International Journal of Gerontology 8 (2014) 143e146
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International Journal of Gerontology journal homepage: www.ijge-online.com
Original Article
Effects of Simple Balance Training on Balance Performance and Fear of Falling in Rural Older Adults* Ladda Thiamwong*, Jom Suwanno School of Nursing, Walailak University, Walailak, Thailand
a r t i c l e i n f o
s u m m a r y
Article history: Received 23 April 2013 Received in revised form 23 July 2013 Accepted 14 August 2013 Available online 19 August 2014
Background: Poor balance is a major risk factor for falls and fear of falling, and exercise which specifically challenges balance is the most effective intervention for preventing falls. This cohort study described the effects of participation in a 3-month simple home-based balancing training program on measures of balance performances and fear of falling in Thai older adults. Methods: The participants included 104 older adults who were living in a rural area of Nakhon Si Thammarat Province, Thailand. The exercise group participated in a 3-month simple home-based balancing training program by trained nurses. Balance was measured by a functional reach test and timed up-and-go test. Fear of falling was measured by Thai Falls Efficacy Scale-International (Thai FES-I). Results: After 12 weeks of balance training, the participants in the exercise group showed a significant difference when compared to baselines for both the functional reach test and timed up-and-go test. The results also showed that the exercise group performed significantly better than the control group in the functional reach test and timed up-and-go test after 3, 6, 9, and 12 months. In addition, fear of falling was reduced in the exercise group after 3, 6, 9, and 12 months. Conclusion: The simple home-based balance training program led by trained nurses is feasible for rural older adults and was safe, effective, and acceptable to older adults and healthcare providers. Copyright © 2014, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: balance performance, fear of falling, older adults, randomized controlled trial, simple balance training
1. Introduction Balance is a critical component of most activities of daily living among older adults. Good balance reach in older adults living independently, productively, and proactively is important in housework, cooking, shopping, and travel1. Maintenance of a balanced independence is essential for staying healthy and for wellbeing. Poor balance is a major risk factor for falls, a leading cause of hospitalization and nursing home requirements; appropriate exercise improved balance and reduced falls in older adults2. Community-dwelling older adults with balance impairment had two-fold increment risks for fall is associated with increased fall risk in community-dwelling older adults with overall summary risk value of relative risk 1.42 (1.08, 1.85) and odds ratio 1.98 (160, 2.46)3. Preventing falls by improving balance in older people has been a public health issue in many studies4e6. The FICSIT meta-analysis *
Conflicts of interest: All contributing authors declare no conflicts of interest. * Correspondence to: Ladda Thiamwong, School of Nursing, Walailak University, Tasala District, Nakhon Si Thammarat Province 80161, Thailand. E-mail address:
[email protected] (L. Thiamwong).
found that the overall effect of any kind of exercise training was a 10% reduction in fall rates in the subsequent year. Balance training of any type reduced falls by 17%, and the multimodal intervention that trained balance, strength, corrected environment, and medications was the most effective FICSIT intervention5,7. Several strategies have been tested to improve balance and reduce falls, including home-based interventions, center-based interventions, and self-selected sites of exercise8. Increasing evidence suggests that an exercise intervention program that includes strengthening of the lower extremities and functional training such as balance training would improve the physical function and reduce risks of falling of older Adults9,10. In addition, previous studies have demonstrated the effectiveness of a home-based strength and balance program in several trials11e14. Home-based exercise programs that included low-intensity strength and balance training have improved balance and reduced fall rates by about 40% compared to controls8. In Thailand, there is a lack of research dealing with simple balance training and a shortage of physical therapists for rural older adults who have limited access to quality healthcare services and whose needs are unmet. A simple home-based exercise program
http://dx.doi.org/10.1016/j.ijge.2013.08.011 1873-9598/Copyright © 2014, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
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L. Thiamwong, J. Suwanno
that is effective, safe, and acceptable to older people, led by trained nurses, and is sustainable in the long term may be needed. We developed a clinical practice guideline for a simple home-based balancing training among Thai rural older adults. This clinical practice guideline is composed of three steps including: (1) screening and assessing balance performances; (2) practicing the simple home-based balance training; and (3) evaluating the balance outcomes15. This cohort study aimed to evaluate the effects of this clinical practice guideline on measures of balance performances, as well as fear of falling, in rural older adults.
possible without overbalancing. Overbalancing was defined as needing to take a step, requiring hands-on assistance to maintain balance, or needing to lean against the wall. The distance of additional reach was recorded (meters)18. Fear of falling was evaluated using the Thai version of Falls Efficacy Scale-International (Thai FES-I). It comprises 16 items and is used to assess concerns relating to basic and more complex physical and social activities. It has good reliability and validity in older Thai adults. Cronbach's alpha overall for the Thai FES-I was 0.95 and mean inter-items correlation of the 16 items in FES-I was 0.6719.
2. Materials and methods
2.3. Intervention
2.1. Samples and recruitments
The intervention or training protocol consisted of a set of balancing exercises that progressed in difficulty. This training protocol was constructed according to the American College of Sports Medicine guidelines (2011)20 and other researches14,15,21,22. The simple home-based balance training program included: (1) emphasizing hip abductors and extensors strengthening exercise; (2) marching; (3) stepping over a bench; (4) closed kinetic chain quadriceps exercise; (5) standing up from a chair with arms folded; and (6) a tandem walk (walking heel-to-toe in a straight line). Participants were shown how to perform and asked to perform 20 repetitions of each balancing exercise, which took about 30 minutes/session. They practiced the exercises until they could perform them correctly. All received brochures and a DVD reminding them how to exercise daily at home15,20e22. The target and intensity of training was individually set. The implementation of the exercise program was conducted and run by two trained nurses. The nurses, who had no previous experience in prescribing exercise, attended a 1 week training course run by a physiotherapist. The trained nurses delivered the exercise program in conjunction with their work as district nurses. A series of site visits and regular telephone calls were made by the supervising physiotherapist to assess and ensure quality control.
This was a randomized, controlled trial with a 1 year follow up. The participants included 104 older adults who were living in a rural area of Tasala District, Nakhon Si Thammarat Province, Thailand. Potential participants were recommended to the study by their healthcare providers and an individual interview determined eligibility using the following criteria: (1) aged 60 years; (2) balance impairment (full tandem standing test < 10 seconds); (3) independent mobility (walks outdoors with no more support than a single point stick); (4) no cognitive impairment (testing by the Chula Mental Test)16; (5) living in the community for 1 year; (6) ability to be contacted via telephone; and (7) willingness to participate in a 3-month simple balance training program. The sample size calculation was based on the proportion of older people who fell once or more in a 12 month prospective community study, an expected reduction from 0.50 to 0.30, and 20% allowance for dropouts11. Potential participants were informed there was an equal chance they would receive the exercise program or act as a control. A total of 104 community-dwelling older adults were selected from two villages and randomized into two groups: the exercise group, submitted for balance training; and the control group, without intervention. The exclusion criteria for this intervention were: (1) cerebral vascular or cardiovascular accidents reported within the past 6 months; (2) acute liver problems or the active phase of chronic hepatitis; (3) diabetic mellitus with a history of hypoglycemic attack, with fasting levels of plasma glucose concentrations of 200 mg/dL, or with complications such as retinopathy or nephropathy; (4) systolic blood pressure > 180 mmHg or diastolic blood pressure > 110 mmHg at rest; and (5) diagnosis of heart disease, an acute orthopedic problem, or dementia diagnosed by a medical doctor and a recommendation by this doctor that the participants be excluded. The study was approved by the ethical clearance committee on human rights related to researches involving human individuals, Walailak University (068/2009). The study was described in detail to each participant before the intervention began, and informed consent was obtained prior to their participation in this study. 2.2. Measurements The balance functions which represent an ability to control their body mass stably were evaluated by the timed up-and-go test, and the functional reach test. In the timed up-and-go test, the participant was instructed to sit back in a firm, upright chair and then rise from it without using his or her arms for support. It uses the time that a person takes to rise from a chair, walk 3 m, turn around, walk back to the chair, and sit down. A score of 14 seconds indicates that the person may be at risk for falls17. In the functional reach test, participants stood next to a wall, unsupported, with their feet a comfortable distance apart and their dominant arm raised to 90 shoulder flexion. They were asked to reach as far forward as
2.4. Statistical analyses SPSS version 15 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. The significance level was set at p < 0.05. Baseline demographic data, balance performance, and fear of falling were compared using the Chi-square test for categorical variables and analysis of covariance for continuous variables. In addition, measures of balance and fear of falling across the active intervention phase were evaluated with repeated measures of analysis of variance. 3. Results A total of 110 rural community-dwelling older adults completed the initial assessment. Six participants were excluded because they did not meet the inclusion criteria. At the end of the 12-week intervention period of the trial, no participant withdrew from the study because of inability to commit to the exercises. Thus, 104 participants could be completely followed up for 1 year. The mean age of the 104 study participants was 71.36 ± 8.49 years (range, 60e96 years), and 64 were women. Table 1 presents the demographic data and medical comorbidities of the exercise and control groups. The exercise and control groups did not differ in demographic data and comorbidities that may influence balance in older adults. In addition, the exercise and control groups did not differ in age, balance performance, and Thai FES-I scores at the initial assessment (Table 2). The results showed that the exercise group performed significantly better than the controls in both the functional reach test and timed up-and-go test. The distance of additional reach of the exercise group was increased significantly
Falling in Rural Older Adults
145
Table 1 Comparison of demographic data and medical comorbidities (n ¼ 104). Variables
Exercise group (n ¼ 52)
Sex Female Male Literacy Illiterate Literate Marital status Married Single/divorced/separated Living alone Yes No Have financial problem Yes No Have stroke history Yes No Use hypertensive drugs Yes No Use sedative or psychotic drugs Yes No
Control group (n ¼ 52)
p
n
%
n
%
36 15
70.6 29.4
28 25
52.8 47.2
0.720
13 39
25.0 75.0
7 45
13.5 86.5
0.213
28 24
53.8 46.2
18 34
34.6 65.4
0.075
3 49
5.8 94.2
0 52
37 15
71.2 28.8
41 11
78.8 21.2
0.497
6 46
11.5 88.5
1 51
1.9 98.1
0.112
22 30
42.3 57.7
13 39
25.0 75.0
0.096
4 48
7.7 92.3
1 51
1.9 98.1
0.363
0 100
0.243
No significant difference between the exercise and control groups at p < 0.05.
when compared with baseline, after 3, 6, 9, and 12 months (p < 0.001). There was no statistically significant difference in the control group after 3, 6, 9, and 12 months (p < 0.05) when compared with baseline, as shown in Fig. 1. The time for performed timed up-and-go test of the exercise group was decreased significantly when compared with baseline, after 3, 6, 9, and 12 months (p < 0.001). There was no statistically significant difference in the control group when compared with baseline, after 3, 6, 9, and 12 months (p < 0.05), as shown in Fig. 2. In addition, the Thai FES-I scores of the exercise group decreased significantly when compared with baseline, after 3, 6, 9, and 12 months (p < 0.001). The Thai FES-I scores indicated no significant difference in the control group when comparing their baseline data with additional data after 3, 6, 9, and 12 months (p < 0.05), as shown in Fig. 3. 4. Discussion The results of this study demonstrated that a simple homebased balance training program is feasible for Thai rural older adults, providing preliminary support to improve outcomes on a number of balance performance measures and fear of falling. These improvements are consistent with previous studies that have shown benefits from the simple home-based balance training22,23.
Fig. 1. Comparison of the functional reach test between the exercise and control groups. Significantly different compared to baseline in the exercise group at p < 0.001. Not significantly different compared to baseline in the control group at p < 0.05.
Additionally, 40% of the older adults who were involved in homebased exercise programs had a reduction in falls8. The simple home-based balance training, as undertaken in this study, tries to meet these criteria. To obtain benefits from balance exercises, it is concluded that exercises should challenge balance reactions, be dynamic in nature, involve weight shift, be performed without upper limb support, be of moderate intensity, and be progressive23. Improving balance and fear of falling may have implications for function and activity for older adults. These physical and psychological changes may also be associated with increased activity levels, which were also evident in previous studies22e24. An individualized balance training home exercise program led by trained nurses is feasible for the community-dwelling older adults and may improve stability during walking and other functional activities. These improvements are consistent with previous studies, which have shown that among relatively healthy older adults, home-based exercise programs have greater adherence rates than groups-based community programs and are effective in improving functional performance and balance in functionally impaired older adults25. In addition, supervision by a healthcare professional in home-based exercise demonstrated more positive health outcomes than in a comparable unsupervised program25. All participants completed the program. When asked whether they were satisfied with the exercise, none of these reported difficulty in completing the program. It is likely that the feasibility of the program is compromised by the response from these participants; however, issues on motivation to undertake exercise may require more focus. It is acknowledged that the study has two limitations. Firstly, the sample size is small because of difficulty
Table 2 Comparison of age, balance performances, and fear of falling (baseline) (n ¼ 104). Variables
Exercise group (n ¼ 52)
Control group (n ¼ 52)
t
p
M
SD
M
SD
Age Balance performances Functional reach test Timed up-and-go test Thai FES-I scores
74.35
8.59
68.37
7.33
1.09
0.297
5.63 15.45 31.46
0.68 0.45 9.28
5.54 14.85 29.69
0.89 0.34 7.25
1.03 0.94 3.15
0.312 0.631 0.790
No significant difference between the exercise and control groups at p < 0.05. FES-I ¼ Falls Efficacy Scale-International; M ¼ mean; SD ¼ standard deviation.
Fig. 2. Comparison of the timed up-and-go test between the exercise and control groups. Significantly different compared to baseline in the exercise group at p < 0.001. Not significantly different compared to baseline in the control group at p < 0.05.
146
Fig. 3. Comparison of the fear of falling scores between the exercise and control groups. Significantly different compared to baseline in the exercise group at p < 0.001. Not significantly different compared to baseline in the control group at p < 0.05.
recruiting participants within the study period. This problem was magnified on measures, because of missing data. There is potential bias in excluding participants with missing data from a specific analysis, but when the mean substitution approach to manage missing data was performed, results remained unchanged. Secondly, it is possible that factors other than balance training may have played a role in the lower fear of falling scores observed in the exercise group. The control group did not take part in an equivalent non-balance training activity, so there is the potential that the educational component of the program may have contributed to behavioral changes and subsequent lower fear of falling scores reported in the exercise group. In summary, an individualized balance training home exercise program led by trained nurses is feasible for rural older adults and may improve stability during walking and other functional activities; however, these outcomes need to be evaluated within a costeffectiveness analysis. This simple home-based balancing training was safe, effective, and acceptable to older adults and healthcare providers. It is likely that nurses are at the forefront of providing community health services and play an essential role in the prevention of falls. Therefore, nurses must concentrate on assessing the fall-prone older adults to identify the potential causes of a fall, especially balance impairment, and provide this effective strategy for improving balance performance and fear of falling. Acknowledgments This project was funded by a grant from the National Grant and Institute of Research and Development, Walailak University (WU53110). We are grateful for the older adults, caregivers and healthcare providers who made this study possible. References 1. Judge JO, Schechtman K, Cress E. The relationship between physical performance measures and independence in instrumental activities of daily living. J Am Geriatr Soc. 1996;44:1332e1341.
L. Thiamwong, J. Suwanno 2. Sturnieks DL, George R, Fitzpatrick RC, et al. Effects of spatial and nonspatial memory tasks on choice stepping reaction time in older people. J Gerontology. 2008;63:1063e1068. 3. Muir SW, Berg K, Chesworth B, et al. Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: a systematic review and meta-analysis. J Clin Epidemiol. 2010;63:389e406. 4. O’Loughlin JL, Robitaille Y, Boivin J, et al. Incidence of risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137:342e354. 5. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Eng J Med. 1994;331:821e827. 6. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Eng J Med. 2003;348:42e49. 7. Howe TE, Rochester L, Jackson A, et al. Exercise for Improving Balance in Older People (Review): the Cochrane Collaboration. 4. 2008:1e20. Available at: http:// onlinelibrary.wiley.com/doi/10.1002/14651858.CD004963.pub3/abstract; jsessionid¼A38AAA4DA06A3A5C90E6641D4B11BD07.d04t01?deniedAccess CustomisedMessage¼&userIsAuthenticated¼false. Accessed 15.01.12. 8. Judge JO. Balance training to maintaining mobility and prevent disability. Am J Prev Med. 2003;25:150e156. 9. Barnett A, Smith B, Loard S, et al. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomized controlled trial. Age Ageing. 2003;32:407e414. 10. Liu-Ambrose T, Khan KM, Eng JJ, et al. Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: A 6-month randomized controlled trial. J Am Geriatr Soc. 2004;52:657e665. 11. Robertson MC, Devlin N, Gardner M, et al. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls: a randomized controlled trial. Brit Med J. 2001;322:697e701. 12. Silsupadol P, Shumway-Cook A, Lugade V, et al. Effects of single-task versus dual-task training on balance performance in older adults: a double-blind, randomized controlled trail. Arch Phys Med Rehabil. 2009;90:381e387. 13. Arai T, Obuchi S, Inaba Y, et al. The relationship between physical condition and change in balance functions on exercise intervention and 12-month follow-up in Japanese community-dwelling older people. Arch Gerontol Geriatr. 2009;48: 61e66. 14. Matsuda PN, Shumway-Cook A, Ciol MA. The effects of a home-based exercise program on physical function in frail older adults. J Geriatr Phys Ther. 2010;33: 78e84. 15. Thiamwong L, Suwanno J. Development of a Clinical Practice Guideline for Practicing a Simple Home-based Balancing Training Among Thai Rural Older Adults, Thailand. Nakhon Si Thammarat: Walailak University; 2012. 16. Jitapunkul S, Lailert C, Worakul P, et al. Chula mental test: a screening test for elderly people in less developed countries. Int J Geriatr Psych. 1996;11: 715e720. 17. Yim-Chiplis PK, Talbot LA. Defining and measuring balance in adults. Biol Res Nurs. 2001;1:321e331. 18. Weiner DK, Duncan PW, Chandler J, et al. Functional reach: a marker of physical frailty. J Am Geriatr Soc. 1992;40:203e207. 19. Thiamwong L. Psychometric testing of the Falls Efficacy Scale-International (FES-I) in Thai older adults. Songklanagarind Med J. 2011;29:277e287. 20. American College of Sport Medicine. Selecting and effectively using balance training for older adults; 2011. Available at: http://www.acsm.org/docs/ brochures/selecting-and-effectively-using-balance-training-for-older-adults. pdf. Accessed 20.05.13. 21. Gardner MM, Buchner DM, Robertson MC, et al. Practical implementation of an exercise-based falls prevention programme. Age Ageing. 2001;30:77e83. 22. Kuptniratsaikul V, Praditsuwan R, Assantachai P, et al. Effectiveness of simple balancing training program in elderly patients with history of frequent falls. Clin Interv Aging. 2011;6:111e117. 23. Sherrington C, Whitney J, Lord S, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56: 2234e2243. 24. Bird M, Hill KD, Ball M, et al. The long-term benefits of a multi-component exercise intervention to balance and mobility in health older adults. Arch Gerontol Geriatr. 2010;52:211e216. 25. Nelson ME, Layne JE, Bernstein MJ, et al. The effects of multidimensional homebased exercise on functional performance in elderly people. J Gerontol. 2004;59:154e160.
