The health benefits of physical activity (PA) include reductions in the risk of cardiovascular disease, type 2 diabetes, osteoporosis and certain cancers.1 There is growing evidence of an association between regular PA and a reduced risk of all-cause mortality,2 and of the potential savings for NHS budgets from exercise promotion for older adults.3 Sedentary behaviour increases the risk of dependence, falls and fractures. Sustained levels of PA in adulthood maintain bone strength and can prevent fragility fractures in later life. Research has shown that a lifetime’s history of regular PA can reduce the risk of hip fracture by up to 50% and much of this benefit is thought to result from a reduction in falls.4 It is now clear that habitual PA and improved access to exercise opportunities is an important public health approach to the prevention of functional decline that can lead to frailty, falls and fractures.5
Falls are common in people aged ≥ 65 years and can have serious consequences, including injury, pain, impaired function, loss of confidence in carrying out everyday activities, loss of independence and autonomy, and even death.6,7 There is evidence that interventions providing some form of exercise may be effective in preventing falls among older people8 and that health-care costs9,10 could be reduced if the number of falls was reduced.7,11–14
Current PA recommendations propose a target of 150 minutes of moderate to vigorous physical activity (MVPA) per week.15 However, surveys have consistently shown a high prevalence of physical inactivity in the UK population.16 A systematic review comparing 17 randomised controlled trials (RCTs) with different interventions designed to encourage sedentary, community-dwelling adults to do more PA17 concluded that interventions were effective in the short- and mid-term, at least in middle age, and that there were no significant increases in adverse events (AEs) in the four studies that reported them. However, it is unclear which individual interventions (e.g. home- or facility-based) are the most effective in increasing PA in the long term or in specific groups (e.g. older people).
Promoting physical activity
The NHS has attempted to address the problem of inactivity in a variety of ways, including exercise referral schemes in primary care (‘exercise on prescription’), which were provided by approximately 90% of primary care trusts (PCTs) in the 2000s and usually involved referring patients to local leisure centres.18 Although exercise on prescription has been shown to be feasible and effective in vulnerable older people,19 there appear to be significant barriers to the uptake of exercise classes in leisure centres. For many older people, home exercise or group exercise in non-intimidating environments (e.g. community halls) may be more appealing, and result in higher uptake of exercise programmes and longer continuation of exercise. Peer activity mentors have also been shown to be effective in increasing uptake and adherence to exercise.20-23
There are currently two existing exercise programmes designed for use in community settings with people aged ≥ 65 years. The first is a home-based programme, the Otago Exercise Programme (OEP), and the second is a community-based group exercise programme, the Falls Management Exercise (FaME) programme.
The OEP24–30 and FaME programme31,32 are both designed for use in community settings, specifically for people aged ≥ 65 years, to reduce falls. FaME is based on the components of fitness and principles of programming for all older adults (i.e. warm-up, mobility, stretches, strength and balance, endurance and a cool down), while OEP includes brief warm-up and strength and balance exercises appropriate for the age group. Both programmes involve strength and balance training which is tailored to the individual’s ability and health status.
The OEP is a home-based exercise programme for older people which is effective in reducing falls and fall-related injuries, improving balance, strength and confidence in performing everyday activities without falling, and has been shown to be cost-effective for people aged ≥ 80 years.24–30 It was designed to be delivered by physiotherapists, and nurses trained and supervised by physiotherapists. A 1-year evaluation of the OEP showed considerable improvements in outdoor activities (walking, shopping, gardening and other outside leisure activities) after 6 months (Professor A J Campbell, University of Otago, 2007, personal communication) with participants continuing to exercise after completing the programme. It also showed significant improvements in executive function after 6 months.30 While the OEP has been evaluated in four controlled trials of older primary care patients in New Zealand and one RCT in Canada, it has not been tested in a primary care setting in the UK for its feasibility, impact, acceptability and cost-effectiveness.
The FaME programme is a group exercise programme which was developed and tested in a controlled trial in the UK,31 but not in a primary care population. It aims to improve balance33 and was designed to be delivered by qualified postural stability instructors (PSIs).32 It has been shown to be effective in reducing falls, and injuries resulting from falls.16,31 Good adherence was demonstrated with the FaME programme and nearly two-thirds of people participating in FaME continued in group exercise programmes for over 1 year after trial completion (Professor D A Skelton, Glasgow Caledonian University, 2007, personal communication). The FaME programme remains to be evaluated for its impact, acceptability and cost-effectiveness within primary care.
This trial aimed to fill the gaps in the current evidence base by evaluating the delivery, impact, acceptability and cost-effectiveness of a community-based exercise programme (FaME) and a home-based exercise programme (OEP) supported by similarly aged (peer) mentors (PMs), compared with usual care for primary care patients. The underlying assumption was that the exercises would produce sufficient subjective well-being and improved mobility to encourage continuation of higher levels of PA after the cessation of the intervention. Each exercise programme was compared with usual care for effectiveness in producing sustained change in PA. The two programmes would be compared for cost-effectiveness if both were effective in promoting sustained change in PA. Our primary hypotheses at the start of the study were (1) both exercise programmes would produce sustained changes in PA compared with usual care and (2) OEP would be more cost-effective than FaME.
