Falls, strength and everyday activity: what rehabilitation research tells us

Getting stronger, feeling steadier and doing more in daily life are related goals, but they are not the same outcome. This week's research brings that distinction into focus. It also asks how reliably people at risk of falling are identified and supported, and how rehabilitation can involve family and technology without losing sight of the person's needs.

We reviewed five papers published from 16 to 21 October. The falls trial was released at the previous edition's reporting cut-off and is included here because of its relevance. The studies differ substantially in design and certainty. None provides an exercise prescription for an individual person.

Falls prevention: helping recommendations reach the person

The strongest study in this edition is the eSTEPS cluster-randomised trial, published on 16 October. It involved 11,945 adults aged 65 or older who had screened positive for increased falls risk at 22 primary-care practices in the United States.

At intervention practices, a decision-support tool in the electronic health record helped clinicians offer tailored strength and balance exercise recommendations, physiotherapy referrals when appropriate, and patient information. Over 12 to 23 months, recorded falls occurred at a rate of 19.3 per 100 patient-years at intervention practices, compared with 21.2 at control practices. The rate of recorded fall-related injuries was 15.7 versus 16.7 per 100 patient-years. These were modest but statistically significant differences. Mortality did not differ significantly.

The trial tested a whole clinical workflow, not one exercise programme. Formal exercise prescriptions were issued to 22.1% of people in the intervention group, and the researchers could not measure whether people followed the recommendations. Falls and injuries were identified largely through diagnostic codes, which may miss events. We therefore cannot say which part of the system produced the benefit or assume the same result would occur in Australian allied-health care.

The practical question is whether a person who reports a fall or feels unsteady receives an appropriate assessment, a workable plan and a review of how it is going. We discussed this trial in more detail in our article on turning a falls care plan into action.

Knee osteoarthritis: strength and activity need separate measures

A study of 90 people with knee osteoarthritis, published on 21 October, examined quadriceps strength and self-reported physical activity before and after a four-week strengthening programme. Participants had an average age of about 62.

After accounting for age, sex, osteoarthritis severity and pain, the researchers found no statistically significant association between strength and reported activity at the start. Improvements in strength during the programme were also not significantly associated with changes in reported activity immediately afterwards or four weeks later.

This does not show that strengthening is ineffective. It suggests that a gain in physical capacity cannot be assumed to change someone's everyday routine. A person may become better able to stand from a chair yet still avoid walking to the shops because of pain, confidence, fatigue or the environment. If returning to an activity matters to them, that activity deserves attention alongside strength and clinic-based tests.

This was a relatively small secondary analysis. Activity was self-reported, and there was no non-exercise control group for this question. It does not establish that strengthening has no effect on activity in other people or over longer periods.

Fear of movement: a question for assessment, not a new treatment rule

A small randomised trial in Iran, published on 20 October, studied 56 older adults with chronic knee osteoarthritis. Researchers compared usual care with a four-week mindfulness-based cognitive therapy programme and measured fear of movement.

The pattern of scores over time differed between groups, but adjusted comparisons at individual assessment points were not statistically significant. The adjusted difference in change to eight weeks had a confidence interval that included no difference. This is preliminary evidence, not proof that the therapy should become routine osteoarthritis care.

The study does, however, highlight a question worth asking when pain and activity avoidance persist: what does the person believe might happen if they move? A clinician can explore those concerns and explain the purpose and safety of an agreed exercise plan. Specialist psychological treatment requires appropriate training and, when indicated, referral.

Dementia rehabilitation: including support people without assuming their availability

A Swedish rehabilitation pilot trial, published on 21 October, paired interdisciplinary rehabilitation for people living with dementia with education and support for their informal caregivers. Sixty-seven pairs were allocated to intervention or usual care; the paper's final analyses included 66 caregivers.

Caregivers who responded after the programme often reported better knowledge and coping. However, the trial did not show a statistically significant improvement in caregiver burden or depressive symptoms compared with usual care. Some later quality-of-life measures favoured the control group. As a feasibility pilot, it was not large enough to establish clinical effectiveness.

Rehabilitation may work best when the person living with dementia can express what matters to them and, with their agreement, the people supporting them understand the plan. Family involvement should be discussed, not presumed. Caregivers have their own capacity, preferences and need for support.

Digital stroke rehabilitation: ask how care is delivered

A scoping review published on 21 October mapped 21 studies of digital rehabilitation after stroke. Eight involved clinician-supported remote care, nine used hybrid or clinician-facilitated approaches, and four were primarily self-directed.

The same broad label, such as an app or wearable sensor, can describe very different levels of clinical input. The useful questions are what the person needs to practise, who reviews progress, and how the programme changes when needs change. A scoping review maps the available research; it does not show that digital rehabilitation is equivalent or superior to face-to-face care.

What we take from this week's research

The eSTEPS trial suggests that a more reliable route from falls-risk identification to recommendations can make a modest difference in one primary-care setting. The osteoarthritis study reminds us to check whether gains in strength are reflected in the activities a person wants to do. The smaller studies raise useful questions about fear of movement, support for people living with dementia and the amount of clinical input in digital care, without establishing new treatment rules.

At Clinics GRP, rehabilitation starts with the person's goals and circumstances. Assessment, a plan that can be carried out, and review of meaningful outcomes help us decide whether that plan is working for them.

About this weekly series

Older Adult Rehabilitation Research is published each Friday by Clinics GRP. We review research concerning falls and balance, musculoskeletal and neurological rehabilitation, exercise and ageing, then explain what it may mean for everyday care.

These studies describe groups of people and are not individual treatment instructions. If you have fallen, are concerned about your balance or are thinking about changing your exercise programme, discuss your circumstances with a treating health professional.