A practical solution for preventing falls after stroke

Falls are one of Australia’s most serious and costly public health problems, and the leading cause of injury related hospitalisation and death among people aged 65 years and over. Each day, around 16 older Australians die following a fall and 400 are hospitalised. Fall‑related injuries in older Australians cost the health system more than $2 billion annually, with additional impacts on rehabilitation, aged care and informal caregiving.

For the 440 000 Australians living with stroke‑related disability, the risk and costs of falls are even greater: after stroke, people fall at up to twice the rate of the general older population, often resulting in serious injury, reduced confidence, social isolation and premature loss of independence.

The challenge of reducing falls after stroke is compounded by a lack of access to ongoing support (including allied health). Stroke survivors feel abandoned in the months and years following the stroke. If they choose to re-engage, they must navigate Australia’s complex and disjointed health and disability systems.

Falls prevention has remained a major gap in post stroke care. No previous intervention had been shown to prevent falls after stroke, and falls have often been viewed as an inevitable consequence.

The Falls After Stroke Trial

The Falls After Stroke Trial (FAST), recently published in the BMJ, is set to change all that: it’s the first effectiveness trial worldwide to demonstrate that falls after stroke can be prevented.

Beginning in 2019, FAST recruited 370 community-dwelling stroke survivors aged over 50 and within five years of their first stroke across New South Wales, Victoria and the ACT and randomised them to usual care or a six-month, home-based intervention.

The intervention was delivered by occupational therapist–physiotherapist dyads and combined three components: habit‑forming functional exercise using the Lifestyle‑integrated Functional Exercise (LiFE) program; targeted home hazard reduction; and goal‑directed community mobility coaching. Importantly, the program was tailored to the participant’s level of stroke‑related disability, with the components prioritised according to mobility.

The fall rate was reduced by 33% in participants randomised to the FAST intervention compared with the group receiving usual care, and these changes were accompanied by clinically meaningful improvements in balance, walking speed, confidence and community participation.

Previous trials aimed at preventing falls after stroke have largely relied on conventional exercise programs or home modification alone, resulting in poor adherence and no significant reduction in falls. A systematic review and meta‑analysis of exercise-based programs showed a trend toward lower post-stroke fall rates compared with no or sham intervention, but estimates were imprecise, and effects varied. FAST showed the most robust reduction in falls, highlighting the trial’s importance and its capacity to transform the falls prevention landscape.

FAST addressed previous limitations by embedding balance challenging exercise into everyday activities, reframing exercise as a habit rather than homework; adherence was high, with more than 85% of participants completing all sessions.

The intervention was also pragmatic and relatively low cost, delivered through seven initial home visits, three booster visits and two phone calls over six months, using simple equipment and home modifications.

FAST Forward: from evidence to access

Health professionals need to be alert to the risk of falls when assessing and treating stroke survivors and ensure referrals are made to ongoing allied health support, prioritising evidence-based falls reduction programs like FAST.

Current Australian and New Zealand stroke guidelines do not yet include clear evidence for preventing falls after stroke, but this is likely to change given the strength of the FAST evidence. Guideline inclusion is essential to reposition falls prevention as a core component of long-term recovery rather than an optional add‑on.

However, providing access to effective falls prevention will require more than guideline endorsement. A Phase 4 implementation study is needed to facilitate widespread adoption into real world settings. Workforce upskilling for physiotherapists and occupational therapists in the FAST model of care will be a critical part. Training in the LiFE program and home hazard identification components are currently available. Further, the FAST study adaptations for stroke, collaborative approach, goal setting and resources will enable progression to implementation.

Conclusion

Falls after stroke are not an unavoidable consequence. High‑quality evidence now shows that a practical, home‑based intervention embedded in daily life can reduce falls and improve outcomes.

The question is no longer whether falls after stroke can be prevented, but whether we will act on the evidence to ensure stroke survivors have access to care that reduces avoidable harm and supports long‑term independence.

Associate Professor Katharine Scrivener is a physiotherapy clinician-researcher specialising in stroke rehabilitation at Macquarie and Monash Universities.

Dr Sally Day is an early career researcher and occupational therapy academic at the University of Sydney.

Professor Catherine Dean is a physiotherapist and leading stroke researcher and educator she is currently and Deputy Dean Education and Employability in the Faculty of Medicine Health and Human Sciences at Macquarie University.

Emeritus Professor Lindy Clemson is an occupational therapist from the University of Sydney and international research leader in falls prevention and public health research in ageing.

Professor Natasha A. Lannin is an occupational therapist clinician-researcher with a joint appointment at Bayside Health and Monash University, where she is the Head of the Brain Recovery and Rehabilitation Research group in the School of Translational Medicine.

Funding: The FAST trial was funded by the National Health and Medical Research Council, Australia (Project Grant #1157739). NL is supported by the Heart Foundation (Australia, grant #106762).