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Exercise that targets balance and strength is proven to prevent falls in older age. The Successful AGEing yoga trial is the first large randomized controlled trial to assess the impact of yoga on falls in people aged ≥60 years. We conducted a realist process evaluation to explain the strong participant engagement observed using interviews (21 participants and three yoga instructors) and focus groups (12 participants and four yoga instructors). Results showed that relaxation, breathing, and yoga's mind-body connection created a satisfying internal focus on bodily sensation which was valued by participants. The mechanisms of mindfulness and embodiment appeared to facilitate this. Mindfulness and embodiment are also linked to, and enhance engagement with, other forms of physical activity. By focusing creatively on these mechanisms, we can develop a range of programs that target improvements in physical and mental health (including reducing falls and fear of falls) and appeal to older people.

Introduction Process evaluations examining programme implementation are often conducted in conjunction with effectiveness studies. Their inclusion in studies with Aboriginal participants can give an understanding of programme delivery in Aboriginal community contexts. The Ironbark: Standing Strong and Tall programme was codesigned with Aboriginal communities and includes exercise and facilitated ‘yarning’ discussion about fall risk and prevention strategies. The programme pilot showed favourable outcomes and acceptability for Aboriginal people aged 45 years and over. The Ironbark: Standing Strong and Tall programme is now being compared with a ‘Healthy Community’ programme in a cluster randomised controlled trial within Aboriginal health and community services. An embedded process evaluation aims to explore relationships between participation and programme outcomes and the quality of programme implementation. Methods and analysis The process evaluation will use a mixed methods design, guided by Indigenous research methodology. It will evaluate quantitative data (number of completed sessions, site coaching checklist tool, participant and facilitator questionnaire data and a participant habit formation scale), as well as qualitative data (open-ended responses from project and site staff and semistructured interviews using yarning with study participants and site managers). A programme logic model was developed to explain the intended inputs, activities, outputs and outcomes, which guided this process evaluation design. Conclusion This process evaluation of a fall prevention programme for older Aboriginal people using a mixed methods design and data triangulation will allow for a comprehensive understanding of study findings. Multiple study sites allow for generalisability of findings and exploration of variation across sites. Trial registration number ACTRN12619000349145.

PURPOSE: To describe technology use and physiotherapy support provided to participants to improve mobility and physical activity in the community phase of the AMOUNT trial. METHODS: Process evaluation including participants (mean age 70 (SD18)) randomised to the intervention group (n=149). Intervention was additional to standard rehabilitation, prescribed using a protocol which matched games/exercises from eight technologies to the participant’s mobility limitations. Technologies included video and computer games/exercises, tablet applications and activity monitors. Participants were taught to use the technologies during inpatient rehabilitation and were then discharged home to use the technologies ≥ 5 days a week for the remainder of the 6-month trial. Trial protocol required the physiotherapist to provide support every 1–2 weeks using a health coaching approach. Intervention datasheets were audited to determine technology use and frequency, duration, mode and type of support provided. RESULTS: Participants used an average of 2 (SD 1) technologies with 98% participants using an activity monitor. Physiotherapists had contact with participants on average 15 (SD 5) times (approximately every 11 days), consisting of 6 (SD 3) home visits (46 min duration), 8 (SD 4) phone calls (8 min duration) and 1 other (email, video conference, hospital) type of contact. Contact primarily incorporated health coaching (68%) with 8% for technology support. Topics discussed during health coaching included discussing data from prescribed technologies (79%), physical activity and mobility status (70%) and adherence (64%). CONCLUSIONS: Technologies to support ongoing exercise are likely to become increasingly important as the proportion of older people in the population increases and rehabilitation resources become limited. A health coaching model to support technology use post hospitalisation is feasible. Some support can be provided remotely limiting the need for frequent home visits.

PURPOSE: To determine the effects of sport and physical recreation on participation, activity and impairment for people with physical disabilities. METHODS: Six electronic databases were searched. Any quantitative study design was included. One author screened the search output, extracted data and this was independently checked by a second author. RESULTS: Ten randomised controlled trials (RCT) were included (n=499; 65% adults; 51% people with Parkinson’s disease, 20% people with Cerebral Palsy), with one RCT on sport (table tennis for children with Developmental Coordination Delay). Non-RCTs included 12 longitudinal and 14 cross-sectional studies (n=829; 58% adults; 49% people with Spinal Cord Injury, 45% people with Cerebral Palsy). A range of physical recreation (e.g. dance and yoga) and sport (e.g. wheelchair rugby) activities were evaluated with majority wheelchair sports. RCTs reported positive findings for participation (1 study, dance in people with Parkinson’s disease) and activity (5 studies); however mixed findings on impairment measures (e.g. fatigue and depression). Similarly, longitudinal studies reported positive findings for participation (1 study, integrated basketball), activity (8 studies including wheelchair skills and mobility) and mixed findings on impairment measures. Three cross-sectional studies measured participation and reported that people who were athletes, who had played more sports, or who had played sports for more years, showed greater societal participation e.g. employment. Six cross-sectional studies also demonstrated sport enabled sufficient time in heart rate training zone for cardiovascular benefit. CONCLUSIONS: Despite the need for some caution in interpreting these results, the included studies consistently found benefits of sport participation for people with physical disabilities. Future research needs to include better designed studies measuring participation outcomes with a focus on ambulant and non- ambulant sports.&nbsp

© 2017 AJA Inc. 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.

© 2015 The Cochrane Collaboration. This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of interventions designed to reduce the incidence of falls in people with Parkinson's disease. ispartof: Cochrane Database of Systematic Reviews vol:2015 issue:3 pages:1-7 status: published

Objective: To determine the effects of leg muscle power training in people with Parkinsons disease. Design: Randomized controlled trial. Setting: University laboratory (outcome measures and experimental intervention), community (control intervention). Subjects: Community-dwelling people with Parkinsons disease. Interventions: Leg muscle power training using pneumatic variable resistance equipment (experimental) was compared with low intensity sham exercise (control). Both groups exercised twice weekly for 12 weeks. Main measures: Primary outcomes were peak power of four leg muscle groups. Secondary outcomes were measures of muscle strength, mobility, balance and falls. Results: Exercise adherence was high in both groups. Leg muscle power was significantly better in the experimental group than the control group in all four primary outcome measures at 12 weeks after adjusting for baseline values: leg extensors (57.9 watts, 95% confidence interval (CI) 22.0-93.7, p = 0.002); knee flexors (29.6 watts, 95% CI 7.4-51.8, p = 0.01); hip flexors (68.1 watts, 95% CI 19.6-116.5, p = 0.007); and hip abductors (37.4 watts, 95% CI 19.9-54.9, p < 0.001). The experimental group performed significantly better on tests of leg muscle strength (p < 0.001 to 0.07) and showed trends toward better performance in the Timed Up and Go (p = 0.13) and choice stepping reaction time (p = 0.11). There was a non-significant reduction in the rate of falls in the experimental group compared with the control group (incidence rate ratio 0.84, p = 0.76). Conclusions: This programme significantly improved muscle power in all trained muscle groups. © The Author(s) 2013.

Introduction: This project concerns the identification of the smallest worthwhile effect (SWE) of exercise-based programmes to prevent falls in older people. The SWE is the smallest effect that justifies the costs, risks and inconveniences of an intervention and is used to inform the design and interpretation of systematic reviews and randomised clinical trials. Methods and analysis: This study will comprise two different methodological approaches: the benefitharm trade-off method and the discrete choice experiment to estimate the SWE of exercise interventions to prevent falls in older people. In the benefit-harm trade-off method, hypothetical scenarios with the benefits, costs, risks and inconveniences associated with the intervention will be presented to each participant. Then, assuming a treatment effect of certain magnitude, the participant will be asked if he or she would choose to have the intervention. The size of the hypothetical benefit will be varied up and down until it is possible to identify the SWE for which the participant would choose to have the intervention. In the discrete choice experiment, the same attributes (benefits, costs, risks and inconveniences) with varying levels will be presented as choice sets, and participants will be asked to choose between these choice sets. With this approach, we will determine the probability that a person will consider the effects of an intervention to be worthwhile, given the particular costs, risks and inconveniences. For each of the two approaches, participants will be interviewed in person and on different occasions. A subsample of the total cohort will participate in both interviews. Ethics and dissemination: This project has received Ethics Approval from the University of Sydney Human Ethics Committee (Protocol number: 14404). Findings will be disseminated through conference presentations, seminars and peer-reviewed scientific journals.

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Background Admission to hospital can lead to persistent deterioration in physical functioning, particularly for the more vulnerable older population. As a result of this physical deterioration, older people who have been recently discharged from hospital may be particularly high users of health and social support services. Quantify usage and costs of services in older adults after hospitalisation and explore the impact of a home-exercise intervention on service usage. Method The present study was a secondary analysis of data from a randomised controlled trial (ACTRN12607000563460). The trial involved 340 participants aged 60 years and over with recent hospitalisation. Service use and costs were compared between intervention (12 months of home-exercise prescribed in 10 visits from a physiotherapist) and control groups. Results 33 % of participants were re-admitted to hospital, 100 % consulted a General Medical Practitioner and 63 % used social services. 56 % of costs were associated with hospital admission and 22 % with social services. There was reduction in General Medical Practitioner services provided in the home in the intervention group (IRR 0.23, CI 0.1 to 0.545, p TrialSearch. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0254-x) contains supplementary material, which is available to authorized users.

BACKGROUND: the smallest worthwhile effect (SWE) of an intervention is the smallest treatment effect that justifies the costs, risks and inconveniences associated with that health intervention. OBJECTIVE: to estimate the SWE of exercise programs designed to prevent falls among older people and to compare estimates derived by two methodological approaches. STUDY DESIGN AND SETTING: discrete choice experiment (n = 220) and benefit-harm trade-off (subsample n = 66) methods were used. PARTICIPANTS: community-dwelling older people who reported a past fall or a mobility limitation answered online or face-to-face questionnaires. RESULTS: a substantial proportion of participants (82% in the discrete choice experiment and 50% in the benefit-harm trade-off study) did not consider that participation in the proposed exercise programs would be worthwhile, even if it reduced their risk of falling to 0%. Among remaining participants, the average SWE of participation in an exercise program was an absolute reduction in the risk of falling of 35% (standard deviation [SD] = 13) in the discrete choice experiment and 16% (SD = 11) in the benefit-harm trade-off study. CONCLUSIONS: many participants did not consider the hypothetical falls' risk reduction of the proposed exercise programs to be worth the associated costs and inconveniences. Greater community awareness of the fall prevention effects of exercise for older people is required.© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]/* */ Language: en

Objective To compare the costs and cost-effectiveness of a multifactorial interdisciplinary intervention versus usual care for older people who are frail. Design Cost-effectiveness study embedded within a randomized controlled trial. Setting Community-based intervention in Sydney, Australia. Participants A total of 241 community-dwelling people 70 years or older who met the Cardiovascular Health Study criteria for frailty. Intervention A 12-month multifactorial, interdisciplinary intervention targeting identified frailty characteristics versus usual care. Measurements Health and social service use, frailty, and health-related quality of life (EQ-5D) were measured over the 12-month intervention period. The difference between the mean cost per person for 12 months in the intervention and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated. Results A total of 216 participants (90%) completed the study. The prevalence of frailty was 14.7% lower in the intervention group compared with the control group at 12 months (95% CI 2.4%–27.0%; P = .02). There was no significant between-group difference in EQ-5D utility scores. The cost for 1 extra person to transition out of frailty was $A15,955 (at 2011 prices). In the “very frail” subgroup (participants met >3 Cardiovascular Health Study frailty criteria), the intervention was both more effective and less costly than the control. A cost-effectiveness acceptability curve shows that the intervention would be cost-effective with 80% certainty if decision makers were willing to pay $A50,000 per extra person transitioning from frailty. In the very frail subpopulation, this reduced to $25,000. Conclusion For frail older people residing in the community, a 12-month multifactorial intervention provided better value for money than usual care, particularly for the very frail, in whom it has a high probability of being cost saving, as well as effective.

Background: The rate of falls in community dwelling older people with cognitive impairment (CI) is twice that of a cognitively intact population, with almost two thirds of people with CI falling annually. Studies indicate that exercise involving balance and/or a home hazard reduction program are effective in preventing falls in cognitively intact older people. However the potential benefit of these interventions in reducing falls in people with CI has not been established. This randomised controlled trial will determine whether a tailored exercise and home hazard reduction program can reduce the rate of falls in community dwelling older people with CI. We will determine whether the intervention has beneficial effects on a range of physical and psychological outcome measures as well as quality of life of participants and their carers. A health economic analysis examining the cost and potential benefits of the program will also be undertaken. Methods and design: Three hundred and sixty people aged 65 years or older living in the community with CI will be recruited to participate in the trial. Each will have an identifiable carer with a minimum of 3.5 hours of face to face contact each week. Participants will undergo an assessment at baseline with retests at 6 and 12 months. Participants allocated to the intervention group will participate in an exercise and home hazard reduction program tailored to their cognitive and physical abilities. The primary outcome measure will be the rate of falls which will be measured using monthly falls calendars. Secondary outcome measures will include the risk of falling, quality of life, measures of physical and cognitive function, fear of falling and planned and unplanned use of health services. Carers will be followed up to determine carer burden, coping strategies and quality of life. Discussion: The study will determine the impact of this tailored intervention in reducing the rate of falls in community dwelling older people with CI as well as the cost-effectiveness and adherence to the program. 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 ACTRN12614000603617

Background: despite evidence on what works in falls prevention, falls in older people remain an important public health problem. Aims: the purpose of this study was to model the impact and cost-effectiveness of a public health falls prevention programme, from the perspective of the health funder Conclusion: serious consideration should be given to implementation of a public health programme of falls prevention as a cost-effective option that enables population-wide access to the intervention strategies Methods: a decision analytic Markov model compared the health benefits in quality-adjusted life years (QALYs) and costs of treatment and residential aged care with and without a population heath falls prevention programme. Different intervention costs, uptake levels and programme effectiveness were modelled in sensitivity analyses. Uncertainty was explored using univariate and probabilistic sensitivity analysis Results: widespread rollout of a public health fall prevention programme could result in an incremental cost-effectiveness ratio (ICER) of $A28,931 per QALY gained, assuming a programme cost of $700 per person and at a fall prevention risk ratio of 0.75. This ICER would be considered cost-effective at a threshold value of $A50,000 per QALY gained. Sensitivity analyses for programme cost and effectiveness indicated that the public health programme produced greater health outcomes and was less costly than no programme when programme costs were $A500 or lower and risk ratio for falls was 0.70 or lower. At a cost of $A2,500, the public health falls prevention programme ceases to be a cost-effective option. Refereed/Peer-reviewed

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. Language: en

This thesis aimed to explore the role of physical activity as an intervention strategy for the treatment of mental illness, with a focus on posttraumatic stress disorder (PTSD). A meta-analysis of randomized controlled trials (RCTs) incorporating physical activity interventions for established mental illness found a large effect of physical activity on depressive symptoms (n=20; standardised mean difference, SMD=0.80). To evaluate the impact of a physical activity intervention on PTSD, an assessor-blinded RCT was conducted. In total 81 participants were randomised to receive either usual care (n=42), or an individualised 12-week exercise program in addition to usual care (n = 39). PTSD symptoms were significantly reduced in the intervention group compared to the usual care group (mean difference at follow-up adjusted for baseline values = -5.4, 95%CI -10.5 to -0.3, p=0.04, n=58). There were also significant between-group differences at follow-up for depression scores, waist circumference, sleep quality and time spent sitting. The trial results support the addition of structured exercise to usual care for PTSD patients. Improving access to, and the provision of, clinical exercise programs within as part of treatment for patients with mental illness is warranted given the results of the studies presented in this thesis.

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.

Background People with Parkinson's disease are twice as likely to be recurrent fallers compared to other older people. As these falls have devastating consequences, there is an urgent need to identify and test innovative interventions with the potential to reduce falls in people with Parkinson's disease. The main objective of this randomised controlled trial is to determine whether fall rates can be reduced in people with Parkinson's disease using exercise targeting three potentially remediable risk factors for falls (reduced balance, reduced leg muscle strength and freezing of gait). In addition we will establish the cost effectiveness of the exercise program from the health provider's perspective. Methods/Design 230 community-dwelling participants with idiopathic Parkinson's disease will be recruited. Eligible participants will also have a history of falls or be identified as being at risk of falls on assessment. Participants will be randomly allocated to a usual-care control group or an intervention group which will undertake weight-bearing balance and strengthening exercises and use cueing strategies to address freezing of gait. The intervention group will choose between the home-based or support group-based mode of the program. Participants in both groups will receive standardized falls prevention advice. The primary outcome measure will be fall rates. Participants will record falls and medical interventions in a diary for the duration of the 6-month intervention period. Secondary measures include the Parkinson's Disease Falls Risk Score, maximal leg muscle strength, standing balance, the Short Physical Performance Battery, freezing of gait, health and well being, habitual physical activity and positive and negative affect schedule. Discussion No adequately powered studies have investigated exercise interventions aimed at reducing falls in people with Parkinson's disease. This trial will determine the effectiveness of the exercise intervention in reducing falls and its cost effectiveness. This pragmatic program, if found to be effective, has the potential to be implemented within existing community services. Trial registration The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).