Research Report
Fall Preventive Exercise With or Without
Behavior Change Support for Community-
Dwelling Older Adults: A Randomized
Controlled Trial With Short-Term Follow-up
Marina Arkkukangas, PT1; Anne Sderlund, PT, PhD1;
Staffan Eriksson, PT, PhD2,3,4; Ann-Christin Johansson, PT, PhD1,5
ABSTRACT
Background and Purpose: In Western countries, falls and fall-
related injuries are a well-known threat to health in the aging
population. Studies indicate that regular exercise improves
strength and balance and can therefore decrease the inci-
dence of falls and fall-related injuries. The challenge, however,
is to provide exercise programs that are safe, effective, and
attractive to the older population. The aim of this study was
to investigate the short-term effect of a home-based exercise
program with or without motivational interviewing (MI) com-
pared with standard care on physical performance, fall self-
efficacy, balance, activity level, handgrip strength, adherence
to the exercise, and fall frequency.
Method: A total of 175 older adults participated in this ran-
domized controlled study. They were randomly allocated for
the Otago Exercise Program (OEP) (n = 61), OEP combined
with MI (n = 58), or a control group (n = 56). The partici-
pants mean age was 83 years. The recruitment period was
from October 2012 to May 2015. Measurements of physical
performance, fall self-efficacy, balance, activity level, handgrip
1School of Health, Care and Social Welfare, Mlardalen
University, Vsters, Sweden.
2Centre for Clinical Research Srmland, Uppsala University,
Eskilstuna, Sweden.
3Department of Community Medicine and Rehabilitation,
Physiotherapy, Ume University, Ume, Sweden.
4Department of Neuroscience, Physiotherapy, Uppsala
University, Uppsala, Sweden.
5Centre for Clinical Research, Uppsala University, Vsters,
Sweden.
Source of support: The National Swedish Board of Health
and Welfare, Grants for the County of Vstmanland.
Regional Research Fund for Uppsala and rebro region,
Sweden. Research and Development Department in the
Community of Eskilstuna, Sweden.
The authors declare no conflict of interest.
Address correspondence to: Marina Arkkukangas, PT,
School of Health, Care and Social Welfare, Box 883,
SE-72123, Mlardalen University, Vsters, Sweden
(marina.arkkukangas@mdh.se).
Bill Andrews was the Decision Editor.
Copyright 2017 Academy of Geriatric Physical Therapy,
APTA.
DOI: 10.1519/JPT.0000000000000129
Journal of GERIATRIC Physical Therapy
Copyright 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
strength, adherence to the exercise, and fall frequency were
done before and 12 weeks after randomization.
Results and Discussion: A total of 161 participants were fol-
lowed up, and there were no significant differences between
groups after a period of 12 weeks of regular exercise. Within
the OEP + MI group, physical performance, fall self-efficacy,
physical activity level, and handgrip strength improved sig-
nificantly; likewise, improved physical performance and fall
self-efficacy were found in the control group. A corresponding
difference did not occur in the OEP group. Adherence to the
exercise was generally high in both exercise groups.
Conclusion: In the short-term perspective, there were no
benefits of an exercise program with or without MI regarding
physical performance, fall self-efficacy, activity level, handgrip
strength, adherence to the exercise, and fall frequency in
comparison to a control group. However, some small effects
occurred within the OEP + MI group, indicating that there
may be some possible value in behavioral change support
combined with exercise in older adults that requires further
evaluation in both short- and long-term studies.
Key Words: behavior, exercise, older adults
(J Geriatr Phys Ther 2017;00:1-9.)
INTRODUCTION
The decreased physical functioning that occurs with aging
often leads to falls and fall-related injuries, which are a major
public health problem globally. Studies indicate that falls and
fall-related injuries can be decreased by regular exercise.1,2
The challenge, however, is to provide exercise programs that
are safe, effective, and attractive to the older population.1 For
older adults with incipient transfer disabilities, home-based
exercise provides many advantages. The possibility of exercis-
ing at home might be important for adherence to prescribed
exercise recommendations.1,3,4 The Otago Exercise Program
(OEP) is a strength and balance retraining program suitable
for performance at home aimed at preventing falls among
older community-dwelling adults.2 The program has been
shown to reduce falls and injuries, especially for women older
than 80 years. In general, the program is effective for those
who adhere to the prescribed exercise recommendations.5
According to the OEP, a training frequency of 3 sessions per
week is recommended, although lower levels of adherence
also might have favorable effects on health outcomes in the
older population.6 The presented effectiveness of the program
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 Research Report
has been based on a training period of 6 to 12 months.6
The OEP does not include any specified behavioral support.
French et al7 highlighted that acceptance of behavior change
techniques was an important consideration when physical
activity interventions were introduced for older adults.7
The perceived gains from participating in physical activ-
ity interventions vary in different age groups. In general,
behavior change techniques are more effective at increasing
physical activity in younger and middle-aged adults than in
older adults.8 Motivational interviewing (MI) is a commu-
nication method that is commonly used to attain behavior
change in health care today.9 Features of MI include listen-
ing and reinforcing the patients thoughts to reflect on his/
her situation and thus reduce the persons resistance to the
behavior change.9 These aspects are important for a person
who is beginning or has an intent to maintain a behavioral
change process.10 Improvement in self-efficacy and activity
limitation when using motivational interventions has been
investigated with some positive results in people of working
age.11 To the best of our knowledge, the OEP combined
with MI has not been studied among older adults who have
an increased need for care services or who use walking aids.
Hence, the aim of this study was to examine the short-term
effect of a home-based exercise program with or without
MI compared with standard care in terms of physical per-
formance, fall self-efficacy, balance, activity level, handgrip
strength, adherence to the exercise, and fall frequency.
METHODS
The study was a randomized controlled trial with 2 treatment
groups and 1 control group. The Consolidated Standards of
Reporting Trials (CONSORT) checklist was used to report
the randomized controlled trial.12 The study was registered
at clinicaltrials.gov under NCT01778972. In this study, the
short-term follow-up (12 weeks) is reported, and future
follow-ups will occur at 12 and 24 months. A total of 175
people from 3 communities in central Sweden who lived in
their own homes participated in the study (Figure).
Care managers, occupational therapists, and physio-
therapists (PTs) collaborated to recruit participants who
had contacted health centers or the municipality to obtain
walking aids or home care. To be eligible, participants were
required to be 75 years or older, have the ability to walk
independently, and the ability to understand written and
oral information in the Swedish language. The exclusion
criteria were scoring less than a 25 on the Mini-Mental
State Examination (MMSE), ongoing regular physical
therapy treatment, or being in terminal care. Patients who
were identified and showed interest in participating when
they visited the health care centers or home care were con-
tacted by phone and given information about the study by
2 of the researchers. If they were willing to participate in
the study, they were contacted by an independent PT for
baseline measurements (Table 1). If those participants met
the study criteria, informed consent was obtained and they
then were randomized into 1 of the 3 groups (Figure).
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Measurements
The measurements were performed single blinded by
6 independent PTs before randomization and 12 weeks
after randomization. All of the PTs had experience working
with older people. The setting was in the participants home
or at a health care center. In addition, the participants filled
in a fall calendar and exercise diary monthly and received
follow-up every month by a PT. Physical performance,
fall self-efficacy, balance, activity level, handgrip strength,
adherence to the program, and fall frequency were col-
lected using the following measures:
The Short Physical Performance Battery (SPPB) was used
to measure physical performance in the lower extremities.
The SPPB consists of 3 components: balance, gait speed,
and lower body power.13 The SPPB has been reported to
be predictive of disability and risk of falls.14 The 3 tasks
are graded on a 4-point scale, with a maximum score of
12 points, where the maximum indicates the best physical
performance. The test-retest reliability has been reported to
be good for the SPPB.13
The Falls Efficacy Scale Swedish version (FES(S)) was
used to measure confidence in the participants ability to
perform various daily activities without falling.15 The
instrument consists of 13 items that are rated on a 0
to 10 scale, with a maximum score of 130, where 130
represents the highest level of self-efficacy. The internal
consistency16 and the test-retest reliability for the FES(S)
have been shown to be high.17
The Mini-BESTest was used to measure balance. The
test includes 14 different tasks on 4 subscales. All tasks
are graded from 0 to 2 points, with a total maximum
score of 28 points; in each task, 0 indicates the lowest
level of balance and 2 indicates the highest level.18 The
test has high reported test-retest reliability and interrater
reliability.19
The Frndin/Grimby Activity Scale was used to measure
the physical activity level, where activity level is estimated
on a 6-point scale. The scale considers activities typically
performed during the winter and summer seasons, and the
reliability has been shown to be good.20
The Jamar hand dynamometer was used to measure
handgrip strength. The test is a valid measure for general
body strength.21 The test provides an excellent test-retest
reliability for grip strength measurement.22
Exercise adherence was monitored by an exercise diary
that was filled in by the participants and followed up on
every month by a PT. Use of an exercise diary has been
shown to be a positive factor for adherence when prescribing
regular physical activity for older adults.23 The 36 exercise
sessions were prescribed during the study period (3 times per
week) according to the original OEP protocol. We set the
acceptable amount of exercise adherence to a minimum of
24 sessions (2 times per week). This was considered appro-
priate because of age and possible upcoming events in the
older adults lives, and it is commonly used as an acceptable
measure when prescribing exercise for older adults.24,25
Walks were encouraged in between exercise days with an

Figure. Participants pass through the trial.
acceptable amount of 24 walks (2 times per week) during
the study period, according to the original OEP protocol.25
Fall frequency was reported by a fall calendar during the
12-week study period, in line with current recommenda-
tions for reporting falls with follow-up from a practitioner.26
Interventions
All participants got a pamphlet with general safety rec-
ommendations for older adults, including fall prevention
recommendations. This was standard care at that time in
the 3 communities, and it was the only intervention for the
control group.
The OEP and OEP + MI groups were supervised and
supported on 5 occasions during the 12 weeks by a PT
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Research Report
for exercise and MI treatment. The treatment was given
by 11 PTs, all of whom had experience working with
older people.
OEP group
The OEP is a home-based exercise program designed to
improve strength, balance, and endurance. With the sup-
port of the PT, the level of difficulty of the individually
tailored exercise program was increased successively during
the 12 weeks. To ensure the safety and intensity of the pro-
gram, the PT increased and supervised the exercise closely
during the 5 home visits. The exercise was estimated to take
30 minutes and was prescribed at a frequency of 3 times
weekly. Ankle cuff weights were used according to the OEP
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 Research Report

Table 1. Baseline Characteristics and P Values for Differences Between Groups

Total OEP OEP + MI Control
Participant Demographics n = 175 n = 61 n = 58 n = 56 P Value
Age, y, mean (SD) 83 (4.7) 83 (5.0) 84 (4.1 ) 82 (4.7) .40
Gender, %
Female 70 67 69 73 .77
Education level, %
Elementary school 43 48 40 45 .43
Secondary school/girl school 14 13 10 18
High school/trade school 18 18 21 14
University 25 21 29 23
Marital status, %
Married 37 40 38 30 .78
Unmarried 12 12 14 11
Widowed 48 46 43 55
Cohabitation 3 2 5 4
Falls during the past year, %
No 58 61 51 63 .39
Yes 42 39 49 37
Use of walking aid, %
Yes 92 92 90 95 .63
Help in daily living, %
No 56 57 57 54 .47
Yes, from relatives/friends 19 23 17 18
Yes, from home help services/private firm 25 20 26 28
SPPB (0-12), mean (SD) 7.7 (2.4) 7.9 (2.4) 7.7 (2.5) 7.5 (2.5) .77
Mini-BESTest (0-28), mean (SD) 15.6 (5.2) 15.8 (5.0) 15.3 (5.5) 15.8 (5.3) .93
Falls Efficacy Scale (0-130), mean (SD) 102.1 (23.8) 104.0 (21.7) 102.6 (23.1) 99.5 (26.8) .84
Jamar handgrip, kg, mean (SD)
Right 24.5 (7.8) 25.0 (8.5) 24.1 (7.7) 24.4 (7.3) .99
Left 23.0 (7.3) 23.6 (8.0) 22.5 (7.1) 23.0 (6.8) .81
Frndin/Grimby (0-6), mean (SD) 2.8 (0.8) 2.9 (0.7) 2.7 (0.7) 2.9 (0.8) .12
Abbreviations: MI, motivational interviewing; OEP, Otago Exercise Program; SD, standard deviation; SPPB, Short Physical Performance Battery.

protocol.6 Walks were recommended for the days between the OEP. Throughout each session, the underlying prin-
the exercise days. Exercise and walks were reported in the ciples of MI were present. The sessions aimed to keep a
exercise diary by the participant. Each session with the PT flexible intervention tailored to the participants needs and
was estimated to take 1 hour. at the same time keeping the standardized structure of the
OEP. Each session was calculated to last approximately 1
OEP + MI group hour, equal to the OEP group.
MI was combined with the OEP to follow the participants
motivation to change regarding exercise. Unlike the OEP Treatment Fidelity
group, the PT in the OEP + MI group strived to enhance Treatment fidelity was considered in both exercise groups
the persons own motivation for and commitment to and consisted of meetings for all of the PTs who delivered
change. The session began with MI, open-ended questions, the OEP and OEP + MI treatments before the study
affirmations, reflective listening and summaries (OARS),27 began and during the study period. Minor adjustments
a collaborative conversation to strengthen and mobilize the to the OEP were made with the agreement of all the PTs
participants inner resources. The session then proceeded to involved, and a consensus was reached regarding how the
discussion and a decision of the individual setup regarding program was administered and delivered. The PTs in both
4 Volume 00 Number 0 000-000 2017
Copyright 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.

intervention groups followed the study protocol and regis-
tered the exercise during the home visits.
All of the PTs who performed the MI had received
education in MI, and they were all experienced and
familiar with the MI method. In addition, the PTs who
worked with the participants in the OEP + MI group
received a 3-day educational training in MI before the
study started with 2 Motivational Interviewing Network
of Trainers (MINT) instructors and 3 booster sessions
during the study period. Control coding during the study
was performed at the Motivational Interviewing Coding
Laboratory (MIC lab) in Sweden; the average was 3.8
for the PTs, which was interpreted as an acceptable score
rated on a 5-point Likert scale, where 0 is a low MI spirit
and 5 is high.28
Ethics
We followed the 1964 Helsinki Declaration, which con-
cerns human rights, informed consent, and correct proce-
dures concerning treatment in research involving human
participants. The participants received no compensation
for their participation, and the study was approved by the
regional ethics committee in Uppsala, Dnr. 2012/147.
Randomization
The participants were randomly allocated in variable
block sizes of 3, 6, 9, and 12 participants to 1 of 3 groups.
The randomization was stratified by the 3 communities.
A statistician independent from the research group gen-
erated the random allocation. The random allocation
sequences were transferred to consecutively numbered
envelopes that were handled by 2 researchers who did not
participate in the data collection or in the intervention.
Statistics
A power calculation based on the SPPB, the main out-
come variable, was performed before the study started. An
estimated small meaningful change was set to 0.5, with a
standard deviation (SD) of 1.5 in the SPPB.29,30 This resulted
in the need for 45 participants in each group, with a signifi-
cance level of 5% and power of 80%. A 15% dropout rate
was estimated, resulting in a total of 52 participants for each
group or a grand total of 155. We had access to 175 par-
ticipants, and therefore they were all included in the study.
A 1-way analysis of variance power analysis was performed
with PASS version 13.0.8. Baseline characteristics were mea-
sured with Kruskal-Wallis and Fisher exact tests, and the 2
test was used for categorical data. Between-group effects
were analyzed with 1-way analysis of variance and post hoc
analysis using the Scheff test. The intention-to-treat analy-
sis was complemented with a per-protocol analysis where
dropouts and nonadherent participants were excluded.
Levenes test was used for homogeneity of the variance
test and skewness and kurtosis for the distribution of data.
Within-group effects were analyzed with the paired t test.
We used an level of 0.05 for all of the statistical tests. The
data analysis was performed using IBM SPSS statistics 20.
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Research Report
RESULTS
The study was conducted from October 2012 to May
2015. Among the 335 eligible older people, 8 participants
scored less than 25 on the MMSE and 152 participants
declined participation for various reasons. The remaining
175 participants were randomized as follows: 61 individu-
als in the OEP group, 58 individuals in the OEP + MI
group, and 56 individuals in the control group (Figure).
No significant baseline differences were observed between
the 3 groups (Table 1). The mean age for the entire
group was 83 years (Table 1). No significant values were
detected with Levenes test, and the data were considered
to be normally distributed, as the values for skewness and
kurtosis fell within 1 for all the outcome variables. A
total of 161 participants were followed up at 12 weeks:
54 individuals in the OEP group, 52 individuals in the
OEP + MI group, and 55 individuals in the control group
(Figure). The 14 dropouts during the study period were
mostly due to participants health-related problems. Of
the remaining 161 participants, a total of 15 persons were
nonadherent to the exercise and were excluded according
to the set limit of acceptable adherence to the exercise in
a per-protocol analysis with a total of 146 participants:
43 individuals in the OEP group, 48 individuals in the
OEP + MI group, and 55 individuals in the control group
(Figure). The per-protocol analysis revealed similar results
as the intention-to-treat analysis (Tables 2 and 3). At least
1 accidental fall was reported during the study by 45
participants (29%), with a total of 74 falls. There were
19 falls in the OEP group reported by 15 persons (31%),
38 falls in the OEP + MI group reported by 18 persons
(33%), of whom 3 individuals fell more than 5 times,
and 17 falls in the control group reported by 12 persons
(22%). According to the fall calendars, no falls occurred
during the exercise.
Physical Performance
No significant differences between the groups were observed
over time regarding physical performance measured by the
SPPB (Table 2). Within groups, the OEP + MI group
(P = .04) (per-protocol analysis, P = 0.03; Table 3) and the
control group (P = .03) showed significant improvements
in physical performance. The difference in the OEP group
was not significant for the SPPB (Table 2).
Falls Efficacy Scale
No significant differences between the groups were
observed over time for the results in the FES (Table 2).
Within groups, the OEP + MI group (P = .02) (per-
protocol analysis, P = .05; Table 3) and the control group
(P = .03) improved significantly. The difference was not
significant in the OEP group (Table 2).
Balance
The Mini-BESTest showed no significant differences in bal-
ance between the groups or within any of the 3 groups over
time (Table 2).
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Table 2. Outcome Measures Between- and Within-Group Analysis Based on Intention-to-Treat Analysis, n = 161, OEP, n = 54, OEP +
[AQ01]
MI, n = 52, Control, n = 55, Mean (SD)
P F Ratio P
Outcome Measures Baseline 12 wk Within-Group Comparison (df) Between-Group Comparison
Short Physical Performance Battery (0-12)
Between-group comparison F(2,158) = 0.41 .67
Within OEP 7.9 (2.5) 7.9 (2.8) .84
Within OEP + MI 8.0 (2.4) 8.3 (2.6) .04
Within control 7.6 (2.5) 8.2 (2.6) .03
Falls-Efficacy Scale (S) (0-130)
Between groups F(2,158) = 1.10 .35
Within OEP 103.3 (21.3) 103.8 (22.1) .53
Within OEP + MI 103.0 (22.6) 109.5 (18.4) .02
Within control group 100.2 (26.5) 106.2 (20.6) .03
Mini-BESTest (0-28)
Between groups F(2,158) = 0.20 .82
Within OEP 15.8 (5.2) 15.8 (5.7) .80
Within OEP + MI 15.8 (5.5) 16.4 (6.0) .21
Within control group 16.0 (5.2) 16.2 (4.7) .48
Frndin/Grimby (1-6)
Between groups F(2,158) = 0.89 .41
Within OEP 2.9 (0.7) 3.0 (0.6) .28
Within OEP + MI 2.7 (0.6) 2.9 (0.6) .02
Within control group 3.0 (0.8) 2.8 (0.5) .23
Handgrip right, kg
Between groups F(2,158) = 0.55 .58
Within OEP 24.7 (8.7) 25.3 (8.7) .66
Within OEP + MI 24.4 (7.5) 25.1 (7.0) .17
Within control group 24.4 (7.7) 23.9 (7.4) .20
Handgrip left, kg
Between groups F(2,158) = 0.27 .76
Within OEP 23.4 (7.9) 23.9 (7.7) .62
Within OEP + MI 22.4 (7.2) 23.3 (6.7) .03
Within control group 23.0 (6.8) 22.9 (7.2) .85
Abbreviations: df, degrees of freedom; MI, motivational interviewing; OEP, Otago Exercise Program; SD, standard deviation. P, p-value, bold figures indicate a significant value 0.05.

Physical Activity Level the OEP + MI group significantly improved (P = .03) in

No significant differences between the groups were (per-protocol analysis, P = .02; Table 3) the Jamar hand-
observed over time regarding the Frndin/Grimby Activity grip on the left side (Table 2). The differences in the OEP
Scale (Table 2). Within groups, the OEP + MI group sig- and control groups regarding the Jamar Handgrip were not
nificantly improved (P = .02). The differences in the OEP significant (Table 2).
and control groups regarding the Frndin/Grimby Activity
Scale were not significant (Table 2). Adherence to Exercise
No significant differences were detected between the
Jamar Handgrip OEP and OEP + MI groups in adherence. In total,
No significant differences between the groups were observed 42% of the participants adhered to the recommenda-
over time in the Jamar handgrip (Table 2). Within groups, tion of 3 times per week; adherence was 42% in the
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 Research Report

Table 3. Outcome Measures Between- and Within-Group Analysis Based on per Protocol Analysis, n = 146, OEP, n = 43, OEP + MI,
n = 48, Control, n = 55, Mean (SD)
P F Ratio P
Outcome Measures Baseline 12 wk Within-Group Comparison (df) Between-Group Comparison
Short Physical Performance Battery (0-12)
Between-group comparison F(2,143) = 0.13 .88
Within OEP 7.9 (2.5) 8.1 (2.8) .52
Within OEP + MI 8.0 (2.4) 8.4 (2.6) .03
Within control 7.6 (2.5) 8.2 (2.6) .03
Falls-Efficacy Scale (S) (0-130)
Between groups F(2,143) = 0.13 .87
Within OEP 103.3 (21.3) 106.5 (20.9) .29
Within OEP + MI 103.0 (22.6) 108.2 (18.5) .05
Within control group 100.2 (26.5) 106.2 (20.6) .03
Mini-BESTest (0-28)
Between groups F(2,143) = 0.09 .92
Within OEP 15.8 (5.2) 16.4 (5.7) .30
Within OEP + MI 15.8 (5.5) 16.7 (5.9) .10
Within control group 16.0 (5.2) 16.2 (4.7) .48
Frndin/Grimby (1-6)
Between groups F(2,143) = 1.04 .36
Within OEP 2.9 (0.7) 3.0 (0.6) .11
Within OEP + MI 2.7 (0.6) 2.9 (0.6) .02
Within control group 3.0 (0.8) 2.8 (0.5) .22
Handgrip right, kg
Between groups F(2,143) = 0.48 .62
Within OEP 24.7 (8.7) 24.8 (8.8) .95
Within OEP + MI 24.4 (7.5) 25.4 (7.2) .12
Within control group 24.4 (7.7) 23.9 (7.4) .20
Handgrip left, kg
Between groups F(2,143) = 0.12 .88
Within OEP 23.4 (7.9) 23.5 (7.7) .89
Within OEP + MI 22.4 (7.2) 23.5 (6.8) .02
Within control group 23.0 (6.8) 22.9 (7.2) .85
Abbreviations: df, degrees of freedom; MI, motivational interviewing; OEP, Otago Exercise Program; SD, standard deviation. P, p-value, bold figures indicate a significant value 0.05.

OEP group and likewise 42% in the OEP + MI group. DISCUSSION

The exercise was accomplished 2 times weekly by 81% We were unable to confirm the hypothesis that exercise
of the participants: by 77% in the OEP and by 84% in (OEP) in combination with MI increases physical function-
the OEP + MI group. ing after 12 weeks of exercise compared with regular exer-
The walking frequency of 2 times weekly was accom- cise (OEP) and a control group. No significant differences
plished by 67% of the participants, and the proportions were found between the 3 study groups in this short-term
within groups were 70% in the OEP group and 64% in follow-up. Over time, effects in physical performance, fall
the OEP + MI group. In total, 25% of the participants self-efficacy, physical activity level, and handgrip strength
had a walking frequency of 4 times per week; this was after the exercise period were achieved in the OEP + MI
21% in the OEP group and 28% in the OEP + MI group. group, and such effects in physical performance and fall
Journal of GERIATRIC Physical Therapy 7
Copyright 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
 Research Report
self-efficacy were also achieved in the control group. These
changes did not occur in the OEP group. Adherence in
exercise was high in both the OEP and OEP + MI groups.
With knowledge of the benefits of the OEP for community-
dwelling older adults, we were interested to see whether the
OEP could have an effect on this sample of older adults with
light disabilities, needing walking aids or home care. Follow-
up was done after 12 weeks because most of the support
provided by the PT was given at this time point. Because
adherence to exercise programs for older adults is generally
low,31 we found it interesting to evaluate whether MI would
increase adherence and therefore also have an impact on
the effects of exercise. The OEP + MI group improved sig-
nificantly in all of the outcome variables except for balance
performance measured by the Mini-BESTest. In contrast, the
OEP group showed no significant changes in any of the out-
come variables. However, because these changes not were
significant when compared between groups, these findings
are not grounds for further conclusions.
MI as a complement to traditional physical therapy
was studied in a systematic review by McGrane et al,32
where it was shown to have some positive effects on long-
term exercise behavior.32 However, several different study
populations were included in the review, and therefore no
specific conclusion could be drawn regarding its effects in
an older population. Observed changes within the OEP +
MI group in our study imply a need for further studies on
MI as a complement to exercise for this age group.
The high adherence in both exercise groups could
also be linked to the transtheoretical stages of change.33
The participants in this study had accepted participation
and, thus, the motivation to exercise was considered to
be present from the study start, regardless of the allo-
cated group. The stages of change consist of 5 stages:
precontemplation, contemplation, preparation, action,
and maintenance. The PTs supported and guided the
participants to proceed through the stages of change.
Prochaska et al33 argued that behavior changes during
the first month in a treatment intervention are the most
important in the process of moving forward toward
behavior change actions.33
Existing guidelines suggest that general exercise should
be undertaken for at least 2 hours per week for older
adults,4 and we considered the minimum of exercise 2 times
per week in combination with walks performed at least 2
times per week to meet this guideline. A total of 81% of
the participants performed the exercise 2 times per week,
and 67% of the participants walked 2 times per week in
both treatment groups. Gardner et al25 showed that exercise
performed 2 times per week during 12 months was highly
associated with physical benefits for older adults older than
65 years.25 Regarding the OEP + MI group, our results
offer some support to the conclusions drawn by Gardner
that physical improvement can be achieved when exercise
is performed 2 times per week after a relatively short period
of training. To reach the desired effect, the exercise has to
be challenging but also done within a safe and comfortable
8 Volume 00 Number 0 000-000 2017
Copyright 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
margin.34 We judged the safety margin to be high in our
study, which might explain the absence of improvement.
Over time, the exercises performed in this study were
intended to prevent falls, but the limited study sample and
the short follow-up time did not allow for conclusions
regarding the effect on falls. In total, 29% of the 175 par-
ticipants reported falls; this was composed of 31% from
the OEP group, 33% from the OEP + MI group, and 22%
from the control group. Home-based exercise including
a walking program may cause an increased risk of falls if
not carefully prescribed. However, none of the participants
reported fall accidents during exercising in the present study.
Limitations and Strength
A 12-week follow-up may have been too short to detect
differences between the groups. Nevertheless, we were
interested to see whether this program, which was sub-
maximal and done within a safe margin, possibly had any
short-term effects. The sample size could also have been
underpowered, because we had a higher dispersion in the
SPPB variable (SD, 2.6) compared with the SD we used
in the power calculation (SD, 1.5). The similarities of the
exercise programs and the unexpected improvement in the
control group were likely limitations of this study, as these
factors contributed to difficulties in detecting differences
between the groups.
The control group did not keep exercise diaries, so it
is unknown whether this group exercised on their own.
A diary for the control group, however, could have been
interpreted as a reminder or request for regular exercise,
which was a reason for not including one.
The balance performance was the only outcome vari-
able that did not change in any of the groups. Perhaps the
Mini-BESTest was not sensitive enough to detect possible
changes; a more sensitive test might have been preferable
for this study sample.
The control of treatment fidelity was a strength in this
study along with thoroughly followed protocols and several
meetings for the involved PTs to attain standardization of
the OEP and MI interventions. In addition, the PTs who
performed the measurements were blinded to group alloca-
tion, and the randomization was performed by 2 researchers
who did not participate in the intervention or measurements.
CONCLUSION
A short-term follow-up of a home-based exercise program
with or without MI compared with standard care showed
no significant differences between the groups in terms of
physical performance, fall self-efficacy, balance, activity
level, handgrip strength, adherence to the exercise, and
fall frequency. Some small effects occurred within the
OEP + MI group regarding physical performance, fall self-
efficacy, activity level, and handgrip strength. Behavioral
change supports for older adults who are recommended
to exercise need to be further developed and evaluated not
only in the short-term perspective but also in the long-term
perspective.

REFERENCES
1. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing
falls in older people living in the community. Cochrane Database Syst Rev.
2012;(9);CD007146.
2. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner
DM. Randomised controlled trial of a general practice programme of home
based exercise to prevent falls in elderly woman. BMJ. 1997;25(315):
1065-1069.
3. Lahti J, Holstila A, Lahelma E, Rahkonen O. Leisure-time physical activity
and all-cause mortality. PLoS One. 2014;9(7):1-7.
4. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to
prevent falls in older adults: an updated meta-analysis and best practice
recommendations. N S W Public Health Bull. 2011;22(3/4):78-83.
5. Robertson MC, Devlin N, Scuffham P, Gardner MM, Buchner DM, Campbell
AJ. Economic evaluation of a community based exercise programme to
prevent falls. J Epidemiol Community Health. 2001;55(8):600-606.
6. Thomas S, Mackintosh S, Halbert J. Does the Otago exercise programme
reduce mortality and falls in older adults? a systematic review and meta-
analysis. Age Ageing. 2010;39(6):681-687.
7. French DP, Olander EK, Chisholm A, Mc Sharry J. Which behaviour change
techniques are most effective at increasing older adults self-efficacy
and physical activity behaviour? A systematic review. Ann Behav Med.
2014;48(2):225-234.
8. Williams SL, French DP. What are the most effective intervention techniques
for changing physical activity self-efficacy and physical activity behaviour
and are they the same? Health Educ Res. 2011;26(2):308-322.
9. Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care:
Helping Patients Change Behavior. New York, NY: Guilford Press; 2008.
10. Miller W. Motivational Interviewing: Preparing People to Change Addictive
Behavior. Guilford Press; 1991.
11. McGrane N, Cusack T, ODonoghue G, Stokes E. Motivational strategies for
physiotherapists. Phys Ther Rev. 2014;19(2):136-142.
12. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: Updated
guidelines for reporting parallel group randomised trials. Int J Surg.
2011;9(8):672-677.
13. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance
battery assessing lower extremity function: association with self-reported
disability and prediction of mortality and nursing home admission. J
Gerontol. 1994;49(2):M85-M94.
14. Gawel J, Vengrow D, Collins J, Brown S, Buchanan A, Cook C. The short
physical performance battery as a predictor for long term disability or
institutionalization in the community dwelling population aged 65 years old
or older. Phys Ther Rev. 2012;17(1):37-44.
15. Hellstrm K, Lindmark B, Wahlberg B, Fugl-Meyer AR. Self-efficacy in relation
to impairments and activities of daily living disability in elderly patients with
stroke: a prospective investigation. J Rehabil Med. 2003;35(5):202-207.
16. Nordell E, Thorngren KG, Andreasson M, Gall K. Evaluating the Swedish
version of the Falls Efficacy Scale-International (FES-I). Adv Physiother.
2009;11(2):81-87.
Journal of GERIATRIC Physical Therapy
Copyright 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Research Report
17. Hellstrm K, Lindmark B. Fear of falling in patients with stroke: a reliability
study. Clin Rehabil. 1999;13(6):509-517.
18. Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using
psychometric techniques to improve the balance evaluation systems test:
the mini-BESTest. J Rehabil Med. 2010;42(4):323-331.
19. Tsang CS, Liao LR, Chung RC, Pang MY. Psychometric properties of the
mini- balance evaluation systems test (Mini-BESTest) in community-
dwelling individuals with chronic stroke. Phys Ther. 2013;93(8):1102-1115.
20. Frndin K, Grimby G. Assessment of physical activity, fitness and
performance in 76-year-olds. Scand J Med Sci Sports. 1994;4(1):41.
21. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of
grip and pinch strength evaluations. J Hand Surg Am. 1984;9(2):222-226.
22. Savva C, Giakas G, Efstathiou M, Karagiannis C. Test-retest reliability of
handgrip strength measurement using a hydraulic hand dynamometer
in patients with cervical radiculopathy. J Manipulative Physiol Ther.
2014;37(3):206-210.
23. Yeom HA, Keller C, Fleury J. Interventions for promoting mobility in
community-dwelling older adults. J Am Acad Nurse Pract. 2009;21(2):
95-100.
24. Cadmus-Bertram L, Irwin M, Alfano C, et al. Predicting adherence of
adults to a 12-month exercise intervention. J Phys Act Health. 2014;11(7):
1304-1312.
25. Gardner M, Buchner DM, Robertson MC, Campbell AJ. Practical
implementation of an exercise-based falls prevention programme. Age
Ageing. 2001;30(1):77-83.
26. Lamb SE, Jrstad-Stein EC, Hauer K, Becker C. Development of a common
outcome data set for fall injury prevention trials: the Prevention of Falls
Network Europe consensus. J Am Geriatr Soc. 2005;53(9):1618-1622.
27. Miller W, Rollnick S. Motivational Interviewing: Preparing People to Change
Addictive Behavior. New York, NY: Guilford Press; 1991.
28. Jelsma JG, Mertens VC, Forsberg L, Forsberg L. How to measure
motivational interviewing fidelity in randomized controlled trials: practical
recommendations. Contemp Clin Trials. 2015;43:93-99.
29. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and
responsiveness in common physical performance measures in older adults.
J Am Geriatr Soc. 2006;54(5):743-749.
30. Bean JF, Kiely DK, LaRose S, Goldstein R, Frontera WR, Leveille SG. Are
changes in leg power responsible for clinically meaningful improvements in
mobility in older adults? J Am Geriatr Soc. 2010;58(12):2363-2368.
31. Picorelli AM, Pereira LS, Pereira DS, Felcio D, Sherrington C. Adherence to
exercise programs for older people is influenced by program characteristics
and personal factors: a systematic review. J Physiother. 2014;60(3):151-156.
32. McGrane N, Galvin R, Cusack T, Stokes E. Addition of motivational
interventions to exercise and traditional physiotherapy: a review and meta-
analysis. Physiotherapy. 2015;101(1):1-12.
33. Prochaska JO, Norcross JC, DiClemente CC. Applying the stages of change.
Psychotherapy Australia. 2013;19(2):10.
34. Fairhall N, Sherrington C, Lord SR, et al. Effect of a multifactorial,
interdisciplinary intervention on risk factors for falls and fall rate in frail older
people: a randomised controlled trial. Age Ageing. 2014;43(5):616-622.
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