Browse the corpus

Home based, tailored intervention to reduce rate of falls after stroke (FAST): randomised trial. OBJECTIVE: To investigate the effectiveness of a multidisciplinary, home based, tailored intervention to reduce falls after stroke. DESIGN: Two armed, randomised trial. SETTING: Three states in Australia. PARTICIPANTS: People within 5 years of stroke, aged >50 years, discharged from formal rehabilitation to the community, and able to walk 10 m across flat ground with or without an aid. Those with moderate-to-severe receptive aphasia or walking speed >1.4 m/s without falls in the previous year were excluded. INTERVENTION: Over 6 months, the experimental group received a habit forming functional exercise, home fall hazard reduction, and goal directed community mobility coaching; the control group received usual care. Physiotherapist and occupational therapist dyadic teams worked collaboratively to deliver the intervention. MAIN OUTCOME MEASURES: The primary outcome was rate of falls over 12 months. Secondary outcomes were proportion of participants having a fall, community participation, self-efficacy, balance, mobility, physical activity, activities of daily living, depression, and health related quality of life. RESULTS: Between August 2019 and December 2023, 370 people with stroke were enrolled. At 12 months, a significant between group difference was seen in the rate of falls in favour of the experimental group, representing a 33% reduction in falls (incidence rate ratio 0.67, 95% confidence interval (CI) 0.48 to 0.94; P=0.02). No significant between group difference was seen in the number of participants having a fall (absolute risk reduction 0.03, 95% CI -0.07 to 0.13; P=0.52). The main between group differences in favour of the experimental group were in community participation (Late Life Function and Disability Instrument disability limitation: mean difference 3% (95% CI 1% to 6%); P=0.02), self-efficacy (mean difference 0.6 (0.2 to 1.0); P=0.004), mobility (fast walking speed: mean difference 0.13 (0.06 to 0.19) m/s (P<0.001); preferred walking speed: 0.06 (0.02 to 0.10) m/s (P=0.02)), and balance (Step Test: mean difference 0.06 (0.01 to 0.12) steps/s; P=0.03). CONCLUSION: A tailored intervention prevented falls in community dwelling, ambulatory people with stroke. The decrease in the rate of falls was underpinned by clinically worthwhile improvements in self-efficacy, mobility, community participation, and balance. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001114134.

Falls and fall related injuries are a leading cause of morbidity and mortality, making their prevention and management a critical global challenge.1 More than twice as many people with stroke have falls compared with the general older population (73% compared with 30%),2 often resulting in fall related injuries and hospital admission.3 4 Stroke survivors are also likely to be repeat fallers, and the consequences of falls severely jeopardise their long term health and wellbeing.5 No effective intervention that prevents falls after stroke is available.6 In three randomised trials, the non-drug interventions investigated to reduce falls after stroke were not effective and involved either home modifications or exercise that was segregated from daily activities.7 8 9 The aim of this phase 3 randomised trial, therefore, was to determine the clinical effect of a multidisciplinary intervention to reduce falls. The intervention combined exercise, home safety, and a community mobility goal, but most important is that the exercise is habit forming because it is integrated into daily activities.10 Specific research questions were as follows. (1) In community dwelling stroke survivors, is a home based, multidisciplinary, tailored intervention effective at reducing the rate of falls and the proportion of people having a fall over a one year period? (2) In addition, does it improve community participation, self-efficacy, balance, mobility, physical activity, activities of daily living, depression, and health related quality of life?

The “falls after stroke trial” (FAST) was a prospective, multistate, phase 3 randomised trial with concealed allocation, masked measurement, and intention-to-treat analysis. The protocol has been published.11 The study is reported in accordance with the updated CONSORT statement 2025.12 It was prospectively registered (12 August 2019) on the Australian New Zealand Clinical Trials Registry (ACTRN12619001114134). People with stroke were screened and invited to participate if they were ≥50 years old, within five years of a first stroke, community dwelling after being discharged from formal rehabilitation, able to walk 10 m across flat ground with or without an aid, and capable of providing consent (fewer than five errors on the Short Portable Mental Status Questionnaire). We excluded people who had moderate-to-severe receptive aphasia (<7/10 on the comprehension component of the Frenchay Screening Aphasia Test13) or if they could walk >1.4 m/s and had not fallen in the previous year. Information (such as age, sex, time since stroke) to describe the sample was collected from the participants. We recruited stroke survivors from New South Wales, Victoria, and the Australian Capital Territory in Australia via the Australian Clinical Stroke Registry, hospital databases, and professional networks.

year. Information (such as age, sex, time since stroke) to describe the sample was collected from the participants. We recruited stroke survivors from New South Wales, Victoria, and the Australian Capital Territory in Australia via the Australian Clinical Stroke Registry, hospital databases, and professional networks. We randomly allocated participants into either the experimental group (six months of habit forming exercise, safety training, and community mobility) or the control group (usual care). The allocation of participants to groups was stratified by level of disability according to walking speed because it is associated with community ambulation.14 Participants were allocated to groups within each of three strata (<0.4, 0.4-0.8, >0.8 m/s) after the baseline measurement. We used an offsite, independent, and automated service (Clinical Trials Centre, University of Sydney) to generate the sequence with stratification and block randomisation, to conceal the schedule from the recruiter, and to reveal allocation to the trial coordinators. Researchers masked to group allocation measured outcomes at baseline, at six months (end of intervention), and at 12 months in the home. Masking participants and therapists to group allocation was not possible. A statistician masked to group allocation did the statistical analysis.

allocation to the trial coordinators. Researchers masked to group allocation measured outcomes at baseline, at six months (end of intervention), and at 12 months in the home. Masking participants and therapists to group allocation was not possible. A statistician masked to group allocation did the statistical analysis. The experimental group received the FAST intervention, a home based intervention consisting of three components—a habit forming functional exercise, home fall hazard reduction, and goal directed community mobility coaching—which were tailored to their level of disability.11 an occupational therapist/physiotherapist dyad delivered the home based, tailored intervention during seven home visits (one in each of weeks 1-7; 60 minute duration) followed by three booster home visits (one in each of weeks 13, 15, and 23; 60 minute duration) with two phone calls (one in each of weeks 9 and 19; 30 minute duration). Therapists were eligible to deliver the intervention if they were occupational therapists or physiotherapists registered with the Australian Health Practitioner Regulation Agency. All therapists received training in the implementation of the intervention plus Lifestyle integrated Functional Exercise (LiFE) therapist and participant manuals.15

to deliver the intervention if they were occupational therapists or physiotherapists registered with the Australian Health Practitioner Regulation Agency. All therapists received training in the implementation of the intervention plus Lifestyle integrated Functional Exercise (LiFE) therapist and participant manuals.15 FAST was tailored to each participant’s level of disability; the faster walkers (>0.8 m/s) had an initial emphasis on exercise, the slower walkers (<0.4 m/s) on home safety, and the medium walkers (0.4-0.8 m/s) on both exercise and home safety. All participants were asked to set a community mobility goal, which therapists could refine or extend when necessary to support progress. Habit forming functional exercise used the LiFE programme,16 which incorporates activities that challenge balance and strength embedded into specific daily activities. They were performed consciously with the aim of them becoming habitual (that is, automatically instigated). Rather than a prescribed set of exercises conducted several times a week, the collaboratively selected activities were integrated with usual daily activities. Action planning, feedback, monitoring, and positive reinforcement were used to encourage consistent performance of these activities and promote self-efficacy.

). Rather than a prescribed set of exercises conducted several times a week, the collaboratively selected activities were integrated with usual daily activities. Action planning, feedback, monitoring, and positive reinforcement were used to encourage consistent performance of these activities and promote self-efficacy. Home fall hazard reduction focused on environmental adaptations to reduce fall hazards and protective behaviours to reduce risk, taking into account level of disability. An occupational therapist used the Westmead Home Safety Assessment and the Falls Behavioural Scale for Older People to identify environmental fall hazards and risks.17 18 The intervention incorporated strategies for enhancing self-efficacy, cueing, and monitoring to boost adherence, as well as engagement in planning, decision making, and follow-through of solutions. Participants had access to simple home adaptations up to the value of 200 AUD (£105; $142; €121) (such as non-slip strips, double sided tape to secure carpets, and LED sensor globes to improve night lighting) and referral to usual home modification services in the community if needed. Goal directed community mobility coaching focused on a community mobility goal that was individualised and, where appropriate, jointly devised with the therapist. Goals included mobilising in specific contexts outside the home such as walking in the park or around a crowded shopping centre or using public transport. If indicated, a session that included supported mastery to boost confidence and skill was implemented.

ed and, where appropriate, jointly devised with the therapist. Goals included mobilising in specific contexts outside the home such as walking in the park or around a crowded shopping centre or using public transport. If indicated, a session that included supported mastery to boost confidence and skill was implemented. We carried out fidelity checks of the intervention. Participants completed the Exercise Adherence Rating Scale at six and 12 months,19 and we audited the implementation of home safety recommendations and the attainment of community mobility goals at six and 12 months. The control group received usual care that equated to no active intervention, reflecting the current situation for community dwelling stroke survivors discharged from rehabilitation in Australia, where opportunities for rehabilitation largely cease by six months.20 We have used the Template for Intervention Description and Replication (TIDieR) checklist to summarise trial interventions (see supplementary materials).21 Falls were recorded prospectively from baseline (daily until day 365) on falls calendars and returned monthly by (e)mail or, if not, by phone call, and we reported them as an annual rate of falls. We defined falls according to consensus statements and Cochrane review recommendations as “an unexpected event in which the participant comes to rest on the ground, floor, or lower level.”22

5) on falls calendars and returned monthly by (e)mail or, if not, by phone call, and we reported them as an annual rate of falls. We defined falls according to consensus statements and Cochrane review recommendations as “an unexpected event in which the participant comes to rest on the ground, floor, or lower level.”22 We also collected the proportion of participants having a fall over the year and information about the nature of any injuries associated with the fall. Other secondary outcomes were collected at six and 12 months and included community participation, falls related self-efficacy, balance, mobility, physical activity, activities of daily living, depression, and health related quality of life. We measured community participation by using the disability component (limitation and frequency) of the Late Life Function and Disability Index (LLFDI),23 reported as a score of 0 to 100 where 100 is less difficulty with participation. In addition, a self-reported estimate of the amount of participation outside the home was reported as outings per week. We measured falls related self-efficacy as how concerned participants were about falling when carrying out usual activities in the home and the community, rated using a Likert-type scale on which 0 is “very concerned” and 6 is “not at all concerned.” Balance was measured using the balance component of the Short Physical Performance Battery (SPPB),24 reported as a score of 0 to 4 where 4 is good balance, and the Step Test,25 reported as steps per second. We measured mobility as preferred and fast walking speed over 5 m,26 reported in metres per second. In addition, two self reported questions estimating maximum duration (using a Likert-type scale on which 0 is <5 min and 4 is >60 min) and maximum distance of walking (using a Likert-type scale on which 0 is <100 m and 4 is >2 km) were reported. Physical activity was measured using the Incidental and Planned Exercise Questionnaire (IPEQ),27 reported as hours per week. We measured activities of daily living by using the function component of the LLFDI,23 reported as a score of 0 to 100 where 100 is less difficulty with activities. Depression was measured using the Patient Health Questionnaire-2,28 reported as a score 0 to 6 where 6 is depression. Health related quality of life was measured using the 0-100 visual analogue scale of the EQ-5D (5L).29 These outcomes are detailed in supplementary table A.

where 100 is less difficulty with activities. Depression was measured using the Patient Health Questionnaire-2,28 reported as a score 0 to 6 where 6 is depression. Health related quality of life was measured using the 0-100 visual analogue scale of the EQ-5D (5L).29 These outcomes are detailed in supplementary table A. We estimated the sample size for the primary outcome. A negative binomial model for the number of falls was assumed,30 with α (measure of over-dispersion in negative binomial regression model) assumed to be 0.8 and annual rate of falls in the control group assumed to be 1.8 falls/person on the basis of Dean and colleagues.8 Assuming a 15% loss to follow-up, with a two sided level of significance of 5% and power of 80%, we needed a sample size of 185 per group to detect a 30% lower rate of falls in the experimental group than in the control group.

lls in the control group assumed to be 1.8 falls/person on the basis of Dean and colleagues.8 Assuming a 15% loss to follow-up, with a two sided level of significance of 5% and power of 80%, we needed a sample size of 185 per group to detect a 30% lower rate of falls in the experimental group than in the control group. Before data analysis, we generated a comprehensive statistical analysis plan, which corrected discrepancies between our protocol and registration and is lodged on the Sydney University eScholarship Repository (https://ses.library.usyd.edu.au/handle/2123/33822.3). We did analyses on an intention-to-treat basis. We analysed the between group difference in annual rate of falls by using negative binomial regression and presented it as an incidence rate ratio.31 We analysed the between group difference in proportion of fallers by using the χ2 test and presented it as relative risk and risk difference. We used R version 4.4.2 to analyse falls data and IBM SPSS version 30 to analyse other secondary data. We analysed interval secondary outcomes by using analysis of variance and presented them as mean between group differences with 95% confidence intervals. We analysed ordinal secondary outcomes by using the non-parametric Mann-Whitney U statistic but presented them as mean between group differences with 95% confidence intervals. We included only participants for whom secondary measures were collected in the between group analyses—that is, we did not impute missing data.

We analysed ordinal secondary outcomes by using the non-parametric Mann-Whitney U statistic but presented them as mean between group differences with 95% confidence intervals. We included only participants for whom secondary measures were collected in the between group analyses—that is, we did not impute missing data. No patients or members of the public were involved in the research, as no funds or time were allocated for patient and public involvement. However, we interviewed experimental and control participants as part of our research, which will inform future implementation

The “falls after stroke trial” (FAST) was a prospective, multistate, phase 3 randomised trial with concealed allocation, masked measurement, and intention-to-treat analysis. The protocol has been published.11 The study is reported in accordance with the updated CONSORT statement 2025.12 It was prospectively registered (12 August 2019) on the Australian New Zealand Clinical Trials Registry (ACTRN12619001114134).

People with stroke were screened and invited to participate if they were ≥50 years old, within five years of a first stroke, community dwelling after being discharged from formal rehabilitation, able to walk 10 m across flat ground with or without an aid, and capable of providing consent (fewer than five errors on the Short Portable Mental Status Questionnaire). We excluded people who had moderate-to-severe receptive aphasia (<7/10 on the comprehension component of the Frenchay Screening Aphasia Test13) or if they could walk >1.4 m/s and had not fallen in the previous year. Information (such as age, sex, time since stroke) to describe the sample was collected from the participants. We recruited stroke survivors from New South Wales, Victoria, and the Australian Capital Territory in Australia via the Australian Clinical Stroke Registry, hospital databases, and professional networks.

We randomly allocated participants into either the experimental group (six months of habit forming exercise, safety training, and community mobility) or the control group (usual care). The allocation of participants to groups was stratified by level of disability according to walking speed because it is associated with community ambulation.14 Participants were allocated to groups within each of three strata (<0.4, 0.4-0.8, >0.8 m/s) after the baseline measurement. We used an offsite, independent, and automated service (Clinical Trials Centre, University of Sydney) to generate the sequence with stratification and block randomisation, to conceal the schedule from the recruiter, and to reveal allocation to the trial coordinators. Researchers masked to group allocation measured outcomes at baseline, at six months (end of intervention), and at 12 months in the home. Masking participants and therapists to group allocation was not possible. A statistician masked to group allocation did the statistical analysis.

The experimental group received the FAST intervention, a home based intervention consisting of three components—a habit forming functional exercise, home fall hazard reduction, and goal directed community mobility coaching—which were tailored to their level of disability.11 an occupational therapist/physiotherapist dyad delivered the home based, tailored intervention during seven home visits (one in each of weeks 1-7; 60 minute duration) followed by three booster home visits (one in each of weeks 13, 15, and 23; 60 minute duration) with two phone calls (one in each of weeks 9 and 19; 30 minute duration). Therapists were eligible to deliver the intervention if they were occupational therapists or physiotherapists registered with the Australian Health Practitioner Regulation Agency. All therapists received training in the implementation of the intervention plus Lifestyle integrated Functional Exercise (LiFE) therapist and participant manuals.15 FAST was tailored to each participant’s level of disability; the faster walkers (>0.8 m/s) had an initial emphasis on exercise, the slower walkers (<0.4 m/s) on home safety, and the medium walkers (0.4-0.8 m/s) on both exercise and home safety. All participants were asked to set a community mobility goal, which therapists could refine or extend when necessary to support progress.

he faster walkers (>0.8 m/s) had an initial emphasis on exercise, the slower walkers (<0.4 m/s) on home safety, and the medium walkers (0.4-0.8 m/s) on both exercise and home safety. All participants were asked to set a community mobility goal, which therapists could refine or extend when necessary to support progress. Habit forming functional exercise used the LiFE programme,16 which incorporates activities that challenge balance and strength embedded into specific daily activities. They were performed consciously with the aim of them becoming habitual (that is, automatically instigated). Rather than a prescribed set of exercises conducted several times a week, the collaboratively selected activities were integrated with usual daily activities. Action planning, feedback, monitoring, and positive reinforcement were used to encourage consistent performance of these activities and promote self-efficacy.

ed and, where appropriate, jointly devised with the therapist. Goals included mobilising in specific contexts outside the home such as walking in the park or around a crowded shopping centre or using public transport. If indicated, a session that included supported mastery to boost confidence and skill was implemented. We carried out fidelity checks of the intervention. Participants completed the Exercise Adherence Rating Scale at six and 12 months,19 and we audited the implementation of home safety recommendations and the attainment of community mobility goals at six and 12 months. The control group received usual care that equated to no active intervention, reflecting the current situation for community dwelling stroke survivors discharged from rehabilitation in Australia, where opportunities for rehabilitation largely cease by six months.20 We have used the Template for Intervention Description and Replication (TIDieR) checklist to summarise trial interventions (see supplementary materials).21

Falls were recorded prospectively from baseline (daily until day 365) on falls calendars and returned monthly by (e)mail or, if not, by phone call, and we reported them as an annual rate of falls. We defined falls according to consensus statements and Cochrane review recommendations as “an unexpected event in which the participant comes to rest on the ground, floor, or lower level.”22

We estimated the sample size for the primary outcome. A negative binomial model for the number of falls was assumed,30 with α (measure of over-dispersion in negative binomial regression model) assumed to be 0.8 and annual rate of falls in the control group assumed to be 1.8 falls/person on the basis of Dean and colleagues.8 Assuming a 15% loss to follow-up, with a two sided level of significance of 5% and power of 80%, we needed a sample size of 185 per group to detect a 30% lower rate of falls in the experimental group than in the control group.

No patients or members of the public were involved in the research, as no funds or time were allocated for patient and public involvement. However, we interviewed experimental and control participants as part of our research, which will inform future implementation

Between 22 August 2019 and 1 December 2023, 769 people with stroke were screened and 370 enrolled. Participants in the experimental (n=186) and control (n=184) groups were similar in terms of age, sex, chronicity, side of hemiplegia, type and severity of stroke, and previous living arrangements (table 1). Two thirds of participants were faster walkers and <10% were slower walkers. The primary outcome (falls) was measured for 337 (91%) participants across the full 12 months and partially for the other 33 (9%) participants across 13-354 days. Secondary outcome measures were collected from 335 (91%) participants at month 6 and 327 (88%) at month 12 (fig 1). In addition, some data were missing: the secondary physical outcomes of a further 34 participants could not be measured at month 6 (all owing to covid-19 restrictions) and a further 21 participants at month 12 (76% owing to covid-19 restrictions). Participants’ characteristics and distribution across states and walking speeds. Values are numbers (percentages) unless stated otherwise SD=standard deviation. CONSORT 2025 flow diagram of participants through trial Thirty three therapists (16 physiotherapists and 17 occupational therapists) delivered the experimental intervention. Of these, 70% had >10 years’ clinical experience and 15% had less than five years’ experience, with 13% having postgraduate qualifications.

SD=standard deviation. CONSORT 2025 flow diagram of participants through trial Thirty three therapists (16 physiotherapists and 17 occupational therapists) delivered the experimental intervention. Of these, 70% had >10 years’ clinical experience and 15% had less than five years’ experience, with 13% having postgraduate qualifications. The mean number of experimental sessions delivered to the 166 participants with a six month assessment out of a possible 12 per participant was 11.6 (standard deviation (SD) 1.3), comprising 6.9 (SD 0.5) home visits of mean duration 60.2 (SD 10.3) min, 2.9 (0.5) booster sessions of mean duration 51.4 (15.1) min, and 1.9 (0.4) phone calls of mean duration 21.7 (12.3) min; 141 (85%) participants received all the sessions. In terms of adherence to the habit forming exercises, the mean Exercise Adherence Rating Scale score was 16/24 (SD 6; n=161) at month 6 and 14/24 (SD 6; n=146) at month 12. One hundred and twenty seven (77%) participants implemented home safety recommendations at least partially (>50%), and 131 (79%) set community mobility goals. In terms of fidelity, 13 random checks were carried out (on nine home visits and four booster sessions) and scored a mean 2.9/3.0 (SD 0.1) where 3 is very good fidelity. In terms of concomitant intervention, 49% of the experimental group and 51% of the control group accessed allied health services over the 12 months.

. In terms of fidelity, 13 random checks were carried out (on nine home visits and four booster sessions) and scored a mean 2.9/3.0 (SD 0.1) where 3 is very good fidelity. In terms of concomitant intervention, 49% of the experimental group and 51% of the control group accessed allied health services over the 12 months. In terms of the primary outcome of rate of falls, the between group difference at 12 months was an incidence rate ratio of 0.67 (95% confidence interval (CI) 0.48 to 0.94; P=0.02) in favour of the experimental group, which represents a 33% reduction in falls (table 2). The annual fall rate for the experimental group was 1.8 (SD 3.0; range 0-19; total 327) per participant compared with 2.7 (SD 5.5; range 0-40; total 500) per participant in the control group. Overall, in 82% of falls, participants reported that they needed no assistance to get up and no medical attention. Few falls resulted in a fracture (2%) or hospital admission (4%). Rate of falls (primary analysis) and number of people having a fall (secondary analysis) ARR=absolute risk reduction; IRR=incidence rate ratio; RR=relative risk. Experimental relative to control. In terms of the proportion of participants having a fall at 12 months, we found no significant difference between groups (relative risk 0.94, 95% CI 0.79 to 1.12; P=0.52) (table 2). The number of participants in the experimental group who had a fall was 104 (56%) compared with 109 (59%) in the control group.

Experimental relative to control. In terms of the proportion of participants having a fall at 12 months, we found no significant difference between groups (relative risk 0.94, 95% CI 0.79 to 1.12; P=0.52) (table 2). The number of participants in the experimental group who had a fall was 104 (56%) compared with 109 (59%) in the control group. Table 3 shows the group means, within group differences, and between group differences of the secondary outcomes. At month 6, we found a statistically significant between group difference in community participation (LLFDI disability limitation: mean difference 3% (95% CI 1 to 6); P=0.01), self-efficacy (mean difference 0.4 (0 to 0.8) out of 6 points; P=0.05), balance (SPPB: mean difference 0.3 (0.1 to 0.6) out of 4 points; P=0.02), and mobility (self-reported walking distance: mean difference 0.2 (0 to 0.4) out of 4 points; P=0.04) in favour of the experimental group. Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI; P value) difference between groups for secondary outcomes ADL=activities of daily living; CI=confidence interval; Con=control group; Exp=experimental group; IPEQ=Incidental and Planned Exercise Questionnaire; LLFDI=Late Life Function and Disability Index; PHQ-2=Patient Health Questionnaire-2; QOL=quality of life; SD=standard deviation; SPPB=Short Physical Performance Battery; VAS=visual analogue scale.

ing; CI=confidence interval; Con=control group; Exp=experimental group; IPEQ=Incidental and Planned Exercise Questionnaire; LLFDI=Late Life Function and Disability Index; PHQ-2=Patient Health Questionnaire-2; QOL=quality of life; SD=standard deviation; SPPB=Short Physical Performance Battery; VAS=visual analogue scale. At month 12, we found a statistically significant between group difference in community participation (LLFDI disability limitation: mean difference 3% (95% CI 1% to 6%); P=0.02), self-efficacy (mean difference 0.6 (0.2 to 1.0); P=0.004), mobility (fast walking speed: mean difference 0.13 (0.06 to 0.19) m/s (P<0.001); preferred walking speed: mean difference 0.06 (0.02 to 0.10) m/s (P=0.02); self-reported walking distance: mean difference 0.3 (0 to 0.5) out of 4 points (P=0.03)), and balance (SPPB: mean difference 0.3 (0.0 to 0.6) out of 4 points (P=0.04); Step Test: mean difference 0.06 (0.01 to 0.12) steps/s (P=0.03)) in favour of the experimental group.

This randomised trial involving community dwelling, ambulatory stroke survivors found that a home based, multidisciplinary, tailored intervention was effective in decreasing the primary outcome of rate of falls over a one year period. The number of people having a fall was not significantly different between groups. The decrease in the rate of falls was underpinned by clinically worthwhile improvements in self-efficacy, balance, community participation, and mobility. At baseline, our participants varied across the spectrum of mobility with an average comfortable walking speed of 0.8 m/s, which is the threshold for full community ambulation.14 However, they had still had falls, with about two thirds having had at least one fall in the year before the study. The beneficial effect of the intervention on the rate of falls was the result of the experimental group managing to prevent falls to a greater extent over the long term, whereas the control group had more falls. The experimental group had an annual rate of 1.9 falls/participant in the year before the study compared with 1.8 falls/participant over the year of the study. This is in contrast to the control group, who had an annual rate of 2.0 falls/participant in the year before the study and 2.7 falls/participant over the year of the study. Notably, we observed a large increase in self-efficacy by the experimental group compared with the control group, suggesting that the tailored intervention had helped them to match their behaviour to their level of disability.

articipant in the year before the study and 2.7 falls/participant over the year of the study. Notably, we observed a large increase in self-efficacy by the experimental group compared with the control group, suggesting that the tailored intervention had helped them to match their behaviour to their level of disability. Only three previous randomised trials have investigated the effectiveness of a non-drug intervention to reduce falls after stroke and reported the annual rate of falls.7 8 9 All found no effect, making ours the first effectiveness trial to find a reduction in the rate of falls relative to the control group after stroke. This may be because adherence to exercise was low and exercise was segregated from everyday activities in two of the earlier trials, and home modification did not directly target falls risk in the other trial. In our trial, participants embedded exercise into everyday activities, thereby promoting habitual behaviour. Furthermore, the intervention included home safety and community mobility coaching, as well as habit forming exercise, with each component tailored to the participant’s level of disability. For example, for participants with very poor mobility, the initial emphasis was on home safety before exercise was introduced. This was supported by the latest Cochrane review of environmental interventions and falls,32 which found high certainty evidence that home fall hazard interventions are effective in reducing the rate of falls in community dwelling people at higher risk of falling. Our results are in contrast to the trial by Dean and colleagues,8 which found that exercise without home safety intervention tended to increase the number of falls for people with more disability.

ll hazard interventions are effective in reducing the rate of falls in community dwelling people at higher risk of falling. Our results are in contrast to the trial by Dean and colleagues,8 which found that exercise without home safety intervention tended to increase the number of falls for people with more disability. The main strengths of this study are the appropriately powered sample size, randomisation based on level of disability, which controls for the heterogeneity of stroke, tailoring of the intervention to level of disability, high retention and adherence, and the collaboration between occupational therapists and physiotherapists, which resulted in high fidelity. The main challenge during the study was the restrictions caused by the covid-19 pandemic that prevented the collection of some secondary outcomes. It also affected the delivery of the intervention, which we overcame by pivoting to telehealth. The main limitation of the study is the large number of therapists needed to provide intervention across multiple sites and regions. However, the resultant variety of expertise may also be viewed as a positive, as it enables confidence that the intervention, rather than the individual therapist, is responsible for the beneficial outcome. Further papers are planned that explore participants’ experience, habit formation, and adherence. Finally, a limitation of this study (initiated a decade ago) was the absence of patient and public involvement.

idence that the intervention, rather than the individual therapist, is responsible for the beneficial outcome. Further papers are planned that explore participants’ experience, habit formation, and adherence. Finally, a limitation of this study (initiated a decade ago) was the absence of patient and public involvement. FAST is the first effectiveness trial to show prevention of falls after stroke. We have established the effectiveness of a home based, multidisciplinary, tailored intervention comprising habit forming exercise, community mobility, and safety training. By recruiting community dwelling stroke survivors and testing an intervention delivered collaboratively by an occupational therapy/physiotherapy dyad in the home and local community, we have ensured that the intervention reflects what can be readily implemented. This world first finding could help to reduce the global burden of falls after stroke.

At baseline, our participants varied across the spectrum of mobility with an average comfortable walking speed of 0.8 m/s, which is the threshold for full community ambulation.14 However, they had still had falls, with about two thirds having had at least one fall in the year before the study. The beneficial effect of the intervention on the rate of falls was the result of the experimental group managing to prevent falls to a greater extent over the long term, whereas the control group had more falls. The experimental group had an annual rate of 1.9 falls/participant in the year before the study compared with 1.8 falls/participant over the year of the study. This is in contrast to the control group, who had an annual rate of 2.0 falls/participant in the year before the study and 2.7 falls/participant over the year of the study. Notably, we observed a large increase in self-efficacy by the experimental group compared with the control group, suggesting that the tailored intervention had helped them to match their behaviour to their level of disability.

Only three previous randomised trials have investigated the effectiveness of a non-drug intervention to reduce falls after stroke and reported the annual rate of falls.7 8 9 All found no effect, making ours the first effectiveness trial to find a reduction in the rate of falls relative to the control group after stroke. This may be because adherence to exercise was low and exercise was segregated from everyday activities in two of the earlier trials, and home modification did not directly target falls risk in the other trial. In our trial, participants embedded exercise into everyday activities, thereby promoting habitual behaviour. Furthermore, the intervention included home safety and community mobility coaching, as well as habit forming exercise, with each component tailored to the participant’s level of disability. For example, for participants with very poor mobility, the initial emphasis was on home safety before exercise was introduced. This was supported by the latest Cochrane review of environmental interventions and falls,32 which found high certainty evidence that home fall hazard interventions are effective in reducing the rate of falls in community dwelling people at higher risk of falling. Our results are in contrast to the trial by Dean and colleagues,8 which found that exercise without home safety intervention tended to increase the number of falls for people with more disability.

The main strengths of this study are the appropriately powered sample size, randomisation based on level of disability, which controls for the heterogeneity of stroke, tailoring of the intervention to level of disability, high retention and adherence, and the collaboration between occupational therapists and physiotherapists, which resulted in high fidelity. The main challenge during the study was the restrictions caused by the covid-19 pandemic that prevented the collection of some secondary outcomes. It also affected the delivery of the intervention, which we overcame by pivoting to telehealth. The main limitation of the study is the large number of therapists needed to provide intervention across multiple sites and regions. However, the resultant variety of expertise may also be viewed as a positive, as it enables confidence that the intervention, rather than the individual therapist, is responsible for the beneficial outcome. Further papers are planned that explore participants’ experience, habit formation, and adherence. Finally, a limitation of this study (initiated a decade ago) was the absence of patient and public involvement.

FAST is the first effectiveness trial to show prevention of falls after stroke. We have established the effectiveness of a home based, multidisciplinary, tailored intervention comprising habit forming exercise, community mobility, and safety training. By recruiting community dwelling stroke survivors and testing an intervention delivered collaboratively by an occupational therapy/physiotherapy dyad in the home and local community, we have ensured that the intervention reflects what can be readily implemented. This world first finding could help to reduce the global burden of falls after stroke.

Falls and fall related injuries are a leading cause of morbidity and mortality, making their prevention and management a critical global challenge No effective interventions to prevent falls after stroke are available; in three randomised trials, non-drug interventions to reduce falls after stroke were not effective

A home based, tailored intervention (habit forming exercise, community mobility and safety training) can substantially prevent falls in community dwelling people after stroke An increase in self-efficacy in the experimental group compared with the control group suggests that the tailored approach to delivery of the intervention supported successful participation in exercise Recruiting community dwelling stroke survivors and testing an intervention delivered in the home and local community ensured that the intervention reflects what can be readily implemented