Miller, Kenneth L. DPT; Magel, John R. PhD; Hayes, Joseph G. DPT
Falls are the leading cause of injury-related visits to emergency departments of hospitals in the United States and the primary etiology of accidental deaths in persons older than 65 years.1 More than a third of adults aged 65 years or older fall each year2,3 with economically costly and devastating physical, psychological, and social consequences.4 Several studies5,6,7,8 on falls and balance deficits have reported that physical therapy intervention has reduced falls risk and improved balance in debilitated and medically compromised older adults, but few have actually provided definitive treatment protocols. Following physical training in institutionalized subjects, Rydwik et al5 reported improvements in muscular strength, mobility and range of motion), but conflicting results on gait, balance, activities of daily living, and endurance. These authors stressed the need for further studies that would evaluate specific intervention protocols with more clinically relevant outcome assessments such as endurance and activities of daily living. Other researchers8 have shown improvements in balance and reductions in falls risk in community-dwelling older adults with supervised group exercise and complementary home exercise programs.
Several authors1,9,10,11 agree that the cause of falling is multifaceted and consists of both intrinsic and extrinsic risk factors. Intrinsic factors include age-related or disease-induced physiologic and perceptual/cognitive impairments, while extrinsic risk factors include the use of multiple medications, level of care, history of falls, and environmental hazards.1,9,11 It also appears that the number of preexisting risk factors for falls may dramatically affect falls outcomes. In fact, Tinetti et al12 reported an increase in falls risk from 8 to 78% when the number of preexisting risk factors increased from 0 to 4 or more, respectively.
Physical therapy intervention can have a positive influence on several modifiable risk factors including muscle weakness and deficits in balance and gait.5,6,8,11,13 Brown et al13 indicated that targeting falls risk factors is effective, and suggested that prevention strategies should be incorporated in rehabilitation treatment plans in clinical practice.
Balance, defined by Shumway-Cook and Woollacott14 as the ability to maintain the body's center of mass over its base of support, can be 1 of 2 types, static or dynamic. Static balance has been described as the ability to control postural sway during quiet standing, and dynamic balance as the ability to anticipate and react to changes in body movement.11 Skelton and Dinan6 recommended training postural muscles and dynamic balance as a means to reduce the risk of falls in older adults. Their balance-training program included freestanding partial support while performing dynamic movement in the opposite lower extremity and strengthening the postural muscles. In addition, investigators have demonstrated the relationship between strength and balance5,8 and strength and gait,6 indicating that increases in strength may also be accompanied by increases in balance and gait. Therefore, the present study focuses on assessment of balance and gait rather than strength, assuming that improvements in balance and gait performance may also indicate improvements in strength.
The key to balance training is to maintain the center of gravity over the base of support while engaging the somatosensory, visual, and vestibular systems.9 The Central Nervous System mediates sensory input or conflicts among the three sensory systems. The vestibular and visual systems work in conjunction to stabilize the eyes and maintain posture during walking. Silsupadol et al4 have reported that balance training enhances motor function through ankle, hip, and stepping movement strategies that depend on coordination of both motor and sensory system functions.
While several studies5,6,7,8 on falls and balance deficits have reported that physical therapy intervention has improved balance and reduced falls risk in patients with Parkinson's disease, stroke, and orthopedic limitations, few have provided definitive treatment protocols that can be recommended to physical therapists engaged in home care practice as a clinically effective intervention for debilitated, but ambulatory community-dwelling older adults with gait and balance deficits. The purpose of this pilot study was to evaluate the effects of a specific 4-week standing exercise and balance training program on balance confidence, balance performance, and gait in debilitated, but ambulatory community-dwelling older adults that can be recommended and implemented by physical therapists in home care practice.
A total of 14 debilitated but ambulatory community-dwelling older adults, 9 male and 5 female, between the ages of 71 and 85 years were recruited from the lead investigator's practice as assigned by 2 nonprofit certified home care agencies. Participants were included if, following an initial physical therapy examination, they were found to possess any of the following risk factors for falling, including polypharmacy, 3 or more medical diagnoses, and a history of falls. However, individuals were excluded if they were nonambulatory, had a past medical history of any neuromuscular disorder, cognitive, vestibular, or visual impairment that would have limited their ability to participate in the study. In addition, individuals who indicated 4/10 or greater (moderate pain and higher) on the Pain Numerical Rating Scale15 were also excluded. Individuals who met the inclusion criteria were asked to sign a statement of informed consent prior to participation in this study. The Institutional Review Board of Touro College approved both the present study and the informed consent document.
Following selection for the study, each participant was evaluated on 3 standardized measurements including the Falls Efficacy Scale (FES), the Performance Oriented Mobility Assessment (POMA), and the One-Leg Stance Test (OLST). All participants received the same testing protocol prior to and following exposure to the 4-week standing exercise and balance training program.
Falls Efficacy Scale
The FES is a self-reporting questionnaire that attempts to associate fear of falling with balance confidence. The FES was chosen because it assessed confidence in a variety of balance activities since psychological trauma, sometimes called fear of falling, may result in a self-imposed decline in activity and function not necessitated by the extent of physical disability or injury.16,17 The FES contains 10 activities or functional tasks that are self-rated on a scale from 1 to 10 with 1 indicating extreme confidence and 10 absolutely no confidence. The overall score ranges from 10 to 100 with lower scores indicating less fear of falling or greater balance confidence. The FES has demonstrated fair (r = 0.71)16 to good (intraclass correlational coefficients [ICC] = 0.88)18 test-retest reliability and good internal consistency (Cronbach α = .90).19
Performance Oriented Mobility Assessment
The POMA, a measure of balance and gait performance commonly referred to as the Tinetti, was developed in 1986 by Tinetti.20 It is a 2-part test that consists of balance and gait sections. Subjects are asked to carry out a variety of routine functional tasks necessary for safe independent movement. The balance section contains 9 routine functional tasks scored as 0, 1, or 2. Total balance scores range from 0 to 16 with higher scores indicating better balance. The gait section contains 7 routine functional tasks also scored as 0, 1, or 2. Total gait scores range from 0 to 12, with higher scores indicating better gait. The overall maximum score on the POMA is 28. In addition, as reported by Lin et al,21 the POMA has demonstrated good intrarater and interrater reliability (test-retest ICC = 0.93–0.99) as well as fair to moderate convergent validity with Functional Reach (r = 0.48), Timed Up and Go (r = −0.55), walking speed (r = −0.54), and activities of daily living scales (r = 0.60). Thomas and Lane22 have reported good intrarater reliability (ICC = 0.84), sensitivity, and specificity for predicting falls risk using the balance section of POMA.
One-Leg Stance Test
The OLST, selected as a measure of balance performance, determines the time that a participant is able to balance on one leg, eyes open, with the arms folded across the chest for as long as possible without using the arms or any other support for balance or stability. Using a stopwatch, the clinician determines the length of time in seconds that the subject can stand on one leg. The clinician stops the watch when the subject's foot either touches the floor or makes contact with the other leg or the patient moves his or her stance foot to create a new base of support or moves arms out of testing position.23,24 The OLST, a simple test administered in only a few minutes, has been reported to have good interrater and intrarater reliability (ICC = 0.93–0.99), but poor convergent validity as OLST was not well correlated with any other balance measures.21 Giorgetti et al23 reported interrater reliability for the OLST to be higher in community-dwelling older adults with disability (ICC = 0.85) than in those without disability (ICC = 0.75). In frail older patients, the intrarater reliability for the OLST as reported by Thomas and Lane22 was even lower (ICC = 0.69) but may be specific to this population. To compensate for the potential variability of the OLST performance in the present study, participants were given a practice trial on each leg followed by two trials on the more stable leg as determined by participant preference. The average of these two trials was used as the OLST score for each participant in the data analysis.
This pilot investigation utilized a quasi-experimental single group pre-to posttest design in 14 debilitated but ambulatory community-dwelling older adults. All participants were evaluated on balance confidence, balance performance, and gait utilizing the FES, POMA, and OLST standardized tests as described previously. All tests were administered by the participant's physical therapist (lead investigator) on the initial and final visits using identical testing procedures. The test administrator did not review pretest data prior to or during the posttest data collection period. In addition, entrance and exit interviews were conducted to determine participant's history of falls in the 6 months prior to, during, and at the conclusion of the study.
All participants performed the standing exercise and balance training program in their home environment, 1 hour per session, twice per day, 5 days per week for 4 weeks. The exercise protocol focused on improving balance confidence, balance performance, and gait. All participants were given an exercise program consisting of 4 standing exercises, including partial squats, heel raises, hip abduction, and hip flexion, and 6 balance training exercises, including side-stepping, tandem walking, retro-walking, braiding crossovers, one-leg stance, and standing external perturbation, which are more fully described in Table 1. All standing exercises were performed with each leg alternately for 3 sets of 10 repetitions each. Following the standing exercise routine and a brief 3-to 5-minute rest period, all participants engaged in the balance training program. Side-stepping, tandem walking, retro-walking, and braiding crossovers were performed for 3 laps of 20 ft each for a total of 60 ft. The one-leg stance with cup tapping was performed with each leg alternately for 3 trials of 1 minute each. The external perturbation required participants to stand motionless on both legs while receiving mild external perturbation for 3 trials of 1 minute each. All standing and balance training exercises utilized blocked practice principles, except for the standing perturbation exercises, which employed variable practice principles that allowed force to be applied in varying directions and magnitudes.14
Table 1Standing Exer...Image Tools
The prescribed home-based exercise program was supervised by caregivers (family members) who were trained by the physical therapist to assist participants in the performance of all standing and balance training exercises on the days and times that their physical therapist was not present to improve compliance and ensure safety. In addition, all participants maintained exercise logs that were checked weekly by the treating physical therapist to ascertain compliance with the home exercise program.
In addition to the exercises listed in Table 1, all participants received instruction in safety awareness, use of durable medical equipment, bed mobility, transfer, and ambulation, and stair climbing techniques where applicable as part of routine home physical therapy care to maximize safety in the home environment.
The software program Microsoft Office Excel 2003 Small Business Edition (©1985–2003) was used for statistical calculation of all descriptive data (subjects' physical characteristics, FES, POMA, and OLST scores) and reported as means, standard deviations, and standard errors of the mean. Analyse-It, a software program for Microsoft Excel General + Clinical Laboratory Statistics version 1.73 (©1997–2000), was used for the nonparametric analysis (pre-to posttest comparisons for FES and POMA qualitative data) with the Wilcoxon signed rank test, and the parametric 2-tailed analysis (pre-to posttest comparisons for OLST quantitative data) with the paired t test, respectively. Statistical results were verified by the use of the Stats Direct Ltd Statistical software program version 2.5.7 8/7/06 (©1990–2005). Statistical significance was set at P ≤ .05 for all statistical comparisons.
The anthropometric characteristics of the participants are presented in Table 2. The heights and weights are typical for male and female participants in these age ranges.25 All 14 participants were “home-bound” at the time of their acceptance into the study, and 6 of 14 participants reported at least 1 fall in the 6 months prior to their acceptance into the study. Two participants had a history of 2 or more falls in the same time period with one participant having fallen 14 times in the 3 months prior to the study. Most participants reported an unsteady gait and a lack of confidence in their ability to maintain balance during ambulation.
Table 2Anthropometri...Image Tools
Comparison of the pre-to posttest changes in the FES scores, Total POMA scores and the POMA Balance, and Gait Sub-Section scores as well as the OLST times are shown in Table 3. Mean FES values, as well as individual FES scores, decreased (ie, improved) by an average of 22.4 points, or 9% to 79%, following exercise and balance training, as shown in Tables 3 and 4, respectively. Statistical analysis with the Wilcoxon signed rank test demonstrated significant improvement (P < .01) in balance confidence as measured by the FES scores.
Total (overall) POMA scores, as well as the POMA Balance and Gait Sub-Section scores, increased on average by 7.0 (6%-100%), 4.0 (11%-133%), and 3.1 points (13%-200%), respectively, following exercise and balance training, as shown in Tables 3, 4, and 5. Statistical analysis with the Wilcoxon signed rank test demonstrated significant improvement (P < .01) in balance performance and gait as measured by the Total and subsection POMA scores. Only 1 participant did not improve in the POMA Gait Sub-Section test.
Table 5Percent Impro...Image Tools
Mean OLST times, as well as individual OLST times, increased by an average of 2.2 seconds, or 6% to 322%, following exercise and balance training, as shown in Tables 3 and 4, respectively. Statistical analysis with the 2-tailed paired t test demonstrated a significant improvement (P < .05) in one-leg stance balance performance as measured by the OLST times.
During exit interviews following the 4-week exercise and balance training program, all 14 participants subjectively reported more stable gait and indicated improved confidence in their ability to maintain balance during ambulation, and only 2 of 14 participants reported a single, minor fall during the 4 weeks of the exercise program. One of the 2 participants was the same individual who reported 14 falls in the 3 months prior to participation in the study. In addition, all 14 participants reported that they were no longer “home-bound” but were able to leave their home to visit family, dine out with friends, and attend various social activities. On the basis of a careful review of the exercise logs, it appeared that all participants were 100% compliant with the 4-week home-based standing exercise and balance training program.
As stated previously, the purpose of the present study was to evaluate the effects of a specific 4-week standing exercise and balance training program on balance confidence, balance performance, and gait in debilitated, but ambulatory community-dwelling older adults.
It has been well documented that physical therapy intervention has been highly effective in reducing falls and increasing balance in the frail older population.26,27,28,29,30,31 The results of the present study demonstrated improved balance confidence, balance performance, and gait in 14 debilitated, ambulatory community-dwelling older adults. The exercise program incorporated static balance activities with and without external perturbation, dynamic balance exercise in multidirectional planes while varying the base of support, and strengthening exercises for postural and core trunk musculature. Many of these exercises are commonly used by physical therapists in home care practice for debilitated or deconditioned community-dwelling older adults.5,6,11 However, it should be noted that several participants reported episodic transient mild pain, and one participant exhibited periodic shortness of breath, that may have impeded their ability to perform all exercises at the prescribed frequency and duration.
The FES, POMA, and OLST selected for this study are frequently used as assessment tools by physical therapists in home care practice with this population. The significant reduction (ie, improvement) in the mean FES scores (from 38.9 to 16.5) may indicate an increased balance confidence. In addition, there was direct observational evidence and individual reports to suggest that participants were more mobile and better able to perform tub and bed transfers and negotiate stairs. Improved safety awareness was also observed with the removal of hazards in the home environment. Functional balance and gait quality may also have improved as indicated by the significant increase in the mean Total POMA scores (16.2–23.2). This was supported by significant improvements in the average POMA Balance (9.6–13.6) and POMA Gait (6.5–9.6) Sub-Section scores. In all but one of the participants, the total POMA score rose above 19. This may suggest a reduced likelihood of falling, since Tinetti et al12 have reported that Total POMA scores of less than 19 were predictive of falls in older adults. In addition, observational and objective evidence suggest that participants also demonstrated better ability to maintain balance while sitting, standing, turning, ambulating, rising from a chair, and responding to a variety of external perturbations.
Interestingly, despite all participants being “home bound” with only 3 venturing outside upon admission, all 14 participants were ambulating outdoors using appropriate assistive devices upon discharge from the agency. It also does not appear that any seasonal or weather-related effects kept participants “home-bound,” since the study took place during the summer and early fall. Even though the OLST proved to be the most difficult test to perform for all participants, they significantly improved their average one-leg stance balance times from 2.9 to 5.1 seconds. Participants, who were initially able to stand on one leg the longest, improved the most. The OLST scores reported in this study were similar to values reported for debilitated older adults,21 lower than those reported for nondebilitated older adults,23,32 and higher than OLST times reported for frail elderly patients.22
Limitations of the Study
The present pilot investigation utilized a quasi-experimental, single-group pre-to posttest design that contained several inherent limitations including lack of a control group, relatively small sample size, and the possibility of research bias, since the investigator in this study was not blinded to data collection. Since the present study was conducted as part of regular physical therapy home care, the level of control was not as rigorous as that required for true experimental designs. In addition, considerable variance in some of the standardized test scores should caution clinicians in the potential application of the present results to larger populations of debilitated, ambulatory community-dwelling older adults.
The results of the present pilot study demonstrated improvement in balance confidence, balance performance, and gait in 14 debilitated, ambulatory, community-dwelling older adults following participation in a 4-week home-based exercise and balance training program. Further studies need to be carried out to establish reliable, reproducible, and valid assessment tools for clinical evaluation of balance deficits and falls risk. In addition, it is important to establish specific treatment protocols for exercise and balance training to reduce falls risk and improve falls prevention in community-dwelling older adults. In this way, the physical therapy profession will be able to provide clinical guidelines for effective treatment and training protocols that may improve the quality and effectiveness of patient care and improve the level of evidence-based practice.
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balance confidence; balance performance; balance training; debilitated community-dwelling older adults; gait; home-based exercise