Hawaii Department of Health surveillance data consistently identify falls as among the most consequential preventable adverse events in the post-stroke population, with community-dwelling stroke survivors facing fall rates two to three times higher than age-matched individuals without neurological impairment. A randomised trial published in The BMJ now offers statistically significant evidence that a structured, home-based, multidisciplinary intervention can reduce fall rates by one third among ambulatory stroke survivors living in the community, with secondary benefits extending to mobility, balance, self-efficacy, and community participation.

The trial, registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001114134), enrolled 370 participants across three Australian states between August 2019 and December 2023. Known by its acronym FAST (Falls After Stroke Trial), the study employed a two-armed randomised controlled trial (RCT) design to evaluate a tailored, habit-forming intervention delivered over six months by paired physiotherapist and occupational therapist teams. The primary outcome was rate of falls over 12 months.

Study Population and Eligibility

Eligible participants were adults older than 50 years who had experienced a stroke within the preceding five years, had been discharged from formal rehabilitation to the community, and retained the ability to walk 10 metres across flat ground with or without an assistive device. The investigators excluded individuals with moderate-to-severe receptive aphasia and those with a walking speed exceeding 1.4 metres per second who had not experienced a fall in the prior year. The latter exclusion criterion effectively concentrated enrollment among participants at demonstrable fall risk, enhancing the clinical applicability of the findings to higher-risk subpopulations.

The enrollment window spanning more than four years reflects the deliberate pace required to achieve adequate statistical power for a falls-related primary outcome, a methodological consideration familiar to researchers working with this population, given the heterogeneity of stroke sequelae and the variability of community living circumstances.

Intervention Structure

The experimental intervention comprised three coordinated components delivered collaboratively by physiotherapist and occupational therapist dyadic teams over the six-month active period. The first component consisted of habit-forming functional exercise, designed to integrate physical conditioning into the daily routines of participants rather than relying on structured exercise sessions that may not persist beyond the intervention window. The second component addressed home fall hazard reduction, an occupational therapy domain with well-established efficacy in general older adult populations, here adapted specifically for the post-stroke context. The third component involved goal-directed community mobility coaching, intended to support participants in navigating environments beyond the home and to address the avoidance behaviours that frequently accompany fall-related fear in this population.

The dyadic model of service delivery merits attention from a health systems standpoint. Physiotherapists and occupational therapists working as paired teams, rather than sequentially or in isolation, reflects an integrated approach to multidomain rehabilitation that aligns with current understanding of fall aetiology in stroke survivors. Falls in this population arise from the intersection of impaired motor control, environmental hazards, reduced self-efficacy, and restricted community engagement. No single discipline addresses all four domains with equivalent competency.

The control group received usual care, defined by whatever community-based services participants would ordinarily access in their respective jurisdictions. This comparator reflects real-world clinical conditions and strengthens the external validity of the findings, though it introduces variability in control group exposure that is inherent to pragmatic trial designs.

Primary Outcome: Rate of Falls

At the 12-month follow-up, the experimental group demonstrated a statistically significant reduction in the rate of falls compared with the control group. The incidence rate ratio (IRR) was 0.67 (95% confidence interval (CI) 0.48 to 0.94; P=0.02), representing a 33% reduction in falls attributable to the intervention. This finding is statistically significant and, given the frequency and clinical consequences of falls in this population, constitutes a clinically considerable effect.

A distinction requires emphasis here. The primary outcome measured rate of falls, which captures the total number of fall events across the observation period. The secondary outcome measuring the proportion of participants who experienced at least one fall did not reach statistical significance (absolute risk reduction 0.03, 95% CI -0.07 to 0.13; P=0.52). This divergence suggests that the intervention may have been particularly effective at reducing recurrent falls among those who did fall, rather than preventing first falls among those who would otherwise have remained fall-free. This interpretation has direct implications for patient selection in clinical practice. Clinicians may consider prioritising referral to interventions of this type for patients with a documented history of multiple falls rather than those experiencing first-time or infrequent falls.

Secondary Outcomes

Several secondary outcomes demonstrated statistically significant between-group differences in favour of the experimental group, and the magnitudes of these differences are worth examining individually.

Community participation, assessed using the Late Life Function and Disability Instrument disability limitation subscale, showed a mean difference of 3% (95% CI 1% to 6%; P=0.02). While the absolute magnitude appears modest, restrictions in community participation following stroke carry compounding consequences for mental health, social isolation, and physical deconditioning. Even incremental improvements in this domain carry population-level relevance.

Self-efficacy demonstrated a mean difference of 0.6 points (95% CI 0.2 to 1.0; P=0.004). Fall-related self-efficacy is a well-characterised mediator of activity restriction and fall risk in older adults, and its responsiveness to a six-month intervention supports the mechanistic plausibility of the observed fall rate reduction. Individuals who report greater confidence in their ability to perform activities without falling tend to remain more physically active, thereby maintaining the musculoskeletal and neuromuscular function that contributes to fall prevention.

Mobility outcomes were notable in their magnitude. Fast walking speed improved by a mean of 0.13 m/s (95% CI 0.06 to 0.19; P less than 0.001), and preferred walking speed improved by 0.06 m/s (95% CI 0.02 to 0.10; P=0.02). Walking speed is a robust proxy measure of overall functional capacity in older adults and stroke survivors, and the improvement in fast walking speed, in particular, approaches or exceeds the minimal clinically important difference thresholds reported in the stroke rehabilitation literature for comparable assessments.

Balance, measured using the Step Test, improved by a mean of 0.06 steps per second (95% CI 0.01 to 0.12; P=0.03). Balance impairment following stroke is a primary biomechanical contributor to fall risk, and its improvement alongside mobility gains supports the interpretation that the exercise component of the intervention produced genuine neuromuscular adaptations rather than behavioural adaptations alone.

Public Health Implications for Hawaii

Hawaii’s post-stroke population presents several characteristics that heighten the relevance of these findings. The state’s demographic profile includes a substantial proportion of residents aged 65 and older, a group in which stroke incidence and cumulative post-stroke disability are concentrated. Geographic dispersion across islands and within rural districts of Hawaii Island and Maui County creates access barriers to outpatient rehabilitation services that a home-based model partially circumvents. Community health worker infrastructure developed through the Hawaii Health Systems Corporation and federally qualified health centres may offer a pathway for adapting and scaling dyadic rehabilitation team models in island communities where specialist workforce availability is constrained.

The FAST trial’s intervention period of six months and its follow-up period of 12 months align with the care transition window during which Hawaii stroke survivors may be most susceptible to falls following discharge from inpatient or residential rehabilitation. State health department data indicate that falls represent one of the leading causes of injury-related emergency department visits among adults over 65, and stroke survivors constitute a disproportionate share of recurrent fallers within that cohort.

Healthcare providers in Hawaii treating community-dwelling stroke survivors should consider whether their current post-discharge protocols adequately address the multidomain fall risk profile documented in this literature. Single-discipline referral, typically to physical therapy alone, may not replicate the integrated dyadic model that characterised the FAST intervention and may therefore not achieve equivalent reductions in fall rate.

Methodological Considerations

Several methodological features of this trial merit consideration when interpreting the findings. The enrollment period spanned more than four years and crossed the 2020-2021 period of service disruptions associated with the COVID-19 pandemic, which may have differentially affected both intervention delivery and usual care access. The trial was conducted in Australia, where healthcare system structure and community rehabilitation resources differ from those in the United States. Generalisability to Hawaii’s population, which includes a high proportion of individuals of Asian and Pacific Islander ancestry, should be assessed with appropriate caution until replication in demographically comparable populations is available.

Additionally, the absence of a statistically significant difference in the proportion of fallers, despite a statistically significant reduction in fall rate, introduces complexity into the interpretation of clinical benefit. Providers should consider whether patients presenting for fall prevention counselling are more appropriately categorised as recurrent fallers or first-time fall risks,