Sanna Sihvonen

Changes in Postural Balance in Frail Elderly Women during a 4-Week Visual Feedback Training: A Randomized Controlled Trial

Background: Balance training programs have not shown consistent results among older adults, and it remains unclear how different training methods can be adapted to frail elderly people. Objective: The purpose of this study was to investigate the effects of a 4-week visual feedback-based balance training on the postural control of frail elderly women living in residential care homes. Methods: Elderly women of two residential care facilities were randomized to an exercise group (EG, n = 20) and to a control group (CG, n = 7). The EG participated in training sessions three times/week for 4 weeks. The exercises were carried out with a computerized force platform with visual feedback screen. The dimensions of balance function studied were standing body sway, dynamic weight shifting, and Berg Balance Scale performance. Results: The EG showed significant improvement in balance functions. The performance time in dynamic balance tests improved on average by 35.9% compared with a 0.6% increase in the CG (p = 0.025–0.193). The performance distance in these tests decreased on average by 28.2% in the EG as compared with a 9.8% decrease seen in the CG. The Berg Balance Scale performance improved by 6.9% compared with a 0.7% increase in the CG (p = 0.003). The standing balance tests in the more demanding standing positions showed improvements in the EG, whereas similar changes in the CG were not found. Conclusions: Our findings suggest that balance training based on visual feedback improves the balance control in frail elderly women living in residential care, also enhancing the performance of functional balancing tasks relevant to daily living. The subjects were motivated to participate in the training, as indicated by the high compliance (97.5%) with the program.

Fall Incidence in Frail Older Women after Individualized Visual Feedback-Based Balance Training

Background: The knowledge concerning balance training actually lowering fall rates among frail older persons is limited. Objective: The aim of this study was to examine the effects of a 4-week individualized visual feedback-based balance training on the fall incidence during 1-year follow-up among frail older women living in residential care. Methods: Twenty-seven older women from 2 residential care homes were randomized into exercise (n = 20) and control (n = 7) groups. Balance measurements were carried out before and after a 4-week training period and falls were monitored by monthly diaries for 1 year. An interview about fear of falling and physical activity was completed before and after the intervention and after the 1-year follow-up. Results: A positive effect of balance training on fall incidence was found. A dynamic Poisson regression model showed that during the follow-up the monthly risk of falling was decreased in the exercise group compared to controls (risk ratio 0.398, 95% CI 0.174–0.911, p = 0.029). In addition, the exercise group reported a reduced fear of falling and increased physical activity after a training period but these changes declined during the follow-up period. Conclusion: Individualized visual feedback-based balance training was shown to be a promising method for fall prevention among frail older women. High compliance (97.5%) with the training program showed that carefully targeted training programs can be carried out among older people with health limitations.

Effects of Resistance Training on Lower-Extremity Impairments in Older People With Hip Fracture

OBJECTIVE To study the effects of resistance training on muscle strength parameters, mobility, and balance. DESIGN Randomized controlled trial. SETTING Research laboratory and senior gym. PARTICIPANTS Population-based sample of eligible 60- to 85-year-old community-dwelling men and women 0.5 to 7.0 years after hip fracture. Forty-six people had no contraindications and were willing to participate in the exercise trial. INTERVENTION Twelve-week intensive progressive strength-power training (n=24), aiming to reduce asymmetric deficit in leg muscle strength and power, or no intervention (n=22). MAIN OUTCOME MEASURES Isometric knee extension torque (KET) and leg extension power (LEP) measured in the weaker and stronger leg and the asymmetric deficit ([weak/sum both legs]x100%), 10-m walking speed, dynamic balance test, and self-reported outdoor mobility. RESULTS KET increased in both legs (P<.021), LEP tended to increase in the weaker leg (P=.071), and asymmetric LEP deficit decreased (P=.010) after training compared with the control group. LEP of the stronger leg, asymmetric KET deficit, walking speed, and balance performance were not significantly affected by training. Self-reported ability to walk outdoors improved after training. The compliance to the training was over 90%, and few adverse events (n=4; mainly musculoskeletal) were likely to be caused by the training. CONCLUSIONS Intensive resistance training is feasible for people with a hip fracture and improved muscle strength and power. More intensive training especially for the weaker leg may be needed to obtain more marked effects on asymmetric deficit, mobility, and balance. Also, the timing and duration of training program should be considered. (ISRCTN identifier ISRCTN34271567.)

Contribution of Musculoskeletal Pain to Postural Balance in Community-Dwelling People Aged 75 Years and Older

BACKGROUND Balance is among the most important prerequisites for safe and independent mobility. Whether musculoskeletal pain is related to standing balance impairment has received limited attention. The aim of this study was to examine the association of musculoskeletal pain with the control of balance in older people. METHODS A total of 605 participants aged 75 years and older (mean age 80.4, 71 % women) were interviewed about presence and severity of musculoskeletal pain. Balance was measured by a force platform, and impaired balance was defined as a high sway velocity moment or inability to maintain semitandem standing. RESULTS Musculoskeletal pain was reported by 48% of the participants, of whom majority had moderate to severe pain in lower extremities or back. Participants with moderate to severe musculoskeletal pain swayed more while standing than those without pain. After controlling for age, gender, body mass, chronic diseases, muscle strength, and physical activity, the participants with moderate to severe pain had more than twice (odds ratio 2.33, 95% confidence interval 1.44-3.76) the risk for impaired balance compared with those without pain. CONCLUSIONS The findings demonstrate a direct relationship between the moderate to severe musculoskeletal pain and impaired postural balance. Pain seems to be an important target for the prevention of balance impairment and further mobility limitation among older people.

Balance confidence and functional balance in relation to falls in older persons with hip fracture history

Purpose: To investigate whether self‐assessed balance confidence and functional balance are associated with falls in older persons with hip fracture history. Methods: This study is a part of a larger study on functional capacity and exercise rehabilitation in hip fracture patients. Seventy‐nine patients, operated at the local hospital for collum or trochanter fracture within one‐half to 7 years, participated in the laboratory measurements. Balance confidence was assessed with Activities‐specific Balance Confidence scale (ABC) and functional balance using the Berg Balance Scale (BBS). According to self‐reported number of falls during the previous 6 months participants were classified as those with falls vs. no falls; recurrent falls (3 or more falls) vs. occasional/no falls (< 3 falls); indoor falls vs. no indoor falls; outdoor falls vs. no outdoor falls. The relationships between ABC, BBS, and fall status were tested by logistic regression. Results: Lower BBS score was associated with all falls during previous 6 months (OR 0.929, 95% CI 0.875–0.987). Lower ABC score was associated with recurrent falling (OR 0.974, 0.952–0.998), as well as lower BBS score (OR 0.876, 0.797–0.962). Additionally, lower ABC and lower BBS scores were related to indoor falls (ABC OR 0.975, 0.957–0.993; BBS OR 0.913, 0.852–0.978). Participants with outdoor falls did not differ from those with no outdoor falls in ABC scores or BBS. Conclusions: Self‐assessed balance confidence and functional balance are related to prevalence of recurrent and indoor falls in older hip fracture patients. Therefore use of Activities‐specific Balance Confidence scale and Berg Balance Scale might be reasoned to expand in evaluating the probability for falls among at‐risk elders.

Postural Balance and Self-Reported Balance Confidence in Older Adults with a Hip Fracture History

Background: Balance dysfunction and loss of balance confidence have been associated with functional limitations and loss of independency in daily tasks. This study examined various aspects of postural balance and balance confidence between older adults with a hip fracture history and their non-fractured counterparts. A comprehensive assessment of balance capacity in older adults with a hip fracture history may help to identify aspects of postural balance that play an important role in the mobility recovery and the avoidance of further falls. Methods: The present study comprised 79 community-dwelling older adults with a hip fracture history and 31 non-fractured subjects of the same age, who participated in balance tests including both force platform measures and functional balance testing (Berg Balance Scale, BBS). In addition, balance confidence was assessed with the Activities-Specific Balance Confidence (ABC) scale. Results: Persons with a hip fracture history had a markedly poorer balance control and were significantly less confident maintaining their balance during daily activities compared to the controls. Sixty percent of the subjects in the hip fracture group versus 87% of the non-fracture group (χ2 test, p = 0.003) were able to perform the semi-tandem standing with their eyes closed. Significantly lower scores in the BBS (hip fracture group 46.3 vs. non-fracture group 52.9) and ABC (hip fracture group 59.4 vs. non-fracture group 77.5%) tests were found among the hip fracture subjects compared to the controls. In addition, the performance time in the lateral weight-shifting task (hip fracture group 13.4 vs. non-fracture group 8.4 s) was significantly slower compared to the controls. Conclusions: Balance impairments along with the loss of balance confidence are persistent problems among community-dwelling older adults with a history of hip fracture and may contribute to mobility limitations and the risk of falling. These areas of function and behaviour in older adults with a hip fracture history should be taken into consideration when planning effective, well-targeted rehabilitation programs.

Physical inactivity and pain in older men and women with hip fracture history.

Hip fracture patients often suffer from pain for several months after surgery. This may lead to physical inactivity and subsequent mobility limitation and disability. The purpose of this study was to investigate the association between severe musculoskeletal pain and the level of physical activity in older people with a history of hip fracture. Data were collected from 60- to 85-year-old (n = 78) community-dwelling people, 0.7–7.5 years after hip fracture. Physical activity was assessed with the Yale Physical Activity Survey (YPAS). According to the YPAS summary index distribution, the participants were divided into the physically inactive and physically active groups. Musculoskeletal pain in the lower back, hip or knee region was assessed by the Visual Analog Scale. Pain was defined as severe pain if the subject rated the pain 66 mm or over (upper third of the scale) in at least one of the relevant body regions in the lower body. Thirty-three subjects (42%) experienced severe pain in the lower body, of whom 23 (70%) reported severe pain in the operated hip. Twenty-three patients (30%) used pain medication prescribed by a physician. The level of musculoskeletal pain was significantly higher in the physically inactive (62%) than in the physically active (31%) group (p = 0.011). Logistic regression analysis showed that people with severe pain had over three times (OR: 3.5, 95% CI: 1.30–9.39) the risk for physical inactivity compared to those with less or no pain. Multivariate adjustments for balance confidence, time since fracture, number of chronic diseases and type of surgery did not materially change the estimate (OR: 3.0, 95% CI: 1.00–9.30). Pain is an important associated factor of physical inactivity in older people with a hip fracture history. Pain management may be important in restoring and sustaining the level of physical activity after hip fracture. Further prospective and experimental studies are, however, needed to explore the causality between pain and physical activity as well as the role of pain management and physical activity interventions in preventing mobility limitation and disability among older people recovering from hip fracture.

Promoting mobility after hip fracture (ProMo): study protocol and selected baseline results of a year-long randomized controlled trial among community-dwelling older people.

BackgroundTo cope at their homes, community-dwelling older people surviving a hip fracture need a sufficient amount of functional ability and mobility. There is a lack of evidence on the best practices supporting recovery after hip fracture. The purpose of this article is to describe the design, intervention and demographic baseline results of a study investigating the effects of a rehabilitation program aiming to restore mobility and functional capacity among community-dwelling participants after hip fracture.Methods/DesignPopulation-based sample of over 60-year-old community-dwelling men and women operated for hip fracture (n = 81, mean age 79 years, 78% were women) participated in this study and were randomly allocated into control (Standard Care) and ProMo intervention groups on average 10 weeks post fracture and 6 weeks after discharged to home. Standard Care included written home exercise program with 5-7 exercises for lower limbs. Of all participants, 12 got a referral to physiotherapy. After discharged to home, only 50% adhered to Standard Care. None of the participants were followed-up for Standard Care or mobility recovery. ProMo-intervention included Standard Care and a year-long program including evaluation/modification of environmental hazards, guidance for safe walking, pain management, progressive home exercise program and physical activity counseling. Measurements included a comprehensive battery of laboratory tests and self-report on mobility limitation, disability, physical functional capacity and health as well as assessments for the key prerequisites for mobility, disability and functional capacity. All assessments were performed blinded at the research laboratory. No significant differences were observed between intervention and control groups in any of the demographic variables.DiscussionTen weeks post hip fracture only half of the participants were compliant to Standard Care. No follow-up for Standard Care or mobility recovery occurred. There is a need for rehabilitation and follow-up for mobility recovery after hip fracture. However, the effectiveness of the ProMo program can only be assessed at the end of the study.Trial registrationCurrent Controlled Trials ISRCTN53680197

Balance Confidence Was Associated With Mobility and Balance Performance in Older People With Fall-Related Hip Fracture: A Cross-Sectional Study

OBJECTIVE To study the relationship between balance confidence, a concept closely related to fear of falling, mobility and balance performance, and perceived mobility limitation in older people after a fall-related hip fracture. DESIGN Cross-sectional analyses of pretrial data of 2 randomized controlled trials of physical rehabilitation. SETTING University research center. PARTICIPANTS Community-dwelling people aged over 60 years, 6 weeks to 7.5 years after a fall-related hip fracture (N=130). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The main outcome was the self-reported Activities-specific Balance Confidence (ABC) scale score. Assessments also included perceived ability to walk outdoors or climb 1 flight of stairs, and assessments of self-preferred walking speed, modified Timed-Up-and-Go test, and Berg Balance Scale. RESULTS Higher ABC scale scores were related to better mobility and balance performance (ρ>.47) and perceived mobility function (ρ>.54). In univariate general linear models, all associations also remained significant after adjustment for age, sex, time since fracture, number of chronic diseases, and either level of physical activity or muscle strength of the fractured leg. An ABC scale score <85 points identified those with mobility and balance limitation across measures. CONCLUSIONS In people who have had a fall-related hip fracture, an independent relationship exists between balance confidence and mobility and balance performance as well as perceived mobility function. Since lack of balance confidence may compromise rehabilitation and recovery, the ABC scale may help to identify older hip fracture patients with mobility and balance limitation.

Postural balance and health-related factors in middle-aged and older women with injurious falls and non-fallers

Background and aims: Older jailers aged over 70 years have shown impaired balance abilities, but it is unclear if impairment in balance control can be detected among jallers who are in their 50’s and 60’s. The aim oj this study was to analyze possible differences in balance control and other health-related factors between female fallers and nonfallers aged 50–68 years. Methods: Women 50–68 years of age (N=40) who had fallen outside and needed medical attention were recruited through a larger fall accident study. Non-fallers (N=97) were women representing the same age group who had not fallen during the preceding 12 months. A battery of standing force platform balance tests were administered together with an interview on health status, use of medication, dizziness, vision, hearing, and physical activity. Results: Significant differences were not found between women with injurious falls and non-fall-ers in the various balance tests. In the younger age group (50–58 years), chronic illnesses, use of medication, dizziness, and self-reported problems with vision and hearing were more common in fallers than in non-fallers. Conclusions: Our results suggest that, in active and independent women aged 50–68 years, it is not possible to use standing force platform balance tests to detect differences between fallers and non-fallers. However, younger women (50–58 years) with injurious falls reported more health-related problems than other groups, a fact which should be taken into consideration to prevent further development of fall-related problems.