Effect of a coaching intervention to enhance physical activity and prevent falls in community-dwelling people aged 60+ years: a cluster randomised controlled trial.

OBJECTIVES: To evaluate the effect of a coaching intervention compared with control on physical activity and falls rate at 12 months in community-dwelling people aged 60+ years. DESIGN: Cluster randomised controlled trial. SETTING: Community-dwelling older people. PARTICIPANTS: 72 clusters (605 participants): 37 clusters (290 participants) randomised to the intervention and 35 (315 participants) to control. INTERVENTION: Intervention group received written information, fall risk assessment and prevention advice by a physiotherapist, activity tracker and telephone-based coaching from a physiotherapist focused on safe physical activity. Control group received written information and telephone-based dietary coaching. Both groups received up to 19 sessions of telephone coaching over 12 months. OUTCOMES: The co-primary outcomes were device-measured physical activity expressed in counts per minute at 12 months and falls rate over 12 months. Secondary outcomes included the proportion of fallers, device-measured daily steps and moderate-to-vigorous physical activity (MVPA), self-reported hours per week of physical activity, body mass index, eating habits, goal attainment, mobility-related confidence, quality of life, fear of falling, risk-taking behaviour, mood, well-being and disability. RESULTS: The mean age of participants was 74 (SD 8) years, and 70% (n=425) were women. There was no significant effect of the intervention on device-measured physical activity counts per minute (mean difference 5 counts/min/day, 95% CI -21 to 31), or falls at 12 months (0.71 falls/person/year in intervention group and 0.87 falls/person/year in control group; incidence rate ratio 0.86, 95% CI 0.65 to 1.14). The intervention had a positive significant effect on device-measured daily steps and MVPA, and self-reported hours per week of walking, well-being, quality of life, and disability. No significant between-group differences were identified in other secondary outcomes. CONCLUSION: A physical activity and fall prevention programme including fall risk assessment and prevention advice, plus telephone-based health coaching, did not lead to significant differences in physical activity counts per minute or falls rate at 12 months. However, this programme improved other physical activity measures (ie, daily steps, MVPA, hours per week of walking), overall well-being, quality of life and disability. TRIAL REGISTRATION NUMBER: ACTRN12615001190594.

"Sharing Success with Someone": Building therapeutic alliance in physiotherapist-delivered physical activity coaching for healthy aging.

INTRODUCTION: Therapeutic alliance, a goal-orientated partnership between clients and practitioners, can enhance program engagement and adherence, and improve treatment outcomes and satisfaction. OBJECTIVES: To develop an empirical model that describes how therapeutic alliances can be operationalized in clinical and research settings and use this in our evaluation of the Coaching for Healthy Ageing (CHAnGE) trial. METHODS: Secondary analysis of interviews with participants in the CHAnGE trial (n = 32) and a focus group with the physiotherapists who delivered health coaching in that trial (n = 3). Analysis was inductive (thematic) and deductive (using a therapeutic alliance model derived from a literature review and informed by earlier analyses). RESULTS: Data from participants and physiotherapists indicated that health coaching in CHAnGE built effective therapeutic alliances (i.e. it facilitated collaborative decision-making and trusting person-centered relationships) which were underpinned by professional skills and structural supports. Components of the intervention that strengthened therapeutic alliance were health coaching training, home visits, the coaching format, and provision of free activity monitors. CONCLUSION: This study identifies key concepts and practical 'building blocks' of therapeutic alliance, showing how these were operationalized within an intervention. This may help those in clinical and research settings to recognize the importance and characteristics of therapeutic alliance and put it into practice.

Using self-determination theory to understand and improve recruitment for the Coaching for Healthy Ageing (CHAnGE) trial.

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.

A combined physical activity and fall prevention intervention improved mobility-related goal attainment but not physical activity in older adults: a randomised trial.

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.

Factors Associated With the Setting of Health-Related Goals Among Community-Dwelling Older People.

This study aimed to summarize the function-related goals set by older people, and to explore gender differences in goal selection and associations between balance-related goals and fall history, self-rated balance, and fear of falling. We included community-dwelling people aged 60 years and older participating in two randomized controlled trials. Participants nominated two function-related goals, which were summarized into components of the International Classification of Functioning, Disability and Health. Chi-square analyses were used to explore associations between goal types and participant characteristics. Goals related to recreation and leisure and walking were the most common function-related goals selected. Men and women set similar goals. Participants who had poor/fair self-reported balance were more likely to set a balance-related goal than people with good self-rated balance. In contrast, fallers and participants who had a fear of falling were not more likely to select a balance-related goal than nonfallers and participants who had no fear of falling, respectively.

A multidisciplinary intervention to prevent subsequent falls and health service use following fall-related paramedic care: a randomised controlled trial.

Background: approximately 25% of older people who fall and receive paramedic care are not subsequently transported to an emergency department (ED). These people are at high risk of future falls, unplanned healthcare use and poor health outcomes. Objective: to evaluate the impact of a fall-risk assessment and tailored fall prevention interventions among older community-dwellers not transported to ED following a fall on subsequent falls and health service use. Design, setting, participants: Randomised controlled trial involving 221 non-transported older fallers from Sydney, Australia. Intervention: the intervention targeted identified risk factors and used existing services to implement physiotherapy, occupational therapy, geriatric assessment, optometry and medication management interventions as appropriate. The control group received individualised written fall prevention advice. Measurements: primary outcome measures were rates of falls and injurious falls. Secondary outcome measures were ambulance re-attendance, ED presentation, hospitalisation and quality of life over 12 months. Analysis was by intention-to-treat and per-protocol according to self-reported adherence using negative binominal regression and multivariate analysis. Results: ITT analysis showed no significant difference between groups in subsequent falls, injurious falls and health service use. The per-protocol analyses revealed that the intervention participants who adhered to the recommended interventions had significantly lower rates of falls compared to non-adherers (IRR: 0.53 (95% CI : 0.32-0.87)). Conclusion: a multidisciplinary intervention did not prevent falls in older people who received paramedic care but were not transported to ED. However the intervention was effective in those who adhered to the recommendations. Trial registration: the trial is registered at the Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921, 13/05/2011.

A home-based, carer-enhanced exercise program improves balance and falls efficacy in community-dwelling older people with dementia.

BACKGROUND: Older people with dementia are at increased risk of physical decline and falls. Balance and mood are significant predictors of falls in this population. The aim of this study was to determine the effect of a tailored home-based exercise program in community-dwelling older people with dementia. METHODS: Forty-two participants with mild to moderate dementia were recruited from routine health services. All participants were offered a six-month home-based, carer-enhanced, progressive, and individually tailored exercise program. Physical activity, quality of life, physical, and psychological assessments were administered at the beginning and end of the trial. RESULTS: Of 33 participants (78.6%) who completed the six-month reassessment ten (30%) reported falls and six (18%) multiple falls during the follow-up period. At reassessment, participants had better balance (sway on floor and foam), reduced concern about falls, increased planned physical activity, but worse knee extension strength and no change in depression scores. The average adherence to the prescribed exercise sessions was 45% and 22 participants (52%) were still exercising at trial completion. Those who adhered to ≥70% of prescribed sessions had significantly better balance at reassessment compared with those who adhered to <70% of sessions. CONCLUSIONS: This trial of a tailored home-based exercise intervention presents preliminary evidence that this intervention can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia. Future research should determine whether exercise interventions are effective in reducing falls and elucidate strategies for enhancing uptake and adherence in this population.

What is the effect of a combined physical activity and fall prevention intervention enhanced with health coaching and pedometers on older adults' physical activity levels and mobility-related goals? Study protocol for a randomised controlled trial.

BACKGROUND: Physical inactivity and falls in older people are important public health problems. Health conditions that could be ameliorated with physical activity are particularly common in older people. One in three people aged 65 years and over fall at least once annually, often resulting in significant injuries and ongoing disability. These problems need to be urgently addressed as the population proportion of older people is rapidly rising. This trial aims to establish the impact of a combined physical activity and fall prevention intervention compared to an advice brochure on objectively measured physical activity participation and mobility-related goal attainment among people aged 60+. METHODS/DESIGN: A randomised controlled trial involving 130 consenting community-dwelling older people will be conducted. Participants will be individually randomised to a control group (n = 65) and receive a fall prevention brochure, or to an intervention group (n = 65) and receive the brochure plus physical activity promotion and fall prevention intervention enhanced with health coaching and a pedometer. Primary outcomes will be objectively measured physical activity and mobility-related goal attainment, measured at both six and 12 months post randomisation. Secondary outcomes will include: falls, the proportion of people meeting the physical activity guidelines, quality of life, fear of falling, mood, and mobility limitation. Barriers and enablers to physical activity participation will be measured 6 months after randomisation. General linear models will be used to assess the effect of group allocation on the continuously-scored primary and secondary outcome measures, after adjusting for baseline scores. Between-group differences in goal attainment (primary outcome) will be analysed with ordinal regression. The number of falls per person-year will be analysed using negative binomial regression models to estimate the between-group difference in fall rates after one year (secondary outcome). Modified Poisson regression models will compare groups on dichotomous outcome measures. Analyses will be pre-planned, conducted while masked to group allocation and will use an intention-to-treat approach. DISCUSSION: This trial will address a key gap in evidence regarding physical activity and fall prevention for older people and will evaluate a program that could be directly implemented within Australian health services. TRIAL REGISTRATION: ACTRN12614000016639, 7/01/2014.

Validity of the Fitbit activity tracker for measuring steps in community-dwelling older adults.

BACKGROUND: Commercially available activity monitors, such as the Fitbit, may encourage physical activity. However, the accuracy of the Fitbit in older adults remains unknown. This study aimed to determine (1) the criterion validity of Fitbit step counts compared to visual count and ActiGraph accelerometer step counts and (2) the accuracy of ActiGraph step counts compared to visual count in community-dwelling older people. METHODS: Thirty-two community-dwelling adults aged over 60 wore Fitbit and ActiGraph devices simultaneously during a 2 min walk test (2MWT) and then during waking hours over a 7-day period. A physiotherapist counted the steps taken during the 2MWT. RESULTS: There was excellent agreement between Fitbit and visually counted steps (intraclass correlation coefficient (ICC2,1)=0.88, 95% CI 0.76 to 0.94) from the 2MWT, and good agreement between Fitbit and ActiGraph (ICC2,1=0.66, 95% CI 0.41 to 0.82), and between ActiGraph and visually counted steps (ICC2,1=0.60, 95% CI 0.33 to 0.79). There was excellent agreement between the Fitbit and ActiGraph in average steps/day over 7 days (ICC2,1=0.94, 95% CI 0.88 to 0.97). Percentage agreement was closest for Fitbit steps compared to visual count (mean 0%, SD 4%) and least for Fitbit average steps/day compared to the ActiGraph (mean 13%, SD 25%). CONCLUSIONS: The Fitbit accurately tracked steps during the 2MWT, but the ActiGraph appeared to underestimate steps. There was strong agreement between Fitbit and ActiGraph counted steps. The Fitbit tracker is sufficiently accurate to be used among community-dwelling older adults to monitor and give feedback on step counts.

A post-hospital home exercise program improved mobility but increased falls in older people: a randomised controlled trial.

BACKGROUND: Home exercise can prevent falls in the general older community but its impact in people recently discharged from hospital is not known. The study aimed to investigate the effects of a home-based exercise program on falls and mobility among people recently discharged from hospital. METHODS AND FINDINGS: This randomised controlled trial (ACTRN12607000563460) was conducted among 340 older people. Intervention group participants (n = 171) were asked to exercise at home for 15-20 minutes up to 6 times weekly for 12 months. The control group (n = 169) received usual care. Primary outcomes were rate of falls (assessed over 12 months using monthly calendars), performance-based mobility (Lower Extremity Summary Performance Score, range 0-3, at baseline and 12 months, assessor unaware of group allocation) and self-reported ease of mobility task performance (range 0-40, assessed with 12 monthly questionaries). Participants had an average age of 81.2 years (SD 8.0) and 70% had fallen in the past year. Complete primary outcome data were obtained for at least 92% of randomised participants. Participants in the intervention group reported more falls than the control group (177 falls versus 123 falls) during the 12-month study period and this difference was statistically significant (incidence rate ratio 1.43, 95% CI 1.07 to 1.93, p = 0.017). At 12-months, performance-based mobility had improved significantly more in the intervention group than in the control group (between-group difference adjusted for baseline performance 0.13, 95% CI 0.04 to 0.21, p = 0.004). Self-reported ease in undertaking mobility tasks over the 12-month period was not significantly different between the groups (0.49, 95% CI -0.91 to 1.90, p = 0.488). CONCLUSIONS: An individualised home exercise prescription significantly improved performance-based mobility but significantly increased the rate of falls in older people recently discharged from hospital. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000563460.

Minimising disability and falls in older people through a post-hospital exercise program: a protocol for a randomised controlled trial and economic evaluation.

BACKGROUND: Disability and falls are particularly common among older people who have recently been hospitalised. There is evidence that disability severity and fall rates can be reduced by well-designed exercise interventions. However, the potential for exercise to have these benefits in older people who have spent time in hospital has not been established.This randomised controlled trial will investigate the effects of a home-based exercise program on disability and falls among people who have had recent hospital stays. The cost-effectiveness of the exercise program from the health and community service provider's perspective will be established. In addition, predictors for adherence with the exercise program will be determined. METHODS AND DESIGN: Three hundred and fifty older people who have recently had hospital stays will participate in the study. Participants will have no medical contraindications to exercise and will be cognitively and physically able to complete the assessments and exercise program.The primary outcome measures will be mobility-related disability (measured with 12 monthly questionnaires and the Short Physical Performance Battery) and falls (measured with 12 monthly calendars). Secondary measures will be tests of risk of falling, additional measures of mobility, strength and flexibility, quality of life, fall-related self efficacy, health-system and community-service contact, assistance from others, difficulty with daily tasks, physical activity levels and adverse events.After discharge from hospital and completion of all hospital-related treatments, participants will be randomly allocated to an intervention group or usual-care control group. For the intervention group, an individualised home exercise program will be established and progressed during ten home visits from a physiotherapist. Participants will be asked to exercise at home up to 6 times per week for the 12-month study period. DISCUSSION: The study will determine the impact of this exercise intervention on mobility-related disability and falls in older people who have been in hospital as well as cost-effectiveness and predictors of adherence to the program. Thus, the results will have direct implications for the design and implementation of interventions for this high-risk group of older people. TRIAL REGISTRATION: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12607000563460.