Most people with idiopathic Parkinson’s disease (PD) live at home or in the community. A major aim of physical therapy is to enable them to remain at home safely for as long as possible [1–3]. Even though it is estimated that more than 7 million people worldwide have PD , there have been few investigations of the most effective home-based exercise and rehabilitation programs for those with this debilitating condition. Falls occur often in people with idiopathic PD as the disease progresses [5, 6], with fall rates of over 60% per annum reported [7, 8]. More than half of these individuals fall more than once every year [8–10]. It appears likely that the cognitive difficulties frequently associated with PD aggravate the risk of falling, particularly by impairing attention .
Potential injury is not the only adverse consequence of a fall. Falling may lead to a fear of falling [12, 13], which can in turn result in further falls [14, 15]. In people with PD, fear of falling has been associated with an increased risk of frequent falls . Falls often lead a person to reduce their activity levels [14, 17, 18], community ambulation  and their participation in outdoor activities , leading to loss of fitness and independence.
Falls not only compromise quality of life , but can sometimes impact negatively on caregiver quality of life, with reported issues including depression, sustained productivity losses, fear for their spouse, and injuries sustained in trying to prevent their spouse’s fall [22, 23]. The costs from health care service utilization following falls are also substantial . A recent study  found annual direct costs of medical care in the USA to be $US23,101 per person in people with PD and only $US11,247 in matched controls, noting that falls were substantial contributors to the difference.
There are several approaches to physical therapy that can be delivered within the home. One effective method, known as movement strategy training (MST), teaches the individual to compensate for the disabling movement disorders that occur in PD. Based on studies by Morris and Iansek [2, 26, 27], these strategies teach people to use attentional strategies to consciously bypass the basal ganglia, instead using the frontal cortex to initiate and execute functional activities. Motor performance is enhanced by the use of structured practice, which breaks down complex movement sequences into segments and focuses attention on each segment before practicing the activity as a whole. Additional components of MST are the mental rehearsal of forthcoming movements, conscious focus on the movement as it occurs, and the use of supplementary visual or auditory cues. While MST can improve the ability to move , its ability to prevent falls within the home and community has not yet been confirmed.
Progressive resistance strength training (PRST) is an exercise therapy that can increase the ability of muscles to generate force. Strength is reduced in many people with PD [29, 30] most likely because hypokinesia and aging lead to reduced physical activity and disuse. There is preliminary evidence that PRST for people with Parkinson’s can result in increased muscle strength and hypertrophy , improved walking ability  and enhanced balance [32, 33]. Although PRST has been shown to reduce falls in people with musculoskeletal conditions such as osteoporosis , it remains to be seen whether PRST can minimize falls and reduce injuries in people with PD who live at home.
Education packages about the causes and prevention of falls have successfully reduced falls incidence in older people without PD, both in acute and sub-acute care  and as part of a multi factorial intervention in community dwelling older people [36–38]. Because PD is more prevalent in the aged population, people with this chronic condition are likely to experience many of the same risk factors for falls as their contemporaries, suggesting that such education packages may also be effective. A study of PD by Sadowski et al.  found they had little knowledge of the risk factors specific to PD, despite having fallen. Falls prevention programs are arguably cost-effective [40, 41], warranting their evaluation in PD.
Preliminary evidence suggests that an integrated program of progressive resistance strength training, movement strategy training, physical activities, and falls education may reduce falls and disability and improve quality of life in those with PD [7, 42, 43]. Although these interventions have been investigated independently in the PD literature [44–46], the effects of combining them to provide an optimal package remain unclear. A recent report of an integrated program of group strength and balance exercises in 130 community dwelling people with PD did not identify a significant reduction in fall rates ; however, there were differences in the incidence rate ratio (IRR) of falls that may have been clinically meaningful (IRR 0.68 during intervention; 0.74 during follow-up). While the intervention utilized exercises previously prescribed for the frail elderly or older recurrent fallers, there was no focus on the specific difficulties encountered in PD, such as turning or gait initiation problems, and no falls education was provided.
Another randomized controlled trial of integrated therapy examined the effect of a 6 weeks home program on falls rate in a sample of 142 community-dwelling individuals with PD who reported falling in the previous year . The intervention of strengthening, flexibility, balance and gait exercises incorporated strategies on falls prevention and for gait initiation and compensation, but no specific falls education program. Despite the addition of some PD-specific activities, there was only a trend to fewer falls and injurious falls in the exercise group, although near falls and repeated falls were significantly decreased in that group.
Most previous trials of exercise therapy in PD have evaluated rehabilitation in the hospital  or outpatient clinic setting [47, 48]. Therapy provided in the home, such as by Ashburn et al. , rather than the clinic may be more appropriate for a relatively frail, generally elderly population as it is convenient, accessible and affordable. Obviating the need for travel may reduce stress on people with PD and the significant others in their lives. Home-based therapy may also allow for treatment of more disabled people, who would have difficulty travelling to a clinic. A less obvious benefit is the specificity of home training. Movement strategy training focuses on improving an individual’s movement difficulties, such as freezing when turning the corner into the bathroom. While practice in a clinical setting may aim to replicate the turn in direction and angle during treatment, only on-site training can be fully specific. There is some evidence that PD reduces the flexibility of motor learning, increasing the need for task-specific practice ; thus home-based therapy seems particularly suitable for people with this condition.
The primary aim of the current study is to investigate whether a short (6 weeks) integrated home rehabilitation program (IR) comprising progressive resistance strength training, movement strategy training and falls prevention education reduces falls incidence over 12 months when compared to a home-based control “life skills” group. Secondary aims are to examine the effects of the IR program on disability and quality of life relative to the control group, and to explore the outcome of injurious falls. An economic evaluation from the perspective of the health care system will be carried out alongside the clinical trial.