Exercise f o r falls p r e v e n t i o n i n

P a r k i n s o n disease
A r a n d o m i z e d c o n t r o l l e d trial

C o l l e e n G .C a n n i n g , P h D

ABSTRACT

Catherine

Objective:

Sherrngton,

P h D
Stephen R .Lord, P h D
J a c q u e l i n e C . T . Cise,
M D
Stephane Heritier, P h D
Giliian Z . Heiler, P h D
Kirsten

Howard, P h D

Natalie E .Alien, P h D
Mark

D .Latt, P h D

Susan M . Murray,
MHlthSci
Sandra D . O'Rourke,
BMedSc

(Hons)

Serene S. Paul, P h D
Jooeun Song, P h D
Vctor S . C . F u n g , P h D

T o determine w h e t h e r falls can be prevented w i t h minimally supervised exercise targeting potentially remediable fall risk factors, Le., poor balance, reduced leg muscle strength,
a n d f r e e z i n g o f gait, in people w i t h P a r k i n s o n disease.
T w o h u n d r e d t h i r t y - o n e p e o p l e w i t h P a r k i n s o n d i s e a s e w e r e r a n d o m i z e d i n t o e x e r c i s e or
usual-care control groups. Exercises were practiced for 4 0 t o6 0 minutes, 3times weekly forj
m o n t h s . P r i m a r y o u t c o m e s w e r e fall rates a n d proportion o f fallers during t h e intervention p e c e
S e c o n d a r y o u t c o m e s w e r e physical (balance, mobility, freezing o f gait, habitual physical activityi
psychological (fear o f falling, affect), a n d quality-of-life m e a s u r e s .

Methods:

T h e r e w a s n o s i g n i f i c a n t d i f f e r e n c e b e t w e e n g r o u p s n t h e r a t e o f f a l l s ( i n c i d e n c e r a t t j
r a t i o [ I R R ] = 0 . 7 3 , 9 5 % c o n f i d e n c e nterval [ C U 0 . 4 5 - 1 . 1 7 , p = 0 . 1 8 ) o r p r o p o r t i o n o f f a l l e r s
(p = 0 . 4 5 ) . P r e p l a n n e d s u b g r o u p a n a l y s i s r e v e a l e d a s i g n i f i c a n t i n t e r a c t i o n f o r d i s e a s e s e v e r i t f
(p < 0 . 0 0 1 ) . I n t h e l o w e r d i s e a s e s e v e r i t y s u b g r o u p , t h e r e w e r e f e w e r f a l l s n t h e e x e r c i s e g r c :
c o m p a r e d w i t h c o n t r o l s ( I R R = 0 . 3 1 , 9 5 % C I 0 . 1 5 - 0 . 6 2 , p < 0 . 0 0 1 ) , w h i l e n t h e h i g h e r d i s e a s e
severity subgroup, t h e r e w a s a trend t o w a r d m o r e falls in t h e exercise group (IRR = 1 . 6 1 , 9 5 % C f
0 . 8 6 - 3 . 0 3 , p = 0 . 1 3 ) . P o s t l n t e r v e n t i o n , t h e e x e r c i s e g r o u p s c o r e d s i g n i f i c a n t l y (p < 0 . 0 5 ) b e t t e r
than controls o n t h e S h o r t Physical Performance Battery, sit-to-stand, fear o f falling, affect, ac
quality o f life, a f t e r a d j u s t i n g f o r baseline p e r f o r m a n c e .
Results:

A n exercise program targeting balance, leg strength, and freezing o f gait did not
reduce falls b u t improved physical a n d psychological health. Falls w e r e reduced ir people a
milder disease b u t n o t in t h o s e w i t h m o r e s e v e r e P a r k i n s o n disease.
Conclusions:

Correspondence t o
Dr. Canning:
colleen.canning@sydney.edu.au

C l a s s i f i c a t i o n o f e v i d e n c e : T h i s s t u d y p r o v i d e s C l a s s III e v i d e n c e t h a t f o r p a t i e n t s w i t h P a r k i n s o n
disease, a minimally supervised exercise p r o g r a m d o e s n o t reduce fall risk. T h i s s t u d y lacked t h e
precisin t o e x e l u d e a modrate r e d u c t i o n o r m o d e s t i n c r e a s e i n f a l l r i s k f r o m e x e r c i s e . T r i a l r e g i s t r a t i o n : A u s t r a l i a n N e w Z e a l a n d C l i n i c a l Triis R e g l s t r y ( A C T R N 1 2 6 0 8 0 0 0 3 0 3 3 4 7 ) .

Neurology 2 0 1 5 ; 8 4 : 3 0 4 - 3 1 2
1

G L O S S A R Y
CI = c o n f i d e n c e i n t e r v a l ; IRR = i n c i d e n c e r a t e r a t i o ; NSW = N e w S o u t h W a l e s ; PD = P a r k i n s o n d i s e a s e ; PIG = - :
i n v e r s e g a u s s i a n ; RR = r e l a t i v e r i s k ; UPDRS = U n i f i e d P a r k i n s o n ' s D i s e a s e R a t i n g S c a l e .

P e o p l e w i t h P a r k i n s o n d i s e a s e ( P D ) f a l l f r e q u e n t l y , w i t h 6 0 % f a l l i n g a n n u a l l y a n d two-thBfW
these falling r e c u r r e n t l y .

1 - 3

T h e s e fall rates are d o u b l e those i n t h e general o l d e r p o p u l a t i o n , a r v

the resulting injuries, p a i n , ' activiry l i m i t a t i o n s , a n d fear o f falling' c o m p r o m i s e health a n d

4

wel/-being.
W h i l e evidence f r o m s y s t e m a t i c r e v i e w s s h o w s t h a t exercise p r o g r a m s are effective i n p r e v e n t i n g
f a l l s i n t h e g e n e r a l o l d e r p o p u l a t i o n / ' o n l y 5 r a n d o m i z e d c o n t r o l l e d triis h a v e e v a l u a t e d e x e r c i s e
7

p r o g r a m s d e s i g n e d t o r e d u c e f a l l s i n p e o p l e w i t h P D . T h r e e u n d e r p o w e r e d triis " r e p o n e d n o
8

10

Suppiemental data
a t Neurology.org
F r o m t h e C l i n i c a l a n d Rehabilitarn S c i e n c e s R e s e a r c h G r o u p , F a c u l t y o f H e a l t h S c i e n c e s ( C . G . C . , N A . S . M . M . , S . D . O . . J . S . j , T h e G e o r g e
Institutc for G l o b a l H e a l t h . Sydney M e d i c a l School (C.S.. S.S.P.), Sydney School o f Public H e a l t h ( K . H . ) , a n d Sydney M e d i c a l School ( S . H . ,
V . S . C . F . ) , T h e U n i v e r s i t y o f Sydney, Australia; N e u r o s o e n c e Research Australia a n d U n i v e r s i t y o f N e w S o u t h W a l e s ( S . R . L . ) , Sydney; Prince o f
Wales Clinical School, U n i v e r s i t y o f N e w S o u t h Wales, a n d Neuroscicnce Research Australia ( J . C . T . C . ) , Sydney; D e p a r t m e n t o f E p i d e m i o l o g y
and Preventive M e d i c i n e ( S . H . ) , M o n a s h U n i v e r s i t y . M e l b o u r n e : D e p a r t m e n t o f Statistics ( G . Z . H . ) , M a e q u a r i e U n i v e r s i t y . a n d Statistics
Divisin, T h e G e o r g e I n s t i t u t c f o r G l o b a l H e a l t h , S y d n e y ; D e p a r t m e n t o f A g e d C a r e ( M . D . L . ) , R o y a l P r i n c e A l f r e d H o s p i t a l , S y d n e y ; a n d
M o v c m e n t D i s o r d e r s U n i r ( V . S . C . F . ) , D e p a r t m e n t o f N e u r o l o g y , W e s t m c a d Fospital, S y d n e y , A u s t r a l i a .
G o t o N e u r o l o g y . o r g r o r r u l l disclosures. F u n d i n g i n t o r m a n o n a n d d i s d o s u r e s d e e m e d r e l e v a n t b y t h e a u t h o t s , i f a n v , a r e p r o v i d e d ar t h e e n d o f r h e a n i d e .

304

2 0 1 4 American Academy o f Neurology

e f f e c t o n f a l l s , w h i l e 2 triis"
icant

reductions

challenged

1 2

u s i n g f u l l y supervised exercise. A f u l l y

reported signif-

i n falls w h e n exercises

balance were compared

with

exer-

sustain

i n

clinical

practice,

while

less-

cises t h a t d i d n o t c h a l l e n g e b a l a n c e . T h e s e p o s -

supervised

i t i v e triis d i d n o t , h o w e v e r , t a r g e t 2 a d d i t i o n a l

offer a m o r e clinically relevant and

indenendenr nhvsiral risk farrors f n r falk. i e .

i n t e r v e n t i o n srafey. T h i s a p p r o a c h h a s b e e n

reduced

leg strength

a n d freezing

w h i c h are also p o t e n t i a l l y

o f gait,'

remediable.

models

o f exercise delivery

may

sustainable

f o u n d t o reduce falls a n d fall-related i n j u r i e s

by

1 3 - 1 6

T h e o u t c o m e s i n t h e 2 positive fall p r e v e n -

3 5 % i n t h e general

older

population.

1 7

Therefore, we aimed t odetermine whether a

-

Figure 1

super-

vised m o d e o fexercise delivery is d i f f i c u l t t o

that

:,-

II..

' i i i ^ n i . u i i . .

i i i i 1 i ! i c U I ,

3 U p V . i

V l d V . U

Flow of participants through the trial

Assessed for eligibility

(n=532)
Excluded (n=301)
Not meeting inclusin criteria (n=135)
Declined to particpate (n=103)
Other reasons (n=63
Concealed randomization
(n= 231 >

Allocation
Allocated to exercise group (n= 115)
6-month exercise program
o Falls prevention advice (n=115)
Did not receive allocated intervention (n=0)

Allocated to control group (n= 116)

Falls prevention advice (n=116)
Did not receive allocated intervention (n=0)

Follow-up

Lost to follow-up primary and secondary

outcomes (n=5)
Withdrew from study (n=5)

Lost to follow-up primary and secondary

outcomes (n=1)
Withdrew from study (n=1)

Lost to follow-up secondary outcomes (n=9)

lllness (unable to attend postassessment)
(n=8)
On holiday (unable to attend
postassessment) (n=1)

Lost to follow-up secondary outcomes (n=3)

lllness (unable to attend postassessment)
(n=3)
Discontinued intervention (n=1)
Did not Hke oroijn ai!oc3tion n = n

Discontinued intervention (n=24)

Pain (n=10)
Personal and/or health problems (n=9)
Preferred other exercises (n=2)
Died (n=1)
I Inknnwn (n=?\
Analysis

Analyzed (primary outcomes: all or some fall

data provided) (n=115)
Excluded from analysis (n=0)

Analyzed (primary outcomes: all or some fall

data provided) (n=116)
Excluded from analysis (n=0)

Analyzed (secondary outcomes) (n=101)

Excluded from analysis (n=14)*
o No post-test assessment data

Analyzed (secondary outcomes) (n=112)

Excluded from analysis (n=4)**
o No post-test assessment data

The 2 4 exercise participants who discontinued intervention include 4 of the participants lost to both primary and secondary outcomes and 7 of the
participants lost to secondary outcomes; **3 exercise and 3 control participants provided posttest questionnaire data but no posttest physical assessment
data.
i\ieuroiogy t w

j a n u a r y u, u i a

program

targeting

balance,

leg

muscle

s t r e n g t h , a n d f r e e z i n g o f gait c o u l d reduce falls

in c o m m u n i t y - d w e l l i n g people w i t h P D .

t e p o r t i n g freezing. B a l a n c e exercises i n c l u d e d s t a n d i n g w i t h
decreased

base

o f support,

forward/sidcways/backward

a n d h e e l taises,
M E T H O D S Design.

prospective, assessor-blinded,
controlled
methods

trial
have

from

been

i n detail

II.J

.,A l

w a sundertaken

described
-cu ,

2008

randomized

to 2012. T h e

elsewhere.

; . ,l.ll:

W e

1 8

:;

w i t h P Dt o a n exercise g r o u p ( i n t e r v e n t i o n ) o t usual-carc

forward

exercises

increased

semisquats,
via weighted

P a t t i c i p a n t s a t t e n d e d a m o n t h l y exercise class l e d b y a

2 1

physical therapist a n d p e r f o r m e d r h er e m a i n i n g exercise sessions

at h o m e . T h e exercises w e r e prescribed

a n d progressed

class, a n d 2 t o 4 h o m e visits w e r e c o n d u c t e d
therapist over t h e6 m o n t h s .

When

group

i n the

b y t h e physical

sessions w e r e n o t

feasible,

supervised

by a

super-

physical therapist. F o rparticipants w i t h freezing o fgait,

cueing

F.ight

vised exercise p r o g r a m targeting balance, l e gm u s c l e strength,

__J c
-r
e . l l . :_ _
j n:
i

participants

p e r f o r m e d a l l exercise sessions a t h o m e .

t o 1 0 o f these

strategv

home

sessions

home

w i t h P D as c o m p a t e d

c o n t a i n i n g standardized fall p r e v e n t i o n

research

were

ttaining w a s undertaken during a n additional 1 o t 2

ama U C C u t g v i J^ait i c u u i . t l a n s n i L u i i i i n u i m v - u w c i l l l l g p c u p i e

w i t h u s u a l care? T h e s e c o n d a r y

Strengthening

a n d lateral step-ups,

w i t h load progressively

activities, a n d

group

(control) (figure 1).

T h e p r i m a r y research q u e s t i o n was: does a m i n i m a l l y

reaching

stepping.

included sit-to-stand,

vests.

graded

visits. T h ei n t e r v e n t i o n g r o u p

also

received

advice.

booklet

2 2

q u e s t i o n was: does t h e exetcise p t o g r a m i m p r o v e fall risk factors,

T h i s study provides Class I I I evidence
FD,

t h a t for p a t i c n t s

with

a m i n i m a l l y supervised exercise p r o g r a m does n o t reduce

falls risk.
Standard

p r o t o c o l approvals,

registrations,

and

patient

c o n s e n t . T h e s t u d y p r o t o c o l w a s a p p r o v e d b y T h e U n i v e r s i t y o
Sydney

Humin

Research

i n f o r m e d consent
was registered

Ethics

Committee

a n d writtcn

w a s o b t a i n e d f r o m a l l participants. T h e trial

prospectively

C l i n i c a l Triis R e g i s t r y

with

T h e c o n t r o l g r o u p received

Control group.

fear o f falling, affect, a n d q u a l i t y o f life?

the Australian N e w

Zealand

(ACTRN12608000303347).

their medical

number
the

o f f a l l s a n d t h e p r o p o r t i o n o f a l l e r s r e c o r d e d

6-month

intervention

unintentionaiiy c o m m g

calendats

c o m p l e t e d calendars

o f idiopathic P D ( c o n -

t o w a l k i n d e p e n d e n d y w i t h o r w i t h o u t a w a l k i n g aid, stable

anti-

p a r k i n s o n i a n m e d i c a t i o n for a t l e a s t 2 w e e k s , a n d o n e o r m o r e f a l l s
i n t h e past year o r a t r i s k o f falls based o n physical
Participants were deemed

assessment.

t o b e a t risk o f falling i ft h e y scored

during

(defined

t o test o n t h e g r o u n d o r o t h e r

were

the

o n entty t o t h e study, w i t h

via Parkinson's N S W consumer support groups, newspaper

b y a medical practitioner), age4 0 years o r older, a b i l i t y

Falls

as
lower

Participants

tecotd

firmed

period.

e v e n t ) * w e r e recorded b y t h e u s e o f a "falls d i a r y . "

appointments;

Eligibility criteria included a diagnosis

2 2

Surface w i t h o u t o v e r w h e l m i n g e x t e r n a l torce o r a m a j o r i n t e r n a !

ney and regional a n drural N e w S o u t h Wales ( N S W ) , Australia,

therapists.

from

booklet

O u t c o m e measures. T h e p r i m a r y o u t c o m e m e a s u r e s w e r e t h e

Participants. P a r t i c i p a n t s w e r e t e c r u i t e d f r o m m e t r o p o l i t a n S y d -

tisements, a n d referrals f r o m neurologists a n d physical

c o n t a i n i n g standatdized fall p r e v e n t i o n advice was p t o v i d e d .

received

adver-

usual care

p r a c t i t i o n e t a n d c o m m u n i t y services.

also

following:

insttuctions t o

falls; n u r s i n g , m e d i c a l , a n d allied h e a l t h

a n d hospitalizations.

Patticipants

returned

m o n t h l y i n prepaid envelopes.

telephoned

monthly

t o record

m e d i c a t i o n s , u s e o f h e a l t h resources,

Participants

a n y changes i n

a n d t overify fall details.

Secondary outcomes included the

following:

the P D Fall Risk

score ; m e a n k n e e extensor m u s c l e s t r e n g t h o f b o t h legs ";

1

d i n a t e d s t a b i l i t y test o fb a l a n c e ' ; t h e S h o r t P h y s i c a l

coor-

Performance

B a t t e r y , w h i c h incudes w a l k i n g , s t a n d i n g b a l a n c e , a n d s i t - t o stand

tests ' ;
2

fast w a l k i n g v e l o c i t y o v e r 4 m ; t h e 5 - r e p e t i t i o n

2 5 c m o r less o n t h e F u n c t i o n a l R e a c h T e s t ' ' o r i f t h e y f a i l e d t o

s i t - t o - s t a n d test; t h e F r e e z i n g o f C a i t Q u e s t i o n n a i r e

reach c r i t e r i o n o n o n e o f t h e b a l a n c e tests i n t h e Q u i c k S c r e e n

Efficacv Scale-lntetnational ;

Clinical Falls R i s k Assessmcnts, "

tionnaire recording t h ea m o u n t o f regular exercise a n d activities

i.e., unable

t o perform

near

; t h e Falls

a habitual physical activity

2 8

tndem s t a n d w i t h e y e s c l o s e d for 1 0 s e c o n d s , u n a b l e t o c o m p l e t e

o f daily living; q u a l i t y o f life u s i n g t h e m e n t a l a n dphysical

8 s t e p s i n t h e altrnate s t e p t e s t ( 1 8 - c m

scores o f t h e S F - 1 2 v 2

seconds. o t unable

s t e p ) i n less t h a n 1 0

t o n e r f n r m S teneririons of sit-to-stand i n

ques-

sub-

( S h o r t F o r m 1 2 versin 2 ) , t h e S F - 6 D

( S h o r t F o r m 6 d i m e n s i o n s ) utility score, a PD-specific

quality-

of-life questionnaire ( P D Q - 3 9 ) ' ; a n d t h e positive affect subscale

less t h a n 1 2 s e c o n d s .

Participants were excluded

i fthey h a da M i n i - M e n t a l

State

o f the Positive and Negative Affect

Schedule."'

disease, o r

H o m e exercise logs w e r e k e p t b y p a t t i c i p a n t s , a n d class r e -

o t h e r u n c o n t r o l l e d c h r o n i c c o n d i t i o n s t h a t woud i n t e r f e r e w i t h

cords were kept b y the physical therapists delivering the interven-

E x a m i n a t i o n score o f < 2 4 , unstable

cardiovascular

t h e saety a n d c o r . d u c r o f t h e t r a i n i n g a n d r e s r i n g p r o t o c o ! .
eligible

volunteers

received

clearance

from

their

A!!

medical

tion. Adverse events

( d e f i n e d as a s i g n i f i c a n t i n i u r y o r m e d i c a l

event causing the participant t o seek a t t e n t i o n f r o m a health p r o fessional o r l i m i t their activities f o r 5 : 2 days) o c e u r r i n g d u r i n g

practitioner.

exercise w e r e m o n i t o r e d a n d recorded t h r o u g h o u t t h e study.

Randomization and masking. P a r t i c i p a n t s w e r e

randomized
Measurements

d o m i z a t i o n w a s s t r a t i f i e d b y fall h i s t o r y (0-9/10 falls i n t h e

coliected o n e n t t y t ot h es t u d y (baseline)

previous

12 months)

random-

intervention

number

schedule

and4.

participants' homes.

with

using

a compurer-generated

variable

block

sizes

o f 2

a n d procedures.

Secondary

to i n t e r v e n t i o n o tc o n t r o l groups after baseline assessment. R a n -

period

(posttest)

b y 1 o f 7 ttained

T h eorder o foutcome

a n d conducted

outcomes

were

a n dafter t h e 6 - m o n t h
assessors i n

measurements was

R a n d o m i z a t i o n w a s performed centrally b y a n investigator n o t

standardized

i n v o l v e d i n r e c r u i t m e n t o r assessments ( C . S . ) . O u t c o m e assessors

m e d i c a t e d , u s u a l l y 1 h o u r a f t e r ingestin o f P D m e d i c a t i o n s .

w h e n participants

were

optmally

were masked t og r o u p allocation.

Statistical analysis. A s t a t i s t i c a l a n a l y s i s p l a n w a s d e v e l o p e d
Intervention
PD-WEBB

group.
program

T h e intervention group
(www.webb.org.au).

included 4 0 t o 6 0 m i n u t e s o f progressive

undertook the

This

program

1 8

certified before
apptoach

and

u n b l i n d i n g a n d analysis. A n intention-to-treat

w a s u s e d for a l l a n a l v s e s .

A b l i n d r e v i e w o f t h e falls

balance a n d lower

data tevealed that t h e negative b i n o m i a l m o d e l w a s n o t flexible

l i m b s t r e n g t h e n i n g e x e t e i s e s 3 t i m e s a w e e k fot 6 m o n t h s , a n d

e n o u g h t o c a p t u r e b o t h t h e n o n i a l l e r s a n d t h e l a r g e n u m b e r o

cueing

mltiple f a l l e r s . I n c o n t r a s t , t h e P o i s s o n i n v e t s e g a u s s i a n

strategies

t o teduce

f r e e z i n g o t gait "' f o r p a r t i c i p a n t s

Neurology 8 4 January 2 0 , 2 0 1 5

(PIG?

Table 1

Demographic and clinical characteristics of the study participants at baseline

Characteristic

Exercise
(n = 115)

Control
(n = 116)

Sex, male, n (%)

69 (60)

66 (57)

Age,

71.4 (8.1)

69.9 (9.3)

Height, m

1.7 (0.1)

1.7 (0.1)

Weight, kg

76.3 (15.7)

76.6 (14.9)

Body mass index, kg/rn-

26.3 (4.5)

26.8 (4.4)

2(4)

2(3)

Falls in past 12 mo, median no. (iQR)'

People who fell in the past year, n (%)

90 (78)

90 (78)

People who fell 2+ times in past year, n (%)

74 (64)

72 (62)

People who fell 10+ times n past year, n (%)

13 (11)

15 (13)

Time since PD diagnosis y

7 5 (5 S)

8.3 (G.G)

Hoehn and Yahr stage, 0-5

2.7 (0.5)

2.7 (0.6)

Stage 2, n (%)

33 (30)

41 (35)

Stage 3, n (%)

77 (67)

69 (60)

Stage 4, n (%)

3(3)

6(5)

Motor examination, 0-108

25.8 (8.9)

26.7 (10.1)

Dyskinesia and dystonia, 0-14

1.3 (2.0)

1.0 (1.6)

Motor fluctuations, 0-7

1.6 (1.6)

1.4 (1.6)

Freezing when walking, 0-4

1.0 (1.2)

1.4 (1.2)

53 (46)

61 (53)

UPDRS*

Freezing of gait in the past month, n (%)

Mini-Mental State Examination. 0-30

2 8 . 7 (1.4)

Frontal Assessment Battery, 0-18

14.2 (2.4)

14.2 (2.5)

Exercise, h/wk

3.6 |3.5)

4.0 (4.1)

Deep brain stimulation received, n (%)

11 (9.6)

15 (12.9)

Daily levodopa equivalent dose, mg

787 (486)

807 (521)

Levodopa, no. of people taking (%)

108 (94.0)

109 (94.0)

Dopamine agonista, no. of people taking (%)

49 (42.6)

52 (44.8)

MAO type B inhibitors, no. of people taking (%)

5 (4.3)

11 (9.5)

COMT Inhibitors, no. of people taking (%)

41 (35.7)

36 (31.0)

Other Parkinson medications, no. of peopie taking (%)

15 (13.0)

27 (23.3)

0, no. of people (%)

18 (15.7)

25 (21.6)

1, no. of people (%)

38 (33.0)

34 (29.3)

2. no. of people (%)

59 (51.3)

57 (49.1)

19 (16.5)

13 (11.2)

Medications

Coexstna ronditinnc

Relevant prior surgery

Knee replacement surgery, no. of people (%)
Total hip replacement surgery, no. of people (%)

12 (10.4)

10 (8.7)

Spinal surgery, no. of people (%)

12 (10.4)

7 (6.0)

Abbreviations: COMT = catechol-O-methyltransferase; IQR = interquartile range; MAO = monoamine oxidase; PD

Parkinson disease; UPDRS = Unified Parkinson's Disease Rating Scale.
Data are mean (SD) unless stated otherwise.
"Median (IQR) scores are presented, as scores ranged from 0 to 1,825 in the control group and 0 to 730 in the
experimental group.
Conditions included arthritis, heart disease, high blood pressure, lung disease, diabetes, osteoporosis, depression, chronic
back pain, and cncer; the number of coexisting conditions ranged from 0 to 9.
b

d i s t r i b u i i o n g a v e a g o o d fit. T h e r e f o r e , c h e i n t e r v e n t i o n e f f e c t o n

Adverse events. T w o p a r t i c i p a n t s f e l l w h i l e

t h e n u m b e r o f falls w a s assessed u s i n g P I G r e g r e s s i o n . w i t h t h e

at h o m e . O n e fell w h i l e p u t t i n g o n t h ew e i g h t e d vest

logarithm

o f t h e days o ff o l l o w - u p i n c l u d e d as a n e x p o s u r e

t e r m i n t h e m o d e l . A n a n a l y s i s a d j u s t e d f o t p t e v i o u s mltiple
f a l l e : ' s t a t u s w a s o k p p e r f o r m e d . T h e oroDortion o f f a l l e r s w a s
compared between groups using a x

test.

exercising

a n d o n efell w h i l e t u r n i n g o n c o m p l e t i o n o f a stepp i n g exercise. N e i t h e r lall resulted i ni n j u r y r e q u i r i n g

medicai a t t e n t i o n o r restriction o f activities.

Prespecified s u b g r o u p analyses f o r t h e p r i m a r y o u t c o m e s w e r e
u n d e r t a k e n t o identify a n y differential i m p a c t o f t h e exetcise

P r i m a r y outcomes. S i x m o n t h s o f f a l l s d a t a w e r e a v a i l -

i n t e r v e n t i o n a c c o r d i n g t o fall h i s t o r y ( 0 - 9 v s a 1 0 falls i n t h e

able f o r 2 2 5 participants

p r c v i c u s y e a r ) , p h y s i c a l unccion ( b a s e d o n . 4-fl c o m f o r r a b l e w a l k
speed a t baseline, d i c h o t o m i z e d a t t h e m e d i a n ) , disease s e v e r i t y
(based o n U n i f i e d P a r k i n s o n ' s Disease R a r i n g Scale
moror

score

[UPDRS]

a t baseline, d i c h o t o m i z e d a t t h e m e d i a n ) , a n d

c o g n i t i o n (based o n F r o n t a l Assessment B a t t e r y score a t baseline,

6 participants.

D u r i n g t h eintervention period, 4 6 7

falls ( 4 . 1 falls/person)

w e r e reported i nt h e exercise

g r o u p a n d8 1 0 ( 7 . 0 falls/person) i nt h ec o n t r o l g r o u p

uiuiuiinizcu t hc m e d i a n ) . T h e RiaR a r . a i y s i ; f o r e a c h s u b -

( f i f i i r e 7 r a b i e 2 ) .T h i s 2 7 % difference i n fall rate i n

g r o u p w a s based

the exercise g r o u p c o m p a r e d

o n interaction

tests i n P I G m o d e l s

using

c o n t i n u o u s interaction terms w h e r e possible, a n d d i c h o t o m o u s

i n t e r a c t i o n t e r m s u s i n g p r e s p e c i f i e d cutoFs w e r e u s e d t o a s s i s t i n
t h e i n t e r p r e t a r o n of s u b g r o u p a n a l y s e s .

confidence

(70%)

for

one

"gamlss"

p e r f o r m a n c e . T h e R versin

2.15.2

package

w a s u s e d t o fit t h e P I G m o d e l t o t h e n u m b e r o f f a l l s ;

3 1

S P S S versin 2 0 s t a t i s t i c a l s o f t w a r e [ I B M C o r p . , A r m o u k , N Y )
was used for all o r h e r analyses.
S a m p l e size. B e c a u s c
binomial

regression

fall

models."

w e conducted

sample-size calculation using t h en b p o w e r c o m m a n d i n t h e

Stata software package.

1 8

o ft h e c o n t r o l participants

1.12, p = 0 . 4 5 ) . T h e results o ft h e p r i m a r y analyses

falls i n t h e exercise g r o u p a n d 1 9 falls i n t h e c o n t r o l

group

(table

e-1 o n t h e

Neurlogo

W e b site a t

Neuroiogy.org).
Prespecified

subgroup

analysis revealed a signifi-

c a n t i n t e r a c t i o n effect f o r disease s e v e r i t y (rate o f falls

p < 0 . 0 0 1 , p r o p o r t i o n o ffallers p = 0 . 0 0 1 ) (figure 2 .

a 3 0 % lower

(i.e., I R R = 0 . 7 0 ) . F i v e m o n t h s w a s used t oa c c o u n t f o r loss t o

follow-up.

flow

table

2 ) . Participants

(motor

U P D R S

reduction

o f participants iss u m m a r i z e d i n

figure

1 .A

total o f 2 3 1 participants ( 1 3 5 male) w i t h a n average

age o f 7 1 ( S D9 ) years w e r e r e c r u i t e d . T h e 1 1 5 exercise
parricipants a n d 1 1 6 control participants were similar
demographic

characteristics,

levodopa

equivalent

ipants atcended s

:;ghr p a
once

per month,

participants

per group

exercise

with

(range

participants

sessions a t h o m e .

to

were

a n average

performed

O n average,

exercise

protocol.

available

exercise narticipants. T

severitv
a 6 9 %

i n t h e exercise

U P D R S

score ^ 2 7 )displayed a t r e n d t o w a r d m e r ;

falls i n t h e exercise g r o u p
0.86-3.03, p =

( I R R=

1 . 6 1 , 95r> C I

0 . 1 3 )with a higher

proportion

1 . 2 8 ,9 5 %C I 1 . 0 1 - 1 . 6 2 , / - = O . f - ,

w i t h t h ec o n t r o l g r o u p . A m a r g i n a l l y sig-

nificant interaction effect was f o u n d for c o g n i t i o n

o f3 . 5

this i n t e r a c t i o n w a sn o ts i g n i f i c a n t w h e n d a t a

a l l exercise

adherence

we-;

i n t e r a c t i o n effect was f o u n d for fall h i s t o r y o rp h v *

n

M U

Secondary outcomes. A t 6 m o n t h s , t h e e x e r c i s e

1 1 5 performed significantly better t h a n t h e control

o n several physical o u t c o m e s

T w e n t y - f i v e participants ( 2 2 % )

outcomes

performed a modified

manee

program t oaccount for pain and coexisting conditions,

Positive

while 2 4 participants ( 2 1 % )

life

d i s c o n t i n u e d t h e exercise

d i c h o t o m i z e d (/> = 0 . 4 5 ) ( t a b l e e - 2 ) . N o s i g n i f i c a n

1 U U C U U I

therapist.

Neurology 8 4 January 2 0 . 2 0 1 5

0.001) a n da lower

r a t e o i f a i i s a s a c o n t i n u o u s v a r i a b l e \p 0 . 0 4 8 i . L

for108 ( 9 4 % ) o f the

program.

( I R R=

trast, participants w i t h h i g h e r disease severity ( m o t o r

1 3 % o f t h e exercise

Exercise

group

p 0.01)compared with thecontrol group. I n con-

e pvprriv a r m i n r o m n l e r e d a
o
r ~
i
m e a n o f7 2 % ( S D3 8 % )o fprescribed exercise sessions.
r

lower

^ernse

2 - 6 ) . T h e remaining

sessions w e r e supervised b y a physical

records

disease

S 2 6 ) demonstrated

wirh

p r o p o r t i o n o ffallers ( R R= 0 . 6 9 , 9 5 % C I 0 . 5 2 - 0 . 9 0 ,

compared
Intervention. G r o u p e x e r c i s e w a s o f f e r e d a t 2 2 l o c a -

Adherence

i n falls

fallers ( R R =

dosages, a n dc o m o r b i d i t i e s a tbaseline (table 1 ) .

class

score

0 . 3 1 , 9 5 % C I0 . 1 5 - 0 . 6 2 , p <

R E S U L T S Tlo o f p a r t i c i p a n t s t h r o u g h t h e t r i a ! . T h e

37

r e p o r t i n g a t least

lall (relative risk [ R R ] = 0 . 9 3 ,9 5 % C I 0 . 7 8 -

over 5 m o n t h s o f follow-up,

rate o f falls f o r exercise p a r r i c i p a n t s t h a n c o n t r o l p a r t i c i p a n t s

in

o ft h e exercise p a r t i c i p a n t s a n d 8 1

participants p e rg r o u p w e r e required t oprovide 8 0 %

p c v v c r t e d e t e c t as s i g n i f i c a n t , a t t h e 5 % l e v e l

trial

There

w e r e essentially u n c h a n g e d after a d j u s t m e n t f o r base-

A s s u m i n g a control g r o u p rate o f

falls o f 1 f a l l / p e r s o n m o n t h
115

group

0.73, 9 5 %

line faller status. M e d i c a l a t t e n t i o n was s o u g h t for 2 1

i tw a so u r intention t ocompare

rates b e t w e e n g t o u p s u s i n g i n c i d e n c e rate ratios ( I R R s ) f r o m

negative

( I R R=

i n t e r v a l [ C I ] 0.45-1.17,/ = 0 . 1 8 ) .

ers w i t h 7 5 ( 6 5 % )

using general linear m o d e l s (analysis o f covariance) c o n t r o l l i n g

baseline

with thecontrol

was n o t statistically significant

was n osignificant difference i n t h ep r o p o r t i o n o f fall-

c o n t i n u o u s l y scored secondary o u t c o m e measures w e r e m a d e

308

( 9 7 % ) a n do n e o r m o r e

m o i u h s o alls d a t a w e r e a v a i l a b l e f o r t h e r e m a i n i n g

Battery
(Falls
Affect

(SF-6D)

(table e - 3 ) .

(Short Physical P e r

a n d sit-to-stand),
Efficacy
Scale),

after

Scale

a n d overall

adjusting

psychok

International
quality

f o r baseline v i

Number of participants

Number of participants

Number of participants

CU

ro

O
-i

-i-i

n
<

il

o
O ><
0 f

"9
i
B- - 5
c

-i
I "
a.

r-i <"

" </>

0X5

T3

1 5!"

<" '

~ 2

&:

g .

r?

3-

a
cr
5

r
n

OO

n
2.

E L 5 . = =I
J5
r

0)

ro
o

c
a.
3
o
3
cr
3

I
co
o

re
r,

re

e.

n>

re

W. -3

"0

re

ri

^3

JJ,

0
c
13
-o

o.

Vi

C
0"

o
-i-i "a

era

n>
O

-a

erre

a.
s : s - T3
3
3
ero
-g
3- o

re

o
3 " O

rT 8

3. - a

sr -5

P-

"O
O

"i

EL 3 " m

fie

O
O

r r

a
-a
o
ero

DI

"O

re

2.

. <fl

03O

Ino.

3 ra

<" era
3 "

4 i

OT

3
O.

"D

0)
3

ii ii

P-

O.

cr> 7
00

O.

w ro-

" 1 (O T 3

g>
E-

sr

* ~-" T

ii - i a
1 "* 2 .

Ni-*/

en -C- o

o
c

3
3

z
c
3

O"

3H

p n> n
5* |. 5

ES*

HJ

re
n
55'

EL

O"

=t

3
u
n
3
3_

re

a.

&.

f i ero

era
S

EL

O.

sr> fu <? a .

u
3

B-l

1 a . ero

2
3

3 " re

E.

era
-a
o
2.

3
re
o

CJ"

n.
3

P g

oo CL
3T

3
ero

(ej"

1-1 "O

re

i:

re

< B

ero

S- - o

g2 P
O
O

s"

1
&.

3-

re

3
o ero
3^

ir-

TI

3
g . era

B. 3

H
sr

=^

p
T3
5 g

HT --J 5 -

3
re

. o v:
35'
era
^

EL' 3 ^

I -a
e>J en

3 -rj

EL
0

o" S
era G
3 "o
5 3

-6'

g.
erar
ero'

P-

'* O

O-

ar
"

ro

O-

2.
-3

2
n

P-

5-

re

>J3 B

Vi

~. en

2"

r- o
3
y "o_
u
3

'. c r

ero

P-

3"

T3

^ 1

5o

3 J en
3^ X

ero

O-

o
o

"-3

"O

Q-

o
c

EL

3 T3

33

O
00
o
c
en
co
O
z

p T ero

si

a.

S.
<">

S . era

I-

o
c

C.

i-

re

re

"3 5'
3 "

2
re

a - ^ - f

H
Y

6>
CL.

c
<
re

CL.

x
i

3"j

ero
2-

33

n ero s
3"
cr "

-i

QP

r.
N

"3

re
-O

D-

c
3 - S.
re
3

3 "2

a.

ra

rf'

Q
"
er- 0
re b
e>J
I
1
O

o
3

T3

E
m

O-

^" S '

c i
-o
-3
O p. "
1
0 0 3 3 oP

I able H

Primary intention-to-treat analysis and disease severity subgroup analysis"

Exercise

Control

IRR (95% CI),

p valu

0.73 (0.45-1.17), p = 0.18

0.79 (0.53-1.19)", p = 0.25

Disease severity x
intervention interaction

RR (95% CI),
p valu

Primary analysis,
Falls
Falls/person/6 mo

467
4.1

810
7.0

Fallers, n
Proportion of fallers, %

75
65

81
70

99

435

Continuous, p = 0.02
Dichotomous, p < 0.001
b

0.93 (0.78-1.12), p - 0.54

0.94 (0.74-1.12), p - 0.71"

Continuous, p = 0.03
Dichotomous, p = 0.001"
b

Lower disease severity

subgroup, E -- 63, C = 59
Falls
Falls/person/6 mo

1.6

7.4

Fallers, n

33

45

Proportion of fallers, %

52

76

rii

36

375

Falls/person/6 mo

7.1

6.6

Fallers, n

42

36

Proportion of fallers, %

81

63

0.31

(0.15-0.62), p < 0.001

0.69 (0.52-0 90), p = 0.01

Higher disease severity

subgroup, E = 52, C = 57
1.61 (0.86-3.03), p 0 13

1.28 (1.01-1.62), p = 0.04

Abbreviations: C = control; CI confidence interval; E = exercise; IRR = incidence rate ratio; RR = relative risk; UPDRS = Unified Parkinson's Disease
Rating Scale.
Lower disease severity = motor UPDRS score -=26; higher disease severity = motor UPDRS score &27.
p < 0.05.
p < 0.001.
Adjusted for baseline mltiple faller status.
p < 0.01.
a

t h e m o r e scveieiy a r r e c t e a

participants were

tially placed a th i g h e r risk o ffalls, t h r o u g h

exposure
improved

t o fall

risk

mobility

situations

a n d reduced

potenincreased
from

i n g b o t h m o t o r a n d n o n m o t o r s y s t e m s (as e v i d e n c e d b y

o f falling

t h e h i g h e r fall risk i n participants w i t h h i g h e r disease

resulting
fear

arhipved i n t h e p r o g r a m . T h elack o f a differential

severity a i baseline, s h o w n i ntable e-5), peopie

effect

m o r e severe disease m a y derive m o r e benefit f r o m a

o ft h e i n t e r v e n t i o n o nother secondary

out-

with

c o m e s f o r those o fl o w e r a n d h i g h e r disease severity

multifactorial, closely supervised i n t e r v e n t i o n . F u r t h e r

m a y s i m p l y reflect l o w statistical p o w e r o f i n t e r a c t i o n

adequately

tests. H o w e v e r , g i v e n t h e d i f f e r e n t i a l i m p a c t

r e o m r e d rn c o n t i r m rhpci*

accord-

ing t odisease severity o n falls themselves, t h e lack o f a

differential impact o nsecondary

outcomes

may

suggest a r o l e o f o t h e r fall risk factors t h a t w e r e

also
not

powered

triis

a n d meta-analyses

T h e significant 6 9 % r e d u c t i o n i nfall rate for t h e

. _

Our

s t u d y h a s severa!

limitations. T h e control

g r o u p d i d n o t receive a n i n t e r v e n t i o n t o c o n t r o l f o r

ications

comparable

required. Nevertheless,

6 - m o n t h , f u l l y s u p e r v i s e d trial o f tai c h i . " T h e m a j o r i t y

continued

their usual medical care i n c l u d i n g a d j u s t m e n t o f m e d -

l o w e r disease severity s u b g r o u p achieved i n o u r trial is

t o t h e6 7 %r e d u c t i o n i nfall rate i na

a n d deep b r a i n s t i m u l a t i o n parameters as
these results p r o v i d e a prag-

matic, clinically relevant evaluation o fthe impact o t

o f participants i n the tai chi trial h a d reiativeiy m i l d P D

a m i n i m a l l y supervised

(i.e.,

w i t h usual care. W echose t o focus o n physical

1 - 2 o n t h e H o e h n a n dY a h r scale), w h i l e t h e

m a j o r i t y o f p a r t i c i p a n t s i n o u r t r i a l s c o r e d 5^ o n t h e
H o e h n a n d Y a h r scale. I nc o n t r a s t , h o w e v e r , a r e d u c ifelkinnmnkwith
3-4

wasreponed

balance-demanding

P D i ni H1 V A . U H duu aiii stages

w h e n a 7-week,

fully

exercise p r o g r a m was

supervised,
delivered.

1 2

T a k e n together, this evidence suggests t h a t m i n i m a l l y

s u p e r v i s e d exercise p r o e r a m s a i m e d a r r e d n r i n g falls i n
Neurology 8 4 January 2 0 , 2 0 1 5

are

currrT^ct-irwit-

t h e H a w t h o r n e effect, a n d all participants

measured.

310

peopie w i t h P Ds h o u l d b e i m p l e m e n t e d early i n t h e
disease process. W i t h t h e progression o f disease affect-

factors a n d a c k n o w l e d g e

exercise p r o g r a m

compared
risk

that interventions designec

to target n o n m o t o r fall risk factors, s u c h as i m p a i r e d

cognition, '
1

3 6

i nc o m b i n a t i o n w i t h exercise m a y

have

a m o r e significant impact o n fails.'

F u t u r e research
i n t o successful

isr e q u i r e d t o gain greater

insigh!

fall r e d u c t i o n p r o g r a m s asw e l l as t h e

potential f o r increasing fall risk i n s o m e

individuis.

i i i u , v i n i n i l \

tUlllliifc

t o r e d u c e falls i n P Ds h o u l d c o n s i d e r t a i l o r i n g m u l t i factorial iiiicfventicns accordir.g r o m o t o r a n d n o n motor

risk factors, absolute

risk

severity, a n d m o t o r phenotype.
ing

o ffalls,

disease

3 8

I naddition, p r o m i s -

pharmacologic therapies" i nc o m b i n a t i o n

with

r n u l r i f a c t o r i a ! nrerventions w a r r a n t i n v e s t i g a t i o n .

Sydney, Motor Acddents Authority o f N e w South Wales, and T h e T r u s t

C o m p a n y . S. Lord has received travel expenses and honoraria for lectures
not tunded by industry; a consunaticv payment for rr.ethede'jgic ^dvirp
by E l i Lilly L t d . ; and research support from the Australian Government
National Health and Medical Research Council, T h e Australian Research
C o u n c i l , Mltiple Sclerosis Australia, and the N S W Ministry of Health.
J. Cise has received travel expenses and honoraria for lectures not tunded
by industry; and research

support

from

the Australian Government

National Health and Medical Research C o u n c i l , Bupa Health Founda-

AUTHOR CONTRIBUTIONS

tion, and the N S W Ministry o f Health. S. Heritier has received funding

Coileen C a n n i n g contributed to the conception and design o f rhe trial,

for 2 Australian Government National Health and Medical Research

analyzed and interpreted the data, drafted the manuscript, and revised

C o u n c i l grants unrelated ro this study; and royalties from Wiley for his

the manuscript f w important intellectual conrent. Catherine Sherrngton

book

conrriburcd to the conception and design o f the trial, interpreted the

relevant to the manuscript. K . Howard has received research suppOi

data, and revised the manuscript

for important

Robust Methods in Bwstatistics.

G . Heller reports no disclosures

intellectual content.

from the Australian Government National Health and Medical Research

Stephen L o r d contributed to the conception and design o f the trial, in-

C o u n c i l and the Australian Research C o u n c i l . N . Alien has received

terpreted the data, and revised the manuscript for important intellectual

research support from Parkinson's N S W . M . Latt has received research

content. Jacquelme Cise contributed to the conception and design of

support from the Australian Government National Health and Medical

the trial, interpreted the data, and revised the manuscript for i m p o n a m

Rcican-i C o u n c i l . S. Murray and S. O ' R n u r k e report no disclosures

intellectual content. Stephane Heritier wrote the statistical analysis plan,

relevant to the manuscript. S. Paul has received research support from

analyzed and interpreted the data, and revised the manuscript for impor-

the

tant intellectual content. Giilian Heller analyzed and interpreted the data

C o u n c i l and Parkinson's N S W . J . Song reports no disclosures. V . Fung

and revised the manuscript for important intellectual content. Kirsten

receives a salary from N S W Health, has received research grants from the

Howaru diidiyud

n d interpreted the dita

Australian Government

National

Health and Medical

Research

" d revised the manuscript

National Health and Medical Research C o u n c i l of Australia, and is on

for important intellectual conrent. Natalie Alien conrributed to the con-

advisorv boards and/or has received travel grants from Abbott/AbbVie,

ception and design o the trial, interpreted the data, and revised the man-

Allergan, Boehringer-Ingelheim,

uscript for important intellectual content. Mark Latt contributed to the

Parkinson's KineriGraph, Solvay, and U C B , G o to Neurology.org for

conception and design o f the trial, interpreted the data, and revised the

ful! disclosures.

Hospira, Ipsen. Lundbeck,

Novartis,

manuscript for important intellectual conrent. Susan Murray contributed

to the design o f the study and revised the manuscript for important intellectual content. Sandra O ' R o u r k e conrributed to the design of the study
and revised the manuscript for important

intellectual content. Serene

Paul interpreted the data and revised the manuscript for important intellectual content. Jooeufi Song analyzed and interpreted the data, drafted
the manuscript, and revised the m a n u M . t i p t for important

Received March 25, 2 0 1 4 . Accepted in finalform September29,

REFERENCES
1.

Latt M D ,Lord S R , Morris J G , F u n g V S . Clinical a n d

phvsioogical a s s e s s m e n t s

inteSectua!

f o rciucidating

P a r k i n s o n ' s disease. M o v D i s o r d

content. Vctor F u n g contributed to rhe conception and design o f the

trial, interpreted the data, and revised the manuscript for important intel-

2014.

2.

lectual content.

falls

risk i n

2009;24:1280-1289.

A l i e n N E , S c h w a r z e l A K , C a n n i n g C G . R e c u r r e n t falls i n
Parkinson's

disease: a systematic

review. Parkinsons D i s

2013;2013:906274.
3.
T h e authors thank the peopie with P D who participated in the study and
Parkinson's N S W for assisting with recruitment, in particular, Miriam

B R , Grirnberge.n

YA, Cramer

M .

Prospective

248:950-958.

Dixon and T r i s h Morgan. T h e authors thank the following physical therapists w h o delivered the intervention: Leah Burton, Cathy Chittenden,

BiGCITi

a s s e s s m e n t o ffalls i n P a r k i n s o n ' s disease. J N e u r o l 2 0 0 1 ;

4.

Wieinski C L , E r i c k s o n - D a v i s

C , Wichmann

R, Waide-

D h C D?v|dm, Paul D e a n , Kate Godfrey, Larraine Griffin, Jill H a l l ,

D o u g l a s M , Parashos S A . Falls a n d injuries resulting f r o m

Diane

fas a m o n g

Hemsworth,

Marty

Hewer,

Mary

Leaveslcy,

Fiona

Mackey,

Jennifer Mannell. Melissa M c C o n a g h y , Raja! Pandya, Neroli Page, Megan

Perry, Jessica Pike, Renee Pirozzi, Elisabeth Preston, W e n d y Robinson,
F.Iizabeth Shannon, Rebecca Snow, Angela Stark, Judy Sunderand, and

5.

Wendy

Kobinson, Lauren

"aikinson's

discase a n d o t h e r

M o v Disord

2005;20:410-415.

f o rParkinson's

P D . Reasons

f o radmission t o

d i s e a s e . ntern M e d J

2006;36:

524-526.

w'auc, and

Geraldine Walibank. T h e authors thank the following people who assisted

with

Temlett JA,Thompson
hospital

Krystle Tace. T h e authors thank the following physical therapists who

assisted with data coliection:

patients

parkinsonian syndromes.

6.

Sherrngton
C u m m i n g

with recruitment: K a y Double, Genda HaJliday, Mariese Hely, Simn

Lewis, Joan Perkins, and C o n n i e Vogler.

vention

C , Whitney

JC, Lord

S R , Herbert R D ,

R G , Cose J C T . E f f e c t i v e e x e r c i s e f o r t h e p r e -

o t ralis: a s y s t e m a t i c

review a n d mera-analysis.

J A m Geriatr Soc 2008;56:2234-2243.

STUDY FUNDING

7.

T h i s study was tunded by the Australian National Health and Medical

Research Councit ( N H M R C

I D : 512326),

and the Harry

Gillespie L D , Robertson
ventions

M C ,Gillespie W J , et al. Inter-

f o rp r e v e n t i n g falls i n o l d e r

the c o m m u n i t y . Cochrane

Secomb

peopie living i n

Datbase S y s t R e v 2 0 1 2 ; 9 :

C D 0 0 7 1 4 6 .

Foundation.
8.

Goodwin

V A , Richards

S H ,Henley

W , Ewings

P,

DISCLOSURE

T a y l c r A H , Carr!pbe! J !

C . C a n n i n g has received travel expenses and honoraria for lectures and

v e n t falls i n p e o p l e w i t h

educational activities not funded by industry; and research support from

r a n d o m i s e d controlled trial. J N e u r o l N e u r o s u r g Psychiatry

the Australian Government

Council,

the Harry

National Health and Medical

Secomb

Foundation,

Research

and Parkinson's N S W .

C . Sherrngton has received travel expenses a n d hcr.crar:a for kctires

and educational activities not funded by industry; and research support
from the Australian Government National Health and Medical Research
Council,

the Consortium

national de formation

en sam (Canad),

Arthriris N e w South Wales, N S W Ministrv o f Health, University of

A nexercise i n t e r v e n t i o n t o p r e P a r k i n s o n ' s disease: a

pragmatic

2011;82:1232-1238.
9.

Ashburn

A , Fazakarley

L , Bainger

C ,

Pickering

R,

McLean L D , F i t t o n C . A i a i i d o m i s c d ccr.iroed t r i a ! o f
a h o m e - b a s e d exercise p r o g r a m a r e
falling a m o n g

people w i t h

Neurosurg Psychiatry

t o reduce t h erisk o f

Parkinson's

disease. J N e u r o l

2007; 8:67&-684.
7

Neurology 84 January 0, 20i5

3X1