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International Journal of Gerontology 8 (2014) 143e146

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International Journal of Gerontology

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Original Article

Effects of Simple Balance Training on Balance Performanceand Fear of Falling in Rural Older Adults*

Ladda Thiamwong*, Jom SuwannoSchool of Nursing, Walailak University, Walailak, Thailand

a r t i c l e i n f o

Article history:Received 23 April 2013Received in revised form23 July 2013Accepted 14 August 2013Available online 19 August 2014

Keywords:balance performance,fear of falling,older adults,randomized controlled trial,simple balance training

* Conflicts of interest: All contributing authors dec* Correspondence to: Ladda Thiamwong, School of

Tasala District, Nakhon Si Thammarat Province 80161E-mail address: tladda@gmail.com (L. Thiamwong

http://dx.doi.org/10.1016/j.ijge.2013.08.0111873-9598/Copyright © 2014, Taiwan Society of Geria

s u m m a r y

Background: Poor balance is a major risk factor for falls and fear of falling, and exercise which specificallychallenges balance is the most effective intervention for preventing falls. This cohort study described theeffects of participation in a 3-month simple home-based balancing training program on measures ofbalance 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 SiThammarat Province, Thailand. The exercise group participated in a 3-month simple home-basedbalancing training program by trained nurses. Balance was measured by a functional reach test andtimed 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 significantdifference when compared to baselines for both the functional reach test and timed up-and-go test. Theresults also showed that the exercise group performed significantly better than the control group in thefunctional reach test and timed up-and-go test after 3, 6, 9, and 12 months. In addition, fear of falling wasreduced 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 ruralolder 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.

1. Introduction

Balance is a critical component of most activities of daily livingamong older adults. Good balance reach in older adults livingindependently, productively, and proactively is important inhousework, cooking, shopping, and travel1. Maintenance of abalanced independence is essential for staying healthy and for well-being. Poor balance is a major risk factor for falls, a leading causeof hospitalization and nursing home requirements; appropriateexercise improved balance and reduced falls in older adults2.Community-dwelling older adults with balance impairment hadtwo-fold increment risks for fall is associated with increased fallrisk in community-dwelling older adults with overall summary riskvalue 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 apublic health issue in many studies4e6. The FICSIT meta-analysis

lare no conflicts of interest.Nursing, Walailak University,, Thailand.).

tric Emergency & Critical Care Me

found that the overall effect of any kind of exercise training was a10% reduction in fall rates in the subsequent year. Balance trainingof any type reduced falls by 17%, and the multimodal interventionthat trained balance, strength, corrected environment, and medi-cations was the most effective FICSIT intervention5,7.

Several strategies have been tested to improve balance andreduce falls, including home-based interventions, center-basedinterventions, and self-selected sites of exercise8. Increasing evi-dence suggests that an exercise intervention program that includesstrengthening of the lower extremities and functional training suchas balance trainingwould improve the physical function and reducerisks of falling of older Adults9,10. In addition, previous studies havedemonstrated the effectiveness of a home-based strength andbalance program in several trials11e14. Home-based exercise pro-grams that included low-intensity strength and balance traininghave improved balance and reduced fall rates by about 40%compared to controls8.

In Thailand, there is a lack of research dealing with simple bal-ance training and a shortage of physical therapists for rural olderadults who have limited access to quality healthcare services andwhose needs are unmet. A simple home-based exercise program

dicine. Published by Elsevier Taiwan LLC. All rights reserved.

L. Thiamwong, J. Suwanno144

that is effective, safe, and acceptable to older people, led by trainednurses, and is sustainable in the long term may be needed. Wedeveloped a clinical practice guideline for a simple home-basedbalancing training among Thai rural older adults. This clinicalpractice guideline is composed of three steps including: (1)screening and assessing balance performances; (2) practicing thesimple home-based balance training; and (3) evaluating the bal-ance outcomes15. This cohort study aimed to evaluate the effects ofthis clinical practice guideline on measures of balance perfor-mances, as well as fear of falling, in rural older adults.

2. Materials and methods

2.1. Samples and recruitments

This was a randomized, controlled trial with a 1 year follow up.The participants included 104 older adults who were living in arural area of Tasala District, Nakhon Si Thammarat Province,Thailand. Potential participants were recommended to the study bytheir healthcare providers and an individual interview determinedeligibility 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 thana single point stick); (4) no cognitive impairment (testing by theChula Mental Test)16; (5) living in the community for 1 year; (6)ability to be contacted via telephone; and (7) willingness toparticipate in a 3-month simple balance training program.

The sample size calculation was based on the proportion ofolder people who fell once or more in a 12 month prospectivecommunity study, an expected reduction from 0.50 to 0.30, and 20%allowance for dropouts11. Potential participants were informedthere was an equal chance theywould receive the exercise programor act as a control. A total of 104 community-dwelling older adultswere selected from two villages and randomized into two groups:the exercise group, submitted for balance training; and the controlgroup, without intervention. The exclusion criteria for this inter-vention were: (1) cerebral vascular or cardiovascular accidents re-ported within the past 6 months; (2) acute liver problems or theactive phase of chronic hepatitis; (3) diabetic mellitus with a his-tory of hypoglycemic attack, with fasting levels of plasma glucoseconcentrations of � 200 mg/dL, or with complications such asretinopathy 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, ordementia diagnosed by a medical doctor and a recommendation bythis doctor that the participants be excluded. The study wasapproved by the ethical clearance committee on human rightsrelated to researches involving human individuals, Walailak Uni-versity (068/2009). The study was described in detail to eachparticipant before the intervention began, and informed consentwas obtained prior to their participation in this study.

2.2. Measurements

The balance functions which represent an ability to control theirbody mass stably were evaluated by the timed up-and-go test, andthe functional reach test. In the timed up-and-go test, the partici-pant was instructed to sit back in a firm, upright chair and then risefrom it without using his or her arms for support. It uses the timethat a person takes to rise from a chair, walk 3 m, turn around, walkback to the chair, and sit down. A score of � 14 seconds indicatesthat the personmay be at risk for falls17. In the functional reach test,participants stood next to a wall, unsupported, with their feet acomfortable distance apart and their dominant arm raised to 90shoulder flexion. They were asked to reach as far forward as

possible without overbalancing. Overbalancing was defined asneeding to take a step, requiring hands-on assistance to maintainbalance, or needing to lean against the wall. The distance of addi-tional reach was recorded (meters)18.

Fear of falling was evaluated using the Thai version of Falls Ef-ficacy Scale-International (Thai FES-I). It comprises 16 items and isused to assess concerns relating to basic andmore complex physicaland social activities. It has good reliability and validity in older Thaiadults. Cronbach's alpha overall for the Thai FES-I was 0.95 andmean inter-items correlation of the 16 items in FES-I was 0.6719.

2.3. Intervention

The intervention or training protocol consisted of a set ofbalancing exercises that progressed in difficulty. This trainingprotocol was constructed according to the American College ofSports 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 chainquadriceps 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 20repetitions of each balancing exercise, which took about 30 mi-nutes/session. They practiced the exercises until they couldperform them correctly. All received brochures and a DVDreminding them how to exercise daily at home15,20e22. The targetand intensity of training was individually set. The implementationof the exercise program was conducted and run by two trainednurses. The nurses, who had no previous experience in prescribingexercise, attended a 1 week training course run by a physiothera-pist. The trained nurses delivered the exercise program inconjunction with their work as district nurses. A series of site visitsand regular telephone calls were made by the supervising physio-therapist to assess and ensure quality control.

2.4. Statistical analyses

SPSS version 15 (SPSS Inc., Chicago, IL, USA) was used for statis-tical analysis. The significance level was set at p < 0.05. Baselinedemographic data, balance performance, and fear of falling werecompared using the Chi-square test for categorical variables andanalysis of covariance forcontinuousvariables. In addition,measuresof balance and fear of falling across the active intervention phasewere evaluated with repeated measures of analysis of variance.

3. Results

A total of 110 rural community-dwelling older adults completedthe initial assessment. Six participants were excluded because theydid not meet the inclusion criteria. At the end of the 12-weekintervention period of the trial, no participant withdrew from thestudy because of inability to commit to the exercises. Thus, 104participants could be completely followed up for 1 year. The meanage of the 104 study participants was 71.36 ± 8.49 years (range,60e96 years), and 64 were women. Table 1 presents the de-mographic data and medical comorbidities of the exercise andcontrol groups. The exercise and control groups did not differ indemographic data and comorbidities that may influence balance inolder adults. In addition, the exercise and control groups did notdiffer in age, balance performance, and Thai FES-I scores at theinitial assessment (Table 2). The results showed that the exercisegroup performed significantly better than the controls in both thefunctional reach test and timed up-and-go test. The distance ofadditional reach of the exercise group was increased significantly

Fig. 1. Comparison of the functional reach test between the exercise and controlgroups. 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.

Table 1Comparison of demographic data and medical comorbidities (n ¼ 104).

Variables Exercise group(n ¼ 52)

Control group(n ¼ 52)

p

n % n %

SexFemale 36 70.6 28 52.8 0.720Male 15 29.4 25 47.2

LiteracyIlliterate 13 25.0 7 13.5 0.213Literate 39 75.0 45 86.5

Marital statusMarried 28 53.8 18 34.6 0.075Single/divorced/separated 24 46.2 34 65.4

Living aloneYes 3 5.8 0 0 0.243No 49 94.2 52 100

Have financial problemYes 37 71.2 41 78.8 0.497No 15 28.8 11 21.2

Have stroke historyYes 6 11.5 1 1.9 0.112No 46 88.5 51 98.1

Use hypertensive drugsYes 22 42.3 13 25.0 0.096No 30 57.7 39 75.0

Use sedative or psychotic drugsYes 4 7.7 1 1.9 0.363No 48 92.3 51 98.1

No significant difference between the exercise and control groups at p < 0.05.

Falling in Rural Older Adults 145

when compared with baseline, after 3, 6, 9, and 12 months(p < 0.001). There was no statistically significant difference in thecontrol group after 3, 6, 9, and 12 months (p < 0.05) whencompared with baseline, as shown in Fig. 1. The time for per-formed timed up-and-go test of the exercise group was decreasedsignificantly when compared with baseline, after 3, 6, 9, and 12months (p < 0.001). There was no statistically significantdifference in the control group when compared with baseline,after 3, 6, 9, and 12 months (p < 0.05), as shown in Fig. 2. Inaddition, the Thai FES-I scores of the exercise group decreasedsignificantly when compared with baseline, after 3, 6, 9, and 12months (p < 0.001). The Thai FES-I scores indicated no significantdifference in the control group when comparing their baseline datawith additional data after 3, 6, 9, and 12 months (p < 0.05), asshown in Fig. 3.

4. Discussion

The results of this study demonstrated that a simple home-based balance training program is feasible for Thai rural olderadults, providing preliminary support to improve outcomes on anumber of balance performance measures and fear of falling. Theseimprovements are consistent with previous studies that haveshown benefits from the simple home-based balance training22,23.

Table 2Comparison 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 74.35 8.59 68.37 7.33 1.09 0.297Balance performancesFunctional reach test 5.63 0.68 5.54 0.89 1.03 0.312Timed up-and-go test 15.45 0.45 14.85 0.34 �0.94 0.631

Thai FES-I scores 31.46 9.28 29.69 7.25 3.15 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.

Additionally, 40% of the older adults who were involved in home-based exercise programs had a reduction in falls8.

The simple home-based balance training, as undertaken in thisstudy, tries to meet these criteria. To obtain benefits from balanceexercises, it is concluded that exercises should challenge balancereactions, be dynamic in nature, involve weight shift, be performedwithout upper limb support, be of moderate intensity, and beprogressive23. Improving balance and fear of falling may have im-plications for function and activity for older adults. These physicaland psychological changes may also be associated with increasedactivity levels, which were also evident in previous studies22e24. Anindividualized balance training home exercise program led bytrained nurses is feasible for the community-dwelling older adultsand may improve stability during walking and other functionalactivities. These improvements are consistent with previousstudies, which have shown that among relatively healthy olderadults, home-based exercise programs have greater adherencerates than groups-based community programs and are effective inimproving functional performance and balance in functionallyimpaired older adults25. In addition, supervision by a healthcareprofessional in home-based exercise demonstrated more positivehealth outcomes than in a comparable unsupervised program25.

All participants completed the program. When asked whetherthey were satisfied with the exercise, none of these reported dif-ficulty in completing the program. It is likely that the feasibility ofthe program is compromised by the response from these partici-pants; however, issues on motivation to undertake exercise mayrequire more focus. It is acknowledged that the study has twolimitations. Firstly, the sample size is small because of difficulty

Fig. 2. Comparison of the timed up-and-go test between the exercise and controlgroups. Significantly different compared to baseline in the exercise group atp < 0.001. Not significantly different compared to baseline in the control group atp < 0.05.

Fig. 3. Comparison of the fear of falling scores between the exercise and controlgroups. 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.

L. Thiamwong, J. Suwanno146

recruiting participants within the study period. This problem wasmagnified on measures, because of missing data. There is potentialbias in excluding participants with missing data from a specificanalysis, but when the mean substitution approach to managemissing data was performed, results remained unchanged. Sec-ondly, it is possible that factors other than balance training mayhave played a role in the lower fear of falling scores observed in theexercise group. The control group did not take part in an equivalentnon-balance training activity, so there is the potential that theeducational component of the program may have contributed tobehavioral changes and subsequent lower fear of falling scores re-ported in the exercise group.

In summary, an individualized balance training home exerciseprogram led by trained nurses is feasible for rural older adults andmay improve stability during walking and other functional activ-ities; however, these outcomes need to be evaluated within a cost-effectiveness analysis. This simple home-based balancing trainingwas safe, effective, and acceptable to older adults and healthcareproviders. It is likely that nurses are at the forefront of providingcommunity health services and play an essential role in the pre-vention of falls. Therefore, nurses must concentrate on assessingthe fall-prone older adults to identify the potential causes of a fall,especially balance impairment, and provide this effective strategyfor improving balance performance and fear of falling.

Acknowledgments

This project was funded by a grant from the National Grant andInstitute of Research and Development, Walailak University(WU53110). We are grateful for the older adults, caregivers andhealthcare providers who made this study possible.

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