prevention programs are currently available for Indigenous populations. In order to inform the development of a new Aboriginal-specific fall prevention program in Australia, we conducted community consultation with older Aboriginal people to identify perceptions and beliefs about falls, and to identify desired program elements. Methods Yarning Circles were held with Aboriginal and Torres Strait Islander people aged 45 years and over. Each Yarning Circle was facilitated by an Aboriginal researcher who incorporated six indicative questions into each discussion. Questions explored the impact of falls on Yarning Circle participants, their current use of fall prevention services and investigated Yarning Circle participant’s preferences regarding the design and mode of delivery of a fall prevention program. Results A total of 76 older Aboriginal people participated in ten Yarning Circles across six sites in the state of New South Wales. Participants associated falls with physical disability, a loss of emotional well-being and loss of connection to family and community. Many participants did not use existing fall prevention services due to a lack of availability in their area, having no referral provided by their GP and/or being unaware of fall prevention programs in general. Program elements identified as important by participants were that it be Aboriginal-specific, group-based, and on-going, with the flexibility to be tailored to specific communities, with free transport provided to and from the program. Conclusions Older Aboriginal people reported falls to be a priority health issue, with a significant impact on their health and well-being. Few older Aboriginal people accessed prevention programs, suggesting there is an important need for targeted Aboriginal-specific programs. A number of important program elements were identified which if incorporated into prevention programs, may help to address the rising burden of falls.

Physical inactivity is common in older age, yet increased activity benefits older people in terms of preventing chronic disease and maximising independence. Health coaching is a behaviour change intervention that has been shown to increase physical activity in clinical populations. This systematic review and meta-analysis investigated the effect of health coaching on physical activity, mobility, quality of life and mood in older people.MEDLINE, EMBASE, CENTRAL, PsycINFO, PEDro, SPORTDiscus, LILACS and CINAHL databases were used to identify randomised controlled trials which evaluated the effect of health coaching on physical activity (primary outcome) among people aged 60+. Secondary outcomes were mobility, quality of life and mood. We calculated standardised mean differences (SMDs, Hedges' g) with 95% CIs from random effects meta-analyses.27 eligible trials were included. Health coaching had a small, statistically significant effect on physical activity (27 studies; SMD = 0.27; 95% CI 0.18 to 0.37; p0.001). There was no evidence of an effect of health coaching on mobility (eight studies; SMD = 0.10; 95% CI -0.03 to 0.23; p=0.13), quality of life (eight studies; SMD = 0.07; 95% CI -0.06 to 0.20; p0.05) or mood (five studies; SMD = 0.02; 95% CI -0.12 to 0.16; p=0.83).Health coaching significantly increased physical activity in people aged 60+. There was no evidence of an effect of health coaching on quality of life, mobility and mood, so different approaches may be required to impact on these outcomes.

BackgroundOlder people with vision impairment have significant ongoing morbidity, including risk of falls, but are neglected in fall prevention programmes. PlaTFORM is a pragmatic evaluation of the Lifestyle-integrated Functional Exercise fall prevention programme for older people with vision impairment or blindness (v-LiFE). Implementation and scalability issues will also be investigated.MethodsPlaTFORM is a single-blinded, randomised trial designed to evaluate the v-LiFE programme compared with usual care. Primary outcomes are fall rate over 12 months, measured using prospective monthly fall calendars, and function and participation assessed by the Late-Life Function and Disability Instrument (Late-Life FDI) Function component. The secondary outcome is rate of falls requiring medical care. Activity-normalised fall rate will be estimated using accelerometer-measured physical activity data. EuroQol 5-dimension 5-level questionnaire will measure quality of life and impact of falls. Health record linkage will estimate resource use associated with falls. v-LiFE cost-effectiveness will be determined compared with usual care. 500 participants (250 per group) can provide 90% power to detect a significant between-group difference in fall rates; 588 will be recruited to allow for drop-out. Falls per person-year and Late-Life FDI will be compared between groups.DiscussionPlaTFORM will determine if falls can be prevented among older people with vision loss through a home-based exercise programme. v-LiFE embeds balance and strength training within everyday activities with the aim of preventing falls. The study will also determine whether the programme can be effectively delivered by personnel who provide Orientation and Mobility training for people with vision impairment.Trial registration numberACTRN12616001186448p.

IntroductionThere is strong evidence that exercise prevents falls in community-dwelling older people. This review summarises trial and participant characteristics, intervention contents and study quality of 108 randomised trials evaluating exercise interventions for falls prevention in community-dwelling older adults.MethodsMEDLINE, EMBASE, CENTRAL and three other databases sourced randomised controlled trials of exercise as a single intervention to prevent falls in community-dwelling adults aged 60+ years to May 2018.Results108 trials with 146 intervention arms and 23 407 participants were included. Trials were undertaken in 25 countries, 90% of trials had predominantly female participants and 56% had elevated falls risk as an inclusion criterion. In 72% of trial interventions attendance rates exceeded 50% and/or 75% of participants attended 50% or more sessions. Characteristics of the trials within the three types of intervention programme that reduced falls were: (1) balance and functional training interventions lasting on average 25 weeks (IQR 16–52), 39% group based, 63% individually tailored; (2) Tai Chi interventions lasting on average 20 weeks (IQR 15–43), 71% group based, 7% tailored; (3) programmes with multiple types of exercise lasting on average 26 weeks (IQR 12–52), 54% group based, 75% tailored. Only 35% of trials had low risk of bias for allocation concealment, and 53% for attrition bias.ConclusionsThe characteristics of effective exercise interventions can guide clinicians and programme providers in developing optimal interventions based on current best evidence. Future trials should minimise likely sources of bias and comply with reporting guidelines.

Background Falls are common among older people, and General Practitioners (GPs) could play an important role in implementing strategies to manage fall risk. Despite this, fall prevention is not a routine activity in general practice settings. The iSOLVE cluster randomised controlled trial aimed to evaluate implementation of a fall prevention decision tool in general practice. This paper sought to describe the strategies used and reflect on the enablers and barriers relevant to successful recruitment of general practices, GPs and their patients. Methods Recruitment was conducted within the geographical area of a Primary Health Network in Northern Sydney, Australia. General practices and GPs were engaged via online surveys, mailed invitations to participate, educational workshops, practitioner networks and promotional practice visits. Patients 65 years or older were recruited via mailed invitations, incorporating the practice letterhead and the name(s) of participating GP(s). Observations of recruitment strategies, results and enabling factors were recorded in field notes as descriptive and narrative data, and analysed using mixed-methods. Results It took 19 months to complete recruitment of 27 general practices, 75 GPs and 560 patients. The multiple strategies used to engage general practices and GPs were collectively useful in reaching the targeted sample size. Practice visits were valuable in engaging GPs and staff, establishing interest in fall prevention and commitment to the trial. A mix of small, medium and large practices were recruited. While some were recruited as a whole-practice, other practices had few or half of the number of GPs recruited. The importance of preventing falls in older patients, simplicity of research design, provision of resources and logistic facilitation of patient recruitment appealed to GPs. Recruitment of older patients was successfully achieved by mailed invitations which was a strategy that was familiar to practice staff and patients. Patient response rates were above the expected 10% for most practices. Many practices (n = 17) achieved the targeted number of 20 or more patients. Conclusions Recruitment in general practice settings can be successfully achieved through multiple recruitment strategies, effective communication and rapport building, ensuring research topic and design suit general practice needs, and using familiar communication strategies to engage patients. Trial registration The trial was prospectively registered on 29 April 2015 with the Australian New Zealand Clinical Trial Registry www.anzctr.org.au (trial ID: ACTRN12615000401550).

ObjectivesTo assess the effects of exercise interventions for preventing falls in older people living in the community.Selection criteriaWe included randomised controlled trials evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+years living in the community.ResultsExercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% CI 0.71 to 0.83; 12 981 participants, 59 studies; high-certainty evidence). Subgroup analyses showed no evidence of a difference in effect on falls on the basis of risk of falling as a trial inclusion criterion, participant age 75 years+ or group versus individual exercise but revealed a larger effect of exercise in trials where interventions were delivered by a health professional (usually a physiotherapist). Different forms of exercise had different impacts on falls. Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies; high-certainty evidence). Multiple types of exercise (commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88; 1374 participants, 11 studies; moderate-certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99; 2655 participants, 7 studies; low-certainty evidence). We are uncertain of the effects of programmes that primarily involve resistance training, dance or walking.Conclusions and implicationsGiven the certainty of evidence, effective programmes should now be implemented.

There is compelling evidence that physical activity has many physical and mental health benefits and can delay the development of disability in older age. However, uptake of this health behaviour is sub-optimal in working women in their middle age. This trial aims to establish the impact of a low-dose information program, incorporating follow-up support using behaviour change techniques, compared with a wait-list control group, on physical activity among women aged 50+ years. 100 female university or health service employees aged 50 years and over who are not sufficiently active according to national guidelines will be recruited and randomised to: [1] attend one information session at the worksite with follow-up email support and provision of resources including use of an activity tracker (Fitbit) for 3 months and free trial class at the university sports facility, or [2] a wait-list control to receive the intervention after the 3-month follow-up period. The primary outcome will be the proportion of people achieving 10,000 steps/day at 3 months post randomisation. Secondary outcomes will include the proportion of people achieving national guideline-recommended physical activity levels, the average self-reported hours of physical activity per week, perceived benefits of and barriers to exercise participation, physical functioning, and mood. Analyses will be planned, conducted while masked to group allocation and will use an intention-to-treat approach. This randomised controlled trial will evaluate the impact of a simple intervention using behaviour change techniques to increase physical activity participation in insufficiently active working women over the age of 50. ACTRN12617000485336 , prospectively registered, approved 04/04/2017.

BackgroundOlder people are at high risk of physical inactivity. Activity trackers can facilitate physical activity. We aimed to investigate the effect of interventions using activity trackers on physical activity, mobility, quality of life and mental health among people aged 60+ years.MethodsFor this systematic review, we searched eight databases, including MEDLINE, Embase and CENTRAL from inception to April 2018. Randomised controlled trials of interventions that used activity trackers to promote physical activity among people aged 60+ years were included in the analyses. The study protocol was registered with PROSPERO, number CRD42017065250.ResultsWe identified 23 eligible trials. Interventions using activity trackers had a moderate effect on physical activity (23 studies; standardised mean difference (SMD)=0.55; 95% CI 0.40 to 0.70; I2=86%) and increased steps/day by 1558 (95% CI 1099 to 2018 steps/day; I2=92%) compared with usual care, no intervention and wait-list control. Longer duration activity tracker-based interventions were more effective than short duration interventions (18 studies, SMD=0.70; 95% CI 0.47 to 0.93 vs 5 studies, SMD=0.14; 95% CI −0.26 to 0.54, p for comparison=0.02). Interventions that used activity trackers improved mobility (three studies; SMD=0.61; 95% CI 0.31 to 0.90; I2=10%), but not quality of life (nine studies; SMD=0.09; 95% CI −0.07 to 0.25; I2=45%). Only one trial included mental health outcomes and it reported similar effects of the activity tracker intervention compared with control.ConclusionsInterventions using activity trackers improve physical activity levels and mobility among older people compared with control. However, the impact of activity tracker interventions on quality of life, and mental health is unknown.

Background Obesity is associated with an increased risk of falls in older women. However, it is not certain whether factors commonly associated with obesity and falls mediate this risk. Research question Do lower-limb muscle quality, foot loads and postural control mediate the relationship between obesity and falls in women aged 60 years and older? Methods At baseline, 246 female participants underwent obesity screening (BMI≥30 kg/m²), and measurements of muscle quality (isokinetic dynamometer and dual-energy X-ray absorptiometry), foot loads (pressure platform) and postural balance (force platform). Incident falls were recorded at the end of the 18-month follow-up period via participant recall. To test whether, and to what extent, biomechanical factors mediated the relationship between obesity and falls, the Natural Indirect Effects (NIE), Natural Direct Effect (NDE) and proportion mediated were calculated using the counterfactual approach. Significance level was set at p Results 204 participants (83 %) completed the follow-up. As expected, obesity was associated with a higher risk of being a faller (RR: 2.13, 95 % CI: 1.39–3.27). Using the counterfactual approach, only specific torque (NIE: 1.11, 95 % CI: 1.01–1.38) and flatfoot (NIE: 1.10, 95 % CI: 1.01–1.32) were significant mediators of the relationship between obesity and falls. Specific torque and flatfoot mediated 19 % and 21 % of the relationship, respectively. Significance Lower-limb muscle quality (specific torque) and foot loads (flatfoot) mediate the relationship between obesity and falls in older women. The inclusion of muscle strengthening and podiatry interventions as part of a fall prevention program may benefit this population.

Background At least one‐third of community‐dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have been found to prevent falls in these people. An up‐to‐date synthesis of the evidence is important given the major long‐term consequences associated with falls and fall‐related injuries Objectives To assess the effects (benefits and harms) of exercise interventions for preventing falls in older people living in the community. Search methods We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers up to 2 May 2018, together with reference checking and contact with study authors to identify additional studies. Selection criteria We included randomised controlled trials (RCTs) evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We excluded trials focused on particular conditions, such as stroke. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. Main results We included 108 RCTs with 23,407 participants living in the community in 25 countries. There were nine cluster‐RCTs. On average, participants were 76 years old and 77% were women. Most trials had unclear or high risk of bias for one or more items. Results from four trials focusing on people who had been recently discharged from hospital and from comparisons of different exercises are not described here. Exercise (all types) versus control Eighty‐one trials (19,684 participants) compared exercise (all types) with control intervention (one not thought to reduce falls). Exercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.71 to 0.83; 12,981 participants, 59 studies; high‐certainty evidence). Based on an illustrative risk of 850 falls in 1000 people followed over one year (data based on control group risk data from the 59 studies), this equates to 195 (95% CI 144 to 246) fewer falls in the exercise group. Exercise also reduces the number of people experiencing one or more falls by 15% (risk ratio (RR) 0.85, 95% CI 0.81 to 0.89; 13,518 participants, 63 studies; high‐certainty evidence). Based on an illustrative risk of 480 fallers in 1000 people followed over one year (data based on control group risk data from the 63 studies), this equates to 72 (95% CI 52 to 91) fewer fallers in the exercise group. Subgroup analyses showed no evidence of a difference in effect on both falls outcomes according to whether trials selected participants at increased risk of falling or not. The findings for other outcomes are less certain, reflecting in part the relatively low number of studies and participants. Exercise may reduce the number of people experiencing one or more fall‐related fractures (RR 0.73, 95% CI 0.56 to 0.95; 4047 participants, 10 studies; low‐certainty evidence) and the number of people experiencing one or more falls requiring medical attention (RR 0.61, 95% CI 0.47 to 0.79; 1019 participants, 5 studies; low‐certainty evidence). The effect of exercise on the number of people who experience one or more falls requiring hospital admission is unclear (RR 0.78, 95% CI 0.51 to 1.18; 1705 participants, 2 studies, very low‐certainty evidence). Exercise may make little important difference to health‐related quality of life: conversion of the pooled result (standardised mean difference (SMD) ‐0.03, 95% CI ‐0.10 to 0.04; 3172 participants, 15 studies; low‐certainty evidence) to the EQ‐5D and SF‐36 scores showed the respective 95% CIs were much smaller than minimally important differences for both scales. Adverse events were reported to some degree in 27 trials (6019 participants) but were monitored closely in both exercise and control groups in only one trial. Fourteen trials reported no adverse events. Aside from two serious adverse events (one pelvic stress fracture and one inguinal hernia surgery) reported in one trial, the remainder were non‐serious adverse events, primarily of a musculoskeletal nature. There was a median of three events (range 1 to 26) in the exercise groups. Different exercise types versus control Different forms of exercise had different impacts on falls (test for subgroup differences, rate of falls: P = 0.004, I² = 71%). Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies; high‐certainty evidence) and the number of people experiencing one or more falls by 13% (RR 0.87, 95% CI 0.82 to 0.91; 8288 participants, 37 studies; high‐certainty evidence). Multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88; 1374 participants, 11 studies; moderate‐certainty evidence) and the number of people experiencing one or more falls by 22% (RR 0.78, 95% CI 0.64 to 0.96; 1623 participants, 17 studies; moderate‐certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99; 2655 participants, 7 studies; low‐certainty evidence) as well as reducing the number of people who experience falls by 20% (RR 0.80, 95% CI 0.70 to 0.91; 2677 participants, 8 studies; high‐certainty evidence). We are uncertain of the effects of programmes that are primarily resistance training, or dance or walking programmes on the rate of falls and the number of people who experience falls. No trials compared flexibility or endurance exercise versus control. Authors' conclusions Exercise programmes reduce the rate of falls and the number of people experiencing falls in older people living in the community (high‐certainty evidence). The effects of such exercise programmes are uncertain for other non‐falls outcomes. Where reported, adverse events were predominantly non‐serious. Exercise programmes that reduce falls primarily involve balance and functional exercises, while programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises plus resistance exercises). Tai Chi may also prevent falls but we are uncertain of the effect of resistance exercise (without balance and functional exercises), dance, or walking on the rate of falls.

Objective Previous meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether characteristics of the trial design, sample or intervention are associated with greater fall prevention effects.Design Update of a systematic review with random effects meta-analysis and meta-regression.Data sources Cochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016.Study eligibility criteria We included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group.Results 99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, pSummary/conclusions Exercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinson's disease and cognitive impairment.

IntroductionLow back pain (LBP) is recognised globally as a prevalent, costly and disabling condition. Recurrences are common and contribute to much of the burden of LBP. Current evidence favours exercise and education for prevention of LBP recurrence, but an optimal intervention has not yet been established. Walking is a simple, widely accessible, low-cost intervention that has yet to be evaluated. This randomised controlled trial (RCT) aims to establish the effectiveness and cost-effectiveness of a progressive and individualised walking and education programme (intervention) for the prevention of LBP recurrences in adults compared with no treatment (control).Methods and analysisA pragmatic, two-armed RCT comparing walking and education (n=349) with a no treatment control group (n=349). Inclusion criteria are adults recovered from an episode of non-specific LBP within the last 6 months. Those allocated to the intervention group will receive six sessions (three face to face and three telephone delivered) with a trained physiotherapist to facilitate a progressive walking programme and education over a 6-month period. The primary outcome will be days to first recurrence of an episode of activity-limiting LBP. The secondary outcomes include days to recurrence of an episode of LBP, days to recurrence of an episode of LBP leading to care seeking, disability and quality of life measured at 3, 6, 9 and 12 months and costs associated with LBP recurrence. All participants will be followed up monthly for a minimum of 12 months. The primary intention-to-treat analysis will assess difference in survival curves (days to recurrence) using the log-rank statistic. The cost-effectiveness analysis will be conducted from the societal perspective.Ethics and disseminationApproved by Macquarie University Human Research Ethics Committee (Reference: 5201949218164, May 2019). Findings will be disseminated through publication in peer-reviewed journals and conference presentations.Trial registration numberACTRN12619001134112.

Nearly a third of people aged over 65 years and over half of people older than 80 have a fall at least once a year. Falls and fall related injuries can be life changing and may result in chronic disability, admission to assisted living, or death. A fall can also precipitate a fear of falling, which may lead to restriction of activity and hence physical deconditioning. This in turn increases the risk of future falls. Clinical guidelines from several countries recommend multifactorial interventions for preventing falls in older people, with exercise as a key component. A recent Cochrane review (108 randomised controlled trials, 23 407 participants) concluded there is strong evidence that well designed exercise programmes reduce the number of falls by about a quarter among older people living in the community. Such programmes also reduce the number of people experiencing one or more falls. Exercise that mainly involved balance and functional training reduced falls. Yoga is a mind-body practice that typically involves a combination of physical postures, breathing exercises, and concentration/meditation. Yoga has become a popular means of promoting physical and mental wellbeing and is shown to improve health related quality of life in older people. Evidence from observational studies suggests it is an acceptable and attractive form of exercise among older people. There are many different types of yoga, each of which places varying emphasis on physical, mental, and spiritual practices. In the West, the term “yoga” often denotes a modern form of hatha yoga, consisting largely of postural exercises performed with the goal of developing strength, balance, and flexibility (see fig 1). Yoga is not recommended specifically in fall prevention guidelines. The effect of yoga on falls in community-dwelling older people is uncertain.