Geriatric Nursing xx (2015) 1e5
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Feature Article
Effectiveness of a balance-training program provided by qualified care workers for community-based older adults: A preliminary study Tatsuya Hirase, PT, PhD a, b, Shigeru Inokuchi, PT, PhD c, *, Nobuou Matsusaka, MD, PhD c, Minoru Okita, PT, PhD b a
Geriatric Health Services Facility, Gaianosato, 2314-1 Otsu, Aino-cho, Unzen, Nagasaki 854-0302, Japan Department of Locomotive Rehabilitation Science, Unit of Rehabilitation Sciences, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan c Department of Health Sciences, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 November 2014 Received in revised form 4 February 2015 Accepted 7 February 2015 Available online xxx
The purpose of this study was to determine the effectiveness of a balance-training program provided by qualified care workers (QCWs) to community-based older adults attending day centers. Weekly balance training was conducted by QCWs working at day centers over a 6-month period. Fall risk factors, fear of falling, and physical function were compared between balance-training (n ¼ 22) and control (n ¼ 23) groups at baseline and after 6 months of intervention. Physical function assessments included the following: one-leg standing test, chair-standing test (CST), timed up-and-go test (TUGT), and a lowerextremity muscle strength test (LEST). Participants who underwent balance training significantly improved in the CST and LEST, and had reduced fear and risk of falling compared with the control group (p < 0.05). In the balance-training group, the TUGT was significantly better at 6 months than at baseline (p < 0.05). A balance-training program for community-dwelling older adults can be effectively implemented by QCWs. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Balance training Older adults Qualified care workers
Introduction Falls and fall-induced injuries are common in older adults in all countries, and aging populations increase the fall-related burden and cost to health care systems.1 Falls that do not result in injury often begin a downward cycle of fear, which leads to inactivity and decreased strength, agility, and balance.2 Many studies have identified risk factors for falls; poor balance and muscle weakness have been associated with an increased risk of falling in older adults.3 Physical functions, such as balance and lower-extremity muscle strength, can predict falls in community-dwelling older adults.4 Therefore, the aging-associated deterioration of physical function that occurs in older adults is a major risk factor for falls. Exercise programs aimed at improving balance and muscle strength have been conducted for community-dwelling older adults.5e9 We previously reported that a balance-training program
Conflicts of interest and source of funding: The authors declare no conflicts of interest or sources of funding. * Corresponding author. Tel./fax: þ81 95 819 7962. E-mail address: [email protected] (S. Inokuchi). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.02.005
performed using a foam rubber pad and supervised by physiotherapists effectively improved balance over a 2-month period, which was faster than the improvements seen with balance training on a stable surface.10 Additionally, balance-training effectively improved lower-extremity muscle strength and reduced the fear of falling, which suggests that our balance-training program is effective for improving physical function. In Japan, the number of frail older adults living in the community has increased, and physical deterioration has been reported to be the main reason for their frailty.5 Consequently, exercise classes are often provided for this population group to improve physical function and activity levels5,10; however, there are a limited number of physiotherapists working in the community who are available to supervise these classes.5,11 Therefore, the development of an effective exercise program that can be conducted by nonphysiotherapists is urgently needed. Qualified care workers (QCWs) are a valuable resource because they provide the vast majority of care services for frail older adults in Japanese community day centers and residential facilities.12 They have the professional skills to provide support to disabled adults. There are several differences between QCWs and nurses. First,
2
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Fig. 1. Number and origin of the participants in each group.
licenses in direct care working are held by QCWs and homehelpers; unlike nurses, QCWs do not hold a professional specialization. Second, medical practice by QCWs is prohibited, except for suction and gastrostomy tube feeding of residents in special nursing homes. Nurses are more likely to perform medical procedures, although QCWs handle the day-to-day care of frail older adults and disabled adults.13 There are fewer nurses than QCWs in community day centers and residential facilities. In communities with a shortage of physiotherapists and nurses, the role of QCWs working in community day centers could include leading exercise classes for frail older adults. Previous studies have reported that exercise programs provided by public health nurses, trained and supervised by physiotherapists, improved physical function in older adults5,14; however, it is unclear whether exercise programs provided by QCWs are effective. If successful, such programs would benefit both clients and service providers because they would not only improve the physical function of older adults, but would also reduce the amount of supervision required by physiotherapists in the community. Thus, the present study tested the hypothesis that a balance-training program for older adults, conducted by QCWs, would effectively improve balance and lowerextremity muscle strength, which are risk factors for falls.
Methods Participants The study participants were older adults using community day centers once or twice a week. We selected four day centers supported by a senior physiotherapist. QCWs at each day center were asked to choose potential participants who were over 65 years old, lived at home, were able to walk with or without a cane, and had at least four risk factors for falls as identified using the questionnaire for fall-assessment described by Suzuki.15 This questionnaire consists of 15 items and has been shown to predict falls with a sensitivity and specificity of 59.4% and 83.1%, respectively. We defined older adults with at least four risk factors for falling as high-risk fallers.16
Participants were excluded if they had participated in exercise at least four times in the month prior to the intervention or if they had musculoskeletal, neurological, or cardiovascular disorders that could be aggravated by exercise. Participants were also excluded if cognitive impairment rendered them unable to respond to interview questions. A flowchart outlining study participation is shown in Fig. 1. In all, 112 potential participants were identified. Of these, 22 refused to participate in the study and 45 did not meet the inclusion criteria. Of the 45 potential participants who were excluded, 11 had severe musculoskeletal or cardiovascular disorders and 34 had exercised regularly four or more times in the month before the initial interview. The remaining individuals (n ¼ 45) were enrolled in the study and were assigned to either the balance-training group (n ¼ 22) or the control group (n ¼ 23). Written informed consent was obtained from each participant in accordance with the guidelines of the Nagasaki University Graduate School of Medicine and the Declaration of Helsinki. Study design We chose a multi-center controlled trial for this study because we had concerns regarding the potential difficulty of enrolling participants into the control group owing to the general popularity of exercise classes among frail older adults.5 Furthermore, we wanted to determine the feasibility of conducting exercise classes in the participants’ communities. The four day centers were nonrandomly assigned to either a balance-training group (two centers) or a control group (two centers). Assignments were made in such a way as to keep the number of participants in the two groups as similar as possible. The physiotherapists supporting the day centers assessed the participants’ physical function, and the QCWs working at the day centers implemented the intervention program. Intervention Participants in the balance-training group attended a 1-h exercise class once weekly for 6 months. All classes consisted of 10 min of warm-up exercises, 40 min of balance training, and 10 min of
T. Hirase et al. / Geriatric Nursing xx (2015) 1e5
3
Table 1 Balance-training program. Exercise
Description
Double-stance standing
One-leg standing
Neck hyperextension Free-leg swinging
Heel and toe raises Neck and trunk rotation Touching the floor Walking in place Sideways walking Walking
Hold for 20 s. Repeat twice with eyes open, twice with eyes closed. Stand on one leg with the other foot placed midway up the calf. Hold for 10 s, if possible. Repeat three times on each leg, once with eyes open and twice with eyes closed. Stand while slowly hyperextending the neck and then tipping the head forward and down. Repeat five times with eyes open, five times with eyes closed. Stand on one leg while moving the other slowly to the front, side and back. Switch legs and repeat three times, then repeat again three times with eyes closed. Initially, participants may slide feet over the floor, but later in the class they should try to completely lift the leg off the floor. Rock slowly up onto the toes and hold, then roll back onto the heels and hold. Repeat three times with eyes open, three times with eyes closed. Stand while slowly rotating the neck and trunk. Repeat three times with eyes open. Touch the floor while squatting down. Repeat five times with eyes open. Walk in place for 20 s. Repeat twice with eyes open. Walk sideways, bringing the trailing foot just up to the lead one. Repeat five times with eyes open, traveling an approximately 7-m distance. Walk forwards without looking at the ground. Repeat five times with eyes open, traveling an approximately 7-m distance.
cool-down exercises. All exercise sessions consisted of training groups of approximately 10 participants led by two QCWs. A total of four QCWs participated in the study. All QCWs received training from the same senior physiotherapist prior to starting the trial; this training consisted of participating in a physiotherapist-conducted exercise session based on a program manual. Physiotherapists were available to provide help or advice to the QCWs, and sessions were videotaped to ensure the consistency of the balance training. The intensity of each 40 min balance-training session was constant for each individual throughout the intervention period. Participants took breaks totaling up to 10 min during the sessions, depending on their physical capacity. Therefore, no clinical decisions, such as changes in exercise intensity for individual participants, needed to be made by the QCWs during the intervention period. The balance-training program included 10 exercises performed in a standing position: double-stance standing, one-leg standing, neck hyperextension, free-leg swinging, heel and toe raises, neck and trunk rotation, touching the floor, walking in place, sideways walking, and walking (Table 1), as described previously.10 During the exercise sessions provided by the QCWs, the participants exercised while watching an instructional video demonstrating the exercises to be performed. The physiotherapists at the day centers observed the first QCW-provided exercise sessions to ensure their safety. All exercises were performed on a 6-cm-thick foam rubber pad measuring 50 40 cm (AirexÒ mat, Sakai Medical, Tokyo, Japan). To ensure the safety of the intervention program, the number of exercises performed on the foam rubber pad was gradually increased over time. During the first 2 months of the training program, participants performed double-stance standing, heel and toe raises and walking in place. During the next 2 months, neck hyperextension, free-leg swinging and neck and trunk rotation were performed in addition to the double-stance standing, heel and toe raises and walking in place. Finally, for the last 2 months, touching the floor, sideways walking, walking, and one-leg standing were added to the exercise regimen. Participants in both groups participated in weekly social programs, including recreational activities, educational programs, and tea breaks. They continued their daily activities at the day centers, but control group participants performed neither balance-training nor muscle-strengthening exercises at the centers or in a structured setting at home.
Assessment Physical function, risk factors for falls, and fear of falling were assessed. Before the study began, the physiotherapists at the day centers were trained in the assessment protocols by one of the authors (TH). Assessment of physical function included the following performance tests: the one-leg standing test (OLST),17 chair-standing test (CST),18 timed up-and-go test (TUGT),19 and lower-extremity muscle strength test (LEST). All performance tests except the LEST were conducted twice, and the best value from the two tests was recorded. The LEST measured maximal isometric knee extension using a hand-held dynamometer (Micro FET2, Nihon Medix, Chiba, Japan). The positioning of the participant and placement of the dynamometer were performed as described by Kato et al.20 Knee extensor strength was tested using a belt, with the participant in a sitting position and the hip and knee flexed at an angle of 90 . Three LEST tests were performed three times for each leg, and the best value for each leg was recorded (expressed in Nm/kg). Risk factors for falls were identified using a fall-assessment questionnaire.15 Fear of falling was evaluated using the modified Falls Efficacy Scale (FES), which was translated into Japanese. The FES employs the 10 items reported by Tinetti et al,21 and each item was assessed based on the following scale: 1, “I have no confidence to do so”; 2, “I have little confidence to do so”; 3, “I have some confidence to do so”; 4, “I have full confidence to do so”. The total scores on the FES ranged from 10 to 40, with higher scores indicating greater confidence. These assessments were self-administered, with guidance from public health nurses or QCWs as needed. Physical function, risk factors for falls, and fear of falling were evaluated before the start of the intervention and at 6 months after it began. Statistical analysis Statistical analyses were performed using SPSS 22.0 for Windows (SPSS Inc., Chicago, IL, USA). Chi-square tests were used to compare sex distributions and the proportion of participants who dropped out between the two groups. Between-group differences in age, height, body weight, and physical function prior to the intervention were assessed using unpaired t tests. The Manne Whitney U test was used to assess between-group differences in
4
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Table 2 Baseline characteristics of the study participants.
Table 3 Physical function of the two groups before and after the intervention period.
Characteristic
Balance training group (n ¼ 22)
Control group (n ¼ 23)
p-value
Age (years) Female, n (%) Height (cm) Weight (kg) OLST (sec) CST (sec) TUGT (sec) LEST (Nm/kg) Risk factors of falls (n) FES scores (points)
83.1 8.5 14 (65.2) 147.9 8.9 47.8 9.5 5.4 7.7 15.1 5.3 15.9 4.6 0.7 0.2 6.6 1.5 28.2 6.8
81.0 7.6 18 (80.0) 152.4 10.3 49.5 10.0 6.6 8.9 13.6 3.9 14.3 4.7 0.6 0.3 7.3 1.5 26.3 3.5
0.392 0.327 0.130 0.576 0.639 0.292 0.261 0.302 0.153 0.140
Values are expressed as means standard deviation (SD). OLST ¼ One-leg standing test; CST ¼ Chair standing test; TUGT ¼ Timed up-and-go test; LEST ¼ Lower-extremity muscle strength test; FES ¼ Falls Efficacy Scale.
the number of risk factors and in FES scores at baseline and 6 months after starting the intervention. The number of risk factors and FES scores within each group were compared using the Wilcoxon signed-rank test. The effect of exercise on physical function was analyzed using mixed 2 2 (group [balance-training group and control group] time [baseline and 6 months after starting the intervention]) analysis of variance. Post hoc Bonferroni tests were used to assess differences between groups or time periods. A two-sided pvalue of 0.05 was considered significant. Results Five participants (11.1%) withdrew from the trial. Two participants (9.0%) in the balance-training group were admitted to hospital with pneumonia, two (8.7%) in the control group were admitted to hospital with heart disease, and one (4.3%) in the control group withdrew because of social problems. There was no significant difference in the number of participants who withdrew from each group (p 0.99) and no participants dropped out as a result of the balance-training program itself. Thus, 40 of the 45 participants completed the 6-month interventiond20 in the balance-training group and 20 in the control group. During the intervention, participants who completed the study attended 78% and 76% of all possible classes in the balance-training and control groups, respectively. There was no significant difference in class attendance between the two groups (p ¼ 0.780). The baseline participant characteristics are summarized in Table 2. There were no significant differences in age, sex distribution, height, body weight, number of fall risk factors, FES scores, or physical function between the two groups (p 0.130). Balance training significantly affected physical function; there were significant group time interactions in the CST (p ¼ 0.003), TUGT (p ¼ 0.009), and LEST (p < 0.001), but not in the OLST (p ¼ 0.377) (Table 3). For the CST and LEST, the mean values at 6 months after the intervention in the balance-training group were significantly improved relative to baseline values, and relative to the 6-month values for the control group (p < 0.05). For the TUGT, there were no significant differences between the balance-training and control groups. In the balance-training group, the mean value at 6 months was significantly improved compared with before the intervention (p < 0.05). No significant improvements were observed in the OLST scores. The mean (standard deviation) number of risk factors for falls 6 months after beginning the intervention was 4.9 (2.1) in the balance-training group and 6.7 (1.6) in the control group. The mean FES scores for the balance-training and control groups were 30.5 (6.9) and 27.5 (3.3), respectively. There were significant differences
Item
Pre-intervention Postintervention Effect Group time size interaction F-value p-value
OLST (sec) Balance training group Control group CST (sec) Balance training group Control group TUGT (sec) Balance training group Control group LEST (Nm/kg) Balance training group Control group
5.4 7.7
8.1 12.9
0.30
6.6 8.9
6.8 5.6
0.02
15.1 5.3
11.0 3.2a,b
0.86
13.6 3.9
14.3 4.3
0.14
15.9 4.6
13.9 3.5b
0.68
14.3 4.7
15.0 5.0
0.20
a,b
0.7 0.2
1.0 0.3
1.24
0.6 0.3
0.6 0.3
0
0.798 0.377
10.044 0.003
7.631 0.009
18.786 0.000
Values are expressed as means standard deviation (SD). OLST ¼ One-leg standing test; CST ¼ Chair standing test; TUGT ¼ Timed up-and-go test; LEST ¼ Lower-extremity muscle strength test. Greater OLST and LEST values indicate better performance. Lower CST and TUGT values indicate better performance. Effect sizes were calculated as the standardized mean difference from pre-intervention to postintervention within each group. a Significant differences between the two groups. b Significant differences relative to pre-intervention (baseline).
between the two groups in the number of risk factors and FES scores (p ¼ 0.014 and p ¼ 0.049, respectively). Within the balancetraining group, there was a significant improvement in the mean number of risk factors for falls at 6 months compared with before the intervention (p ¼ 0.002); however, the FES scores did not change significantly over the study period. At 6 months, the control group showed no significant differences from baseline in the mean number of risk factors or the FES scores.
Discussion The main finding of our study was that a balance-training program provided by QCWs effectively improved physical function and reduced fall risk factors and fear of falling in older adults. In Japan, although the number of frail older adults is increasing, there are few physiotherapists working in the community.5,11 This has led to an urgent need for exercise programs that can be provided by nonphysiotherapists. The QCWs working in community day centers have the professional knowledge to support disabled adults and are well suited to supervise exercise classes for frail older adults. Our findings suggest that the balance training provided by the QCWs in this study effectively improved the physical function of the participants, and that such exercise programs can be conducted by non-physiotherapists. During this study, no study-related adverse events occurred. Both the balance-training and control groups had similarly high attendance rates at all offered classes and activities. This good compliance rate indicates broad acceptance of the program and that it can be safely delivered to ambulatory participants by QCWs employed at day centers. These results suggest that this exercise program is both a feasible and safe means of improving physical function in older adults, and that non-physiotherapists in the community are able to provide the program successfully. The balance-training group performed exercises on a foam rubber pad, and lower-extremity strength (measured by the LEST and CST18) was significantly higher in the balance-training group than the control group after 6 months. In the balance-training
T. Hirase et al. / Geriatric Nursing xx (2015) 1e5
group, measures of lower-extremity strength (CST and LEST) and dynamic balance19 (TUGT) improved from baseline over the 6month training period. In addition, fall risk factors were reduced, and FES scores were improved after 6 months of training in the balance-training group compared with the control group. Previously, we reported that balance training performed using a foam rubber pad effectively improved physical function because of improved proprioception in the lower limbs and sensitivity of the cutaneous receptors in the soles.10 We believe that these mechanisms likely contributed to the positive effects of the balance-training program we observed in this study. However, in the current study, there were no significant differences in the interaction between the groups and the intervention periods for the OLST. Vellas et al17 defined impaired OLST as the inability to stand for 5 s or more, and it has been reported that exercise interventions have no effect on OLST performance in individuals with impaired OLST.22 The mean time for the OLST among our participants was 6 s at baseline. This suggests impaired OLST ability in some of our participants, which may explain the limited effect of the balance-training program on that variable. In addition, participants in our previous study attended exercise classes once a week and also followed a home-based exercise routine10; therefore, the low exercise frequency in the current study may also account for the limited effect of our balance-training protocol on OLST performance. The balance-training group showed significant improvements in risk factors for falls and FES scores relative to the control group. Previous studies have reported that deterioration of physical function is a major fall risk factor, and that fall-related emotional status (such as fear of falling) is associated with poor physical performance.3,10,23 Therefore, we believe that these outcomes may be improved through better physical performance. This study had some limitations. Our results may have been influenced by the instructors’ expertise. Also, participants in the balance-training group may not have wanted to report the number of fall risk factors and FES to avoid disappointing their instructors.24 However, given the significant improvements in physical function observed in the balance-training group, the participants’ attitudes appear to have played a minimal role. Moreover, all of the QCWs who participated in the study received the same level of training (based on a program manual) from a senior physiotherapist prior to initiating the trial, and the exercise program was videotaped to ensure consistency. Therefore, instructor expertise is unlikely to have affected the results. Additionally, we did not record the number of falls during the intervention period. Thus, we do not know whether the balance-training program provided by QCWs prevents fall occurrence; however, improved physical function has been associated with fewer falls in older adults.3,5 Finally, since we used a relatively small study population and short intervention period, we cannot be certain that frail older adults will continue to perform the exercises after a formal program has been completed or that a similar exercise program would result in the same improvements in different populations of older adults. Further prospective studies, with large study populations and long follow-up periods, will help to clarify these issues. In conclusion, balance training provided by QCWs improved physical function in community-dwelling older adults. This finding suggests that QCW-provided balance training may be beneficial to both clients and service providers, since the program improves physical function without requiring supervision by physiotherapists. Provision of such a program may enhance the quality of, and client satisfaction with, community care services provided by QCWs for older adults. We propose that implementing communitybased, QCW-provided, balance-training programs is an effective
5
means of improving physical function and reducing the fear and risk of falling in older adults.
Acknowledgments The authors thank all the participants in this study and the qualified care workersdSoko Hamada, Chieko Nakamura, Soichi Matsuzoe, and Kazuhiko Yokoyamadwho conducted the exercise program. No financial assistance was received for this project.
References 1. Kannus P, Sievanen H, Palvanen M, et al. Prevention of falls and consequent injuries in elderly people. Lancet. 2005;366(9500):1885e1893. 2. Soriano TA, DeCherrie LV, Thomas DC. Falls in the community-dwelling older adults: a review for primary-care providers. Clin Interv Aging. 2007;2(4):545e 553. 3. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on falls prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49(5):664e672. 4. Hirase T, Inokuchi S, Matsusaka N, et al. A modified fall risk assessment tool that is specific to physical function predicts falls in community-dwelling elderly people. J Geriatr Phys Ther. 2014;37(4):159e165. 5. Inokuchi S, Matsusaka N, Hayashi T, et al. Feasibility and effectiveness of a nurse-led community exercise programme for prevention of falls among frail elderly people: a multi-centre controlled trial. J Rehabil Med. 2007;39(6): 479e485. 6. 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(5):657e665. 7. Hitkamp HC, Horstmann T, Mayer F, et al. Gain in strength and muscular balance after balance training. Int J Sports Med. 2001;22(4):285e290. 8. Taylor-Piliae RE, Haskell WL, Stotts NA, et al. Improvement in balance, strength, and flexibility after 12 weeks of Tai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors. Altern Ther Health Med. 2006;12(2):50e58. 9. Audette JF, Jin YS, Newcomer R, et al. Tai chi versus brisk walking in elderly women. Age Ageing. 2006;35(4):388e393. 10. Hirase T, Inokuchi S, Matsusaka N, et al. Effects of a balance training program using a foam rubber pad in community-based older adults: a randomized controlled trial. J Geriatr Phys Ther; 2014. http://dx.doi.org/10.1519/JPT. 0000000000000023 [published online ahead of print Jun 27 2014]. 11. Matsusaka N, McLellan DL. Experiences of professionals providing community care for disabled people in Nagasaki and Southampton. J Rehabil Med. 2003;35(suppl 42):5e22. Accessed 10.01.14. 12. Nakanishi M, Imai H. Job role quality and intention to leave current facility and to leave profession of direct care workers in Japanese residential facilities for elderly. Arch Gerontol Geriatr. 2012;54(1):102e108. 13. Takai Y, Yamamoto-Mitani N, Kawasaki S, et al. Differences between nurses’ and care workers’ estimations of pain prevalence among older residents. Pain Manag Nurs. 2015;16(1):20e32. 14. Robertson MC, Devlin N, Gardner MM, et al. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls.1: randomized controlled trial. BMJ. 2001;322(7288):697e701. 15. Suzuki T. Questionnaire for Falls Assessment of Elderly People and its Application: Health Assessment Manual. Tokyo, Japan: Kosei Kagaku Kenkyusho; 2000:142e 163 [in Japanese]. 16. Demura S, Sato S, Shin S, et al. Setting the criterion for fall risk screening for healthy community-dwelling elderly. Arch Gerontol Geriatr. 2012;54(2): 370e373. 17. Vellas BJ, Wayne SJ, Romero L, et al. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45(6):735e738. 18. Gardner MM, Buchner DM, Robertson MC, et al. Practical implementation of an exercise-based falls prevention programme. Age Ageing. 2001;30(1):77e83. 19. Podsiadlo D, Richardson S. The timed up-and-go: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142e148. 20. Kato M, Yamasaki H, Hiiragi Y, et al. Measurements of isometric knee extension force with a hand-held dynamometer: effect for interrater reliability using fixing-belt. Sogoriha. 2001;29(11):1047e1050 [in Japanese]. 21. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45(6):M239eM243. 22. Jodge JO, Lindsey C, Underwood M, et al. Balance improvements in older women: effects of exercise training. Phys Ther. 1993;73(4):254e265. 23. Tinetti ME, Mendes de Leon CF, Doucette JT, et al. Fear of falling and fall related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994;49(3):M140eM147. 24. De Amici D, Klersy C, Ramajoli F, et al. Impact of the Hawthorne effect in a longitudinal clinical study: the case of anesthesia. Control Clin Trials. 2000;21(2):103e114.
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Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Effectiveness of a balance-training program provided by qualified care workers for community-based older adults: A preliminary study Tatsuya Hirase, PT, PhD a, b, Shigeru Inokuchi, PT, PhD c, *, Nobuou Matsusaka, MD, PhD c, Minoru Okita, PT, PhD b a
Geriatric Health Services Facility, Gaianosato, 2314-1 Otsu, Aino-cho, Unzen, Nagasaki 854-0302, Japan Department of Locomotive Rehabilitation Science, Unit of Rehabilitation Sciences, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan c Department of Health Sciences, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 November 2014 Received in revised form 4 February 2015 Accepted 7 February 2015 Available online xxx
The purpose of this study was to determine the effectiveness of a balance-training program provided by qualified care workers (QCWs) to community-based older adults attending day centers. Weekly balance training was conducted by QCWs working at day centers over a 6-month period. Fall risk factors, fear of falling, and physical function were compared between balance-training (n ¼ 22) and control (n ¼ 23) groups at baseline and after 6 months of intervention. Physical function assessments included the following: one-leg standing test, chair-standing test (CST), timed up-and-go test (TUGT), and a lowerextremity muscle strength test (LEST). Participants who underwent balance training significantly improved in the CST and LEST, and had reduced fear and risk of falling compared with the control group (p < 0.05). In the balance-training group, the TUGT was significantly better at 6 months than at baseline (p < 0.05). A balance-training program for community-dwelling older adults can be effectively implemented by QCWs. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Balance training Older adults Qualified care workers
Introduction Falls and fall-induced injuries are common in older adults in all countries, and aging populations increase the fall-related burden and cost to health care systems.1 Falls that do not result in injury often begin a downward cycle of fear, which leads to inactivity and decreased strength, agility, and balance.2 Many studies have identified risk factors for falls; poor balance and muscle weakness have been associated with an increased risk of falling in older adults.3 Physical functions, such as balance and lower-extremity muscle strength, can predict falls in community-dwelling older adults.4 Therefore, the aging-associated deterioration of physical function that occurs in older adults is a major risk factor for falls. Exercise programs aimed at improving balance and muscle strength have been conducted for community-dwelling older adults.5e9 We previously reported that a balance-training program
Conflicts of interest and source of funding: The authors declare no conflicts of interest or sources of funding. * Corresponding author. Tel./fax: þ81 95 819 7962. E-mail address: [email protected] (S. Inokuchi). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.02.005
performed using a foam rubber pad and supervised by physiotherapists effectively improved balance over a 2-month period, which was faster than the improvements seen with balance training on a stable surface.10 Additionally, balance-training effectively improved lower-extremity muscle strength and reduced the fear of falling, which suggests that our balance-training program is effective for improving physical function. In Japan, the number of frail older adults living in the community has increased, and physical deterioration has been reported to be the main reason for their frailty.5 Consequently, exercise classes are often provided for this population group to improve physical function and activity levels5,10; however, there are a limited number of physiotherapists working in the community who are available to supervise these classes.5,11 Therefore, the development of an effective exercise program that can be conducted by nonphysiotherapists is urgently needed. Qualified care workers (QCWs) are a valuable resource because they provide the vast majority of care services for frail older adults in Japanese community day centers and residential facilities.12 They have the professional skills to provide support to disabled adults. There are several differences between QCWs and nurses. First,
2
T. Hirase et al. / Geriatric Nursing xx (2015) 1e5
Fig. 1. Number and origin of the participants in each group.
licenses in direct care working are held by QCWs and homehelpers; unlike nurses, QCWs do not hold a professional specialization. Second, medical practice by QCWs is prohibited, except for suction and gastrostomy tube feeding of residents in special nursing homes. Nurses are more likely to perform medical procedures, although QCWs handle the day-to-day care of frail older adults and disabled adults.13 There are fewer nurses than QCWs in community day centers and residential facilities. In communities with a shortage of physiotherapists and nurses, the role of QCWs working in community day centers could include leading exercise classes for frail older adults. Previous studies have reported that exercise programs provided by public health nurses, trained and supervised by physiotherapists, improved physical function in older adults5,14; however, it is unclear whether exercise programs provided by QCWs are effective. If successful, such programs would benefit both clients and service providers because they would not only improve the physical function of older adults, but would also reduce the amount of supervision required by physiotherapists in the community. Thus, the present study tested the hypothesis that a balance-training program for older adults, conducted by QCWs, would effectively improve balance and lowerextremity muscle strength, which are risk factors for falls.
Methods Participants The study participants were older adults using community day centers once or twice a week. We selected four day centers supported by a senior physiotherapist. QCWs at each day center were asked to choose potential participants who were over 65 years old, lived at home, were able to walk with or without a cane, and had at least four risk factors for falls as identified using the questionnaire for fall-assessment described by Suzuki.15 This questionnaire consists of 15 items and has been shown to predict falls with a sensitivity and specificity of 59.4% and 83.1%, respectively. We defined older adults with at least four risk factors for falling as high-risk fallers.16
Participants were excluded if they had participated in exercise at least four times in the month prior to the intervention or if they had musculoskeletal, neurological, or cardiovascular disorders that could be aggravated by exercise. Participants were also excluded if cognitive impairment rendered them unable to respond to interview questions. A flowchart outlining study participation is shown in Fig. 1. In all, 112 potential participants were identified. Of these, 22 refused to participate in the study and 45 did not meet the inclusion criteria. Of the 45 potential participants who were excluded, 11 had severe musculoskeletal or cardiovascular disorders and 34 had exercised regularly four or more times in the month before the initial interview. The remaining individuals (n ¼ 45) were enrolled in the study and were assigned to either the balance-training group (n ¼ 22) or the control group (n ¼ 23). Written informed consent was obtained from each participant in accordance with the guidelines of the Nagasaki University Graduate School of Medicine and the Declaration of Helsinki. Study design We chose a multi-center controlled trial for this study because we had concerns regarding the potential difficulty of enrolling participants into the control group owing to the general popularity of exercise classes among frail older adults.5 Furthermore, we wanted to determine the feasibility of conducting exercise classes in the participants’ communities. The four day centers were nonrandomly assigned to either a balance-training group (two centers) or a control group (two centers). Assignments were made in such a way as to keep the number of participants in the two groups as similar as possible. The physiotherapists supporting the day centers assessed the participants’ physical function, and the QCWs working at the day centers implemented the intervention program. Intervention Participants in the balance-training group attended a 1-h exercise class once weekly for 6 months. All classes consisted of 10 min of warm-up exercises, 40 min of balance training, and 10 min of
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3
Table 1 Balance-training program. Exercise
Description
Double-stance standing
One-leg standing
Neck hyperextension Free-leg swinging
Heel and toe raises Neck and trunk rotation Touching the floor Walking in place Sideways walking Walking
Hold for 20 s. Repeat twice with eyes open, twice with eyes closed. Stand on one leg with the other foot placed midway up the calf. Hold for 10 s, if possible. Repeat three times on each leg, once with eyes open and twice with eyes closed. Stand while slowly hyperextending the neck and then tipping the head forward and down. Repeat five times with eyes open, five times with eyes closed. Stand on one leg while moving the other slowly to the front, side and back. Switch legs and repeat three times, then repeat again three times with eyes closed. Initially, participants may slide feet over the floor, but later in the class they should try to completely lift the leg off the floor. Rock slowly up onto the toes and hold, then roll back onto the heels and hold. Repeat three times with eyes open, three times with eyes closed. Stand while slowly rotating the neck and trunk. Repeat three times with eyes open. Touch the floor while squatting down. Repeat five times with eyes open. Walk in place for 20 s. Repeat twice with eyes open. Walk sideways, bringing the trailing foot just up to the lead one. Repeat five times with eyes open, traveling an approximately 7-m distance. Walk forwards without looking at the ground. Repeat five times with eyes open, traveling an approximately 7-m distance.
cool-down exercises. All exercise sessions consisted of training groups of approximately 10 participants led by two QCWs. A total of four QCWs participated in the study. All QCWs received training from the same senior physiotherapist prior to starting the trial; this training consisted of participating in a physiotherapist-conducted exercise session based on a program manual. Physiotherapists were available to provide help or advice to the QCWs, and sessions were videotaped to ensure the consistency of the balance training. The intensity of each 40 min balance-training session was constant for each individual throughout the intervention period. Participants took breaks totaling up to 10 min during the sessions, depending on their physical capacity. Therefore, no clinical decisions, such as changes in exercise intensity for individual participants, needed to be made by the QCWs during the intervention period. The balance-training program included 10 exercises performed in a standing position: double-stance standing, one-leg standing, neck hyperextension, free-leg swinging, heel and toe raises, neck and trunk rotation, touching the floor, walking in place, sideways walking, and walking (Table 1), as described previously.10 During the exercise sessions provided by the QCWs, the participants exercised while watching an instructional video demonstrating the exercises to be performed. The physiotherapists at the day centers observed the first QCW-provided exercise sessions to ensure their safety. All exercises were performed on a 6-cm-thick foam rubber pad measuring 50 40 cm (AirexÒ mat, Sakai Medical, Tokyo, Japan). To ensure the safety of the intervention program, the number of exercises performed on the foam rubber pad was gradually increased over time. During the first 2 months of the training program, participants performed double-stance standing, heel and toe raises and walking in place. During the next 2 months, neck hyperextension, free-leg swinging and neck and trunk rotation were performed in addition to the double-stance standing, heel and toe raises and walking in place. Finally, for the last 2 months, touching the floor, sideways walking, walking, and one-leg standing were added to the exercise regimen. Participants in both groups participated in weekly social programs, including recreational activities, educational programs, and tea breaks. They continued their daily activities at the day centers, but control group participants performed neither balance-training nor muscle-strengthening exercises at the centers or in a structured setting at home.
Assessment Physical function, risk factors for falls, and fear of falling were assessed. Before the study began, the physiotherapists at the day centers were trained in the assessment protocols by one of the authors (TH). Assessment of physical function included the following performance tests: the one-leg standing test (OLST),17 chair-standing test (CST),18 timed up-and-go test (TUGT),19 and lower-extremity muscle strength test (LEST). All performance tests except the LEST were conducted twice, and the best value from the two tests was recorded. The LEST measured maximal isometric knee extension using a hand-held dynamometer (Micro FET2, Nihon Medix, Chiba, Japan). The positioning of the participant and placement of the dynamometer were performed as described by Kato et al.20 Knee extensor strength was tested using a belt, with the participant in a sitting position and the hip and knee flexed at an angle of 90 . Three LEST tests were performed three times for each leg, and the best value for each leg was recorded (expressed in Nm/kg). Risk factors for falls were identified using a fall-assessment questionnaire.15 Fear of falling was evaluated using the modified Falls Efficacy Scale (FES), which was translated into Japanese. The FES employs the 10 items reported by Tinetti et al,21 and each item was assessed based on the following scale: 1, “I have no confidence to do so”; 2, “I have little confidence to do so”; 3, “I have some confidence to do so”; 4, “I have full confidence to do so”. The total scores on the FES ranged from 10 to 40, with higher scores indicating greater confidence. These assessments were self-administered, with guidance from public health nurses or QCWs as needed. Physical function, risk factors for falls, and fear of falling were evaluated before the start of the intervention and at 6 months after it began. Statistical analysis Statistical analyses were performed using SPSS 22.0 for Windows (SPSS Inc., Chicago, IL, USA). Chi-square tests were used to compare sex distributions and the proportion of participants who dropped out between the two groups. Between-group differences in age, height, body weight, and physical function prior to the intervention were assessed using unpaired t tests. The Manne Whitney U test was used to assess between-group differences in
4
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Table 2 Baseline characteristics of the study participants.
Table 3 Physical function of the two groups before and after the intervention period.
Characteristic
Balance training group (n ¼ 22)
Control group (n ¼ 23)
p-value
Age (years) Female, n (%) Height (cm) Weight (kg) OLST (sec) CST (sec) TUGT (sec) LEST (Nm/kg) Risk factors of falls (n) FES scores (points)
83.1 8.5 14 (65.2) 147.9 8.9 47.8 9.5 5.4 7.7 15.1 5.3 15.9 4.6 0.7 0.2 6.6 1.5 28.2 6.8
81.0 7.6 18 (80.0) 152.4 10.3 49.5 10.0 6.6 8.9 13.6 3.9 14.3 4.7 0.6 0.3 7.3 1.5 26.3 3.5
0.392 0.327 0.130 0.576 0.639 0.292 0.261 0.302 0.153 0.140
Values are expressed as means standard deviation (SD). OLST ¼ One-leg standing test; CST ¼ Chair standing test; TUGT ¼ Timed up-and-go test; LEST ¼ Lower-extremity muscle strength test; FES ¼ Falls Efficacy Scale.
the number of risk factors and in FES scores at baseline and 6 months after starting the intervention. The number of risk factors and FES scores within each group were compared using the Wilcoxon signed-rank test. The effect of exercise on physical function was analyzed using mixed 2 2 (group [balance-training group and control group] time [baseline and 6 months after starting the intervention]) analysis of variance. Post hoc Bonferroni tests were used to assess differences between groups or time periods. A two-sided pvalue of 0.05 was considered significant. Results Five participants (11.1%) withdrew from the trial. Two participants (9.0%) in the balance-training group were admitted to hospital with pneumonia, two (8.7%) in the control group were admitted to hospital with heart disease, and one (4.3%) in the control group withdrew because of social problems. There was no significant difference in the number of participants who withdrew from each group (p 0.99) and no participants dropped out as a result of the balance-training program itself. Thus, 40 of the 45 participants completed the 6-month interventiond20 in the balance-training group and 20 in the control group. During the intervention, participants who completed the study attended 78% and 76% of all possible classes in the balance-training and control groups, respectively. There was no significant difference in class attendance between the two groups (p ¼ 0.780). The baseline participant characteristics are summarized in Table 2. There were no significant differences in age, sex distribution, height, body weight, number of fall risk factors, FES scores, or physical function between the two groups (p 0.130). Balance training significantly affected physical function; there were significant group time interactions in the CST (p ¼ 0.003), TUGT (p ¼ 0.009), and LEST (p < 0.001), but not in the OLST (p ¼ 0.377) (Table 3). For the CST and LEST, the mean values at 6 months after the intervention in the balance-training group were significantly improved relative to baseline values, and relative to the 6-month values for the control group (p < 0.05). For the TUGT, there were no significant differences between the balance-training and control groups. In the balance-training group, the mean value at 6 months was significantly improved compared with before the intervention (p < 0.05). No significant improvements were observed in the OLST scores. The mean (standard deviation) number of risk factors for falls 6 months after beginning the intervention was 4.9 (2.1) in the balance-training group and 6.7 (1.6) in the control group. The mean FES scores for the balance-training and control groups were 30.5 (6.9) and 27.5 (3.3), respectively. There were significant differences
Item
Pre-intervention Postintervention Effect Group time size interaction F-value p-value
OLST (sec) Balance training group Control group CST (sec) Balance training group Control group TUGT (sec) Balance training group Control group LEST (Nm/kg) Balance training group Control group
5.4 7.7
8.1 12.9
0.30
6.6 8.9
6.8 5.6
0.02
15.1 5.3
11.0 3.2a,b
0.86
13.6 3.9
14.3 4.3
0.14
15.9 4.6
13.9 3.5b
0.68
14.3 4.7
15.0 5.0
0.20
a,b
0.7 0.2
1.0 0.3
1.24
0.6 0.3
0.6 0.3
0
0.798 0.377
10.044 0.003
7.631 0.009
18.786 0.000
Values are expressed as means standard deviation (SD). OLST ¼ One-leg standing test; CST ¼ Chair standing test; TUGT ¼ Timed up-and-go test; LEST ¼ Lower-extremity muscle strength test. Greater OLST and LEST values indicate better performance. Lower CST and TUGT values indicate better performance. Effect sizes were calculated as the standardized mean difference from pre-intervention to postintervention within each group. a Significant differences between the two groups. b Significant differences relative to pre-intervention (baseline).
between the two groups in the number of risk factors and FES scores (p ¼ 0.014 and p ¼ 0.049, respectively). Within the balancetraining group, there was a significant improvement in the mean number of risk factors for falls at 6 months compared with before the intervention (p ¼ 0.002); however, the FES scores did not change significantly over the study period. At 6 months, the control group showed no significant differences from baseline in the mean number of risk factors or the FES scores.
Discussion The main finding of our study was that a balance-training program provided by QCWs effectively improved physical function and reduced fall risk factors and fear of falling in older adults. In Japan, although the number of frail older adults is increasing, there are few physiotherapists working in the community.5,11 This has led to an urgent need for exercise programs that can be provided by nonphysiotherapists. The QCWs working in community day centers have the professional knowledge to support disabled adults and are well suited to supervise exercise classes for frail older adults. Our findings suggest that the balance training provided by the QCWs in this study effectively improved the physical function of the participants, and that such exercise programs can be conducted by non-physiotherapists. During this study, no study-related adverse events occurred. Both the balance-training and control groups had similarly high attendance rates at all offered classes and activities. This good compliance rate indicates broad acceptance of the program and that it can be safely delivered to ambulatory participants by QCWs employed at day centers. These results suggest that this exercise program is both a feasible and safe means of improving physical function in older adults, and that non-physiotherapists in the community are able to provide the program successfully. The balance-training group performed exercises on a foam rubber pad, and lower-extremity strength (measured by the LEST and CST18) was significantly higher in the balance-training group than the control group after 6 months. In the balance-training
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group, measures of lower-extremity strength (CST and LEST) and dynamic balance19 (TUGT) improved from baseline over the 6month training period. In addition, fall risk factors were reduced, and FES scores were improved after 6 months of training in the balance-training group compared with the control group. Previously, we reported that balance training performed using a foam rubber pad effectively improved physical function because of improved proprioception in the lower limbs and sensitivity of the cutaneous receptors in the soles.10 We believe that these mechanisms likely contributed to the positive effects of the balance-training program we observed in this study. However, in the current study, there were no significant differences in the interaction between the groups and the intervention periods for the OLST. Vellas et al17 defined impaired OLST as the inability to stand for 5 s or more, and it has been reported that exercise interventions have no effect on OLST performance in individuals with impaired OLST.22 The mean time for the OLST among our participants was 6 s at baseline. This suggests impaired OLST ability in some of our participants, which may explain the limited effect of the balance-training program on that variable. In addition, participants in our previous study attended exercise classes once a week and also followed a home-based exercise routine10; therefore, the low exercise frequency in the current study may also account for the limited effect of our balance-training protocol on OLST performance. The balance-training group showed significant improvements in risk factors for falls and FES scores relative to the control group. Previous studies have reported that deterioration of physical function is a major fall risk factor, and that fall-related emotional status (such as fear of falling) is associated with poor physical performance.3,10,23 Therefore, we believe that these outcomes may be improved through better physical performance. This study had some limitations. Our results may have been influenced by the instructors’ expertise. Also, participants in the balance-training group may not have wanted to report the number of fall risk factors and FES to avoid disappointing their instructors.24 However, given the significant improvements in physical function observed in the balance-training group, the participants’ attitudes appear to have played a minimal role. Moreover, all of the QCWs who participated in the study received the same level of training (based on a program manual) from a senior physiotherapist prior to initiating the trial, and the exercise program was videotaped to ensure consistency. Therefore, instructor expertise is unlikely to have affected the results. Additionally, we did not record the number of falls during the intervention period. Thus, we do not know whether the balance-training program provided by QCWs prevents fall occurrence; however, improved physical function has been associated with fewer falls in older adults.3,5 Finally, since we used a relatively small study population and short intervention period, we cannot be certain that frail older adults will continue to perform the exercises after a formal program has been completed or that a similar exercise program would result in the same improvements in different populations of older adults. Further prospective studies, with large study populations and long follow-up periods, will help to clarify these issues. In conclusion, balance training provided by QCWs improved physical function in community-dwelling older adults. This finding suggests that QCW-provided balance training may be beneficial to both clients and service providers, since the program improves physical function without requiring supervision by physiotherapists. Provision of such a program may enhance the quality of, and client satisfaction with, community care services provided by QCWs for older adults. We propose that implementing communitybased, QCW-provided, balance-training programs is an effective
5
means of improving physical function and reducing the fear and risk of falling in older adults.
Acknowledgments The authors thank all the participants in this study and the qualified care workersdSoko Hamada, Chieko Nakamura, Soichi Matsuzoe, and Kazuhiko Yokoyamadwho conducted the exercise program. No financial assistance was received for this project.
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