Delivery Matters: A Cluster Randomized Trial of a Brief Action Planning-Based Physiotherapy Intervention with Digital Support to Improve Adherence to a Fall Prevention Exercise Program in Older Adults at Risk of Falls

Objectives Older adults with arthritis are at increased risk of falls. The Otago Exercise Program (OEP), implemented worldwide, reduces falls by 35% in high-risk populations. While OEP is cost-effective for older adults with arthritis, participation and adherence remain low. This study assessed whether training physiotherapists in behavior change techniques improved participant adherence to prescribed exercises.

Methods Physiotherapists working in the Greater Vancouver Area were randomly assigned to receive OEP training either alone (OEP group) or with Brief Action Planning (BAP) training and use of an exercise tracking app (OEP+ group; NCT04851405). BAP is a structured coaching approach involving goal setting, action planning, and monitoring/feedback. Following training, physiotherapists were matched with older adults with a recent history of falls recruited through the Vancouver Falls Prevention Clinic. They delivered the program through 5 home visits over 6 months, followed by monthly phone calls for 6 months. Older adults were instructed to perform lower-body exercises (>3x/week) and short walks (2x/week). OEP adherence (primary outcome) was self-reported by monthly calendar over 12 months. Secondary outcomes included prospective fall count, Short Physical Performance Battery (SPPB), daily step count, and EuroQol-5D-5L assessed at baseline, 6 months, and 12 months. Exercise and walking adherence were calculated separately as: (sessions completed/sessions expected) × 100. Analyses followed an intention-to-treat approach using Generalized Linear Mixed-effect Models for longitudinal outcomes adjusting for age and sex. Fall counts were analyzed using quasi-Poisson regressions with robust sandwich standard errors to address potential overdispersion. Missing data was handled using multiple imputations.

Results Thirty-five physiotherapists visited 128 older adults (OEP+: n=58, 81.0% female; OEP: n=70, 68.6% female). Both groups were similar in age [OEP+: 80.9 years (SD 6.1); OEP: 82.0 years (SD 6.8)]. 61.7% reported arthritis and 37.5% participated during the COVID-19 pandemic. The adjusted mean difference in exercise adherence was 11.4% (95% CI 0.4, 22.4), favoring OEP+ (Table 1). Multiple imputation analyses showed a similar magnitude of difference in exercise adherence; 8.0% (95% CI 1.6%, 14.3%). Walking adherence was similar between groups. The adjusted mean difference from baseline to 12 months for SPPB was 0.83 (95% CI 0.14, 1.52). Fall rates were lower in OEP+ (incident rate ratio: 0.63; 95% CI 0.48-0.82).

Conclusion Delivery of the OEP by physiotherapists trained in BAP and supported by an exercise tracking app improved exercise adherence, physical performance, and fall counts over 12 months in older adults at risk of falls. This research may inform the delivery of fall prevention interventions among older adults with arthritis.