異なる身体機能の地域高齢者に対する8週間の『Fallproof!』プログラムの効果

mp#asik7

ag34tsth8e

316-327R

(2007ff)

Nwereigasva

The

Effects

of

an

Eight

Week

Fallproof!TM

CIass

Comparing

High

and

Low

Functioning

Participants

*

Peggy

R,

TRUEBLOOD,

PT,

PhD"",

Toni

TYNER,

PT,

MSL,

Nancy

WUBENHORST,

MPT,

Jody

BRADLEY,

MPT,

Ulia

CUMMINGS,

MPT,

Jenneryn

de

MESA,

MPT,

Taylor

LE,

MPT,

Danny

NORRDIN,

MPT,

Natasha

PIPER,

MPT,

Kim

RIGGS,

MPT

and

Kathy

SILVA,

MPT

tntroduction

Adults

ever

the

age ef

65

represent

the

fastest

growing

population

in

the

United

States.

Of

increasing

concern

for

this

segment of

the

pepulation

is

the

rising

incidence

of

falls.

More

than

one-third of adults ages

65

years

and older

fall

each

yeari).

Falls

pose

a significant

probEem

for

elder adults and result

in

considerable

human

and economical costs.

Among

older adults,

falls

are

the

leading

cause of

injury

deaths

and

the

most common cause of non-fatal

injuries

and

hospital

admissions

for

trauma2)3),

Of

those

who

faLl,

20-30

%

suffer moderate

to

severe

injuries

such as

hip

fractures

or

head

traumas

that reduce mobility and

independence,

and

increase

the

risk of premature

death4).

Besides

the

pain,

injury,

and

disability

associated wtth

falls,

older adults who

have

fallen

one er more

times

often experience a

height-ened

fear

of

falling

and a

loss

of self-confidence

in

their

abil-ity

to

perform

routine activities encountered

in

daily

life2)

Costs

asseciated with

falls

among

the

eLderly are estimated

to

range

from

75-100

billion

dellars

per

yeai}.

In

order

to

minimize

the

negative econemic and social

impact

that

results

from

falls,

clevelopment

of specific ancl effective

bal-ance and mobility

intervention

_programs

designed

to

reduce

the

number of

falls

amollg older adults are a public

health

pnonty.

Preserving

balance

is

acritical

_part

of maintaining

mobil-ity

and

function.

Clark

et ai.

defines

balance

as ''the

inte-gration

and organization of sensory

inputs

used to maintain upright

balance

and volitional and reactive

baEance

control

in

_dynarnic

environments"4).

The

sensory

inputs

from

three

sensory systems

(visual,

somatosensory, and vestibular)

help

'

_{".ig6fitsrc#Ea)tutuntvagv:tsJ't6sxamaa)}

_rFallproofll

7'u

f7AOstM

"

_h

_i)

7 t;le=7{･[･[iJ

"le\1itift7pt

(Xva)

Correspondence/

Peggy

R.

Trueblood,

PhD,

PT.

'

Professor,

Physical

Therapy,

CaLifornia

State

University,

Fresno

2345

East

San

Ramon

Ave;

MfS

MH29

Fresno,

CA

93740-8031,

USA

maintam and regain

balance

during

vanous activities3)5'S}.

It

is

the

connbination of

inputs

from

all

three

systems

that

com-prise

balance.

The

redundancy allows one

to

two

systems

to

compensate

for

anether when one system

is

compro-mised4).

The

ability

to

maintain

balance

deteriorates

during

the

aging

process3)9}.

Examples

of age related changes

include:

an

increased

threshold

for

excitability

for

proprioception,

decreased

visuat acuity, or

the

reduction of

the

hair

celis

in

the

vestibuiar system9)iO).

According

to

Woollacott

et al.iO),

these

altered

inputs

can result

in

a sensory conftict and ulti-mately affect

balance

and

put

the

older adult at

high

risk

for

falls,

Identifying

risk

factors,

therefore,

is

important

for

rnaintaining

baLance

in

the

older adult3}9)ii'i6}.

Risk

factors

can

be

extrinsie or

intrinsic.

Extrinsic

factors

(situational

risks) are environmental

in

nature and

include:

the

time

of

day,

lighting,

stairs, uneven surfaces,

tripping

hazards,

and

the

type

of surface

that

was

landed

uponi]).

IntrTnsic

factors

are `within'

the

individuaL

and can range

frem

decreasecl

muscular strength and

joint

fiexibility

to

medication

inter-actien, or

impairment

of

the

three

sensory systemsi4'i6}.

Fortunately,

comprehensively addressing

the

multiple risk

factors

assoeiated with

falls

can

potentially

help

prevent

fatls

from

eccurring3)4)9'i6).

Numerous

studies

have

investigated

other

predisposing

risk

factors

that

appeared

to

convey a rTsk of

falling

and

include

factors

such as age,

gender,

low

bedy

mass

index,

cognitive

impairments,

previous

falis,

demographic

data,

chronic

diseases,

and medicationii'i3) i6'2i),

The

risk of

falling

increases

linearly

with the number of risk

factors

and

declines

11%

with a

decrease

of one risk

factori2)

i3).

_Tinetti

et al.ii) suggested

that

preventative

programs

addressing

both

predisposing

and situational risk

factors

may result

in

the

greatest

injury

reduction.

Previous

studies suggest varied results

for

interventions

such as exercise

in

a community-based

program

or an

indi-vldual

home

program

to

improve

balance

and reduce risks

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysical Therapy Association

The

Effects

of an

Eight

Week

FallproqfYTM

CIass

for

falls22'24}.

one

study23) suggests

that

exercise as an

tnter-ventTon can significantly

improve

balance

and reduce

falls

in

elders, whereas

in

another study24), a community-based physical activity

lntervention

did

not sTgnificantly reduce

fall

risk

factors.

One

limitation

of

these

studies

is

that

a

one-dlmensional

measure of

balance

to

predict

falls

is

unreliable

due

to

underlying

_pathologies

that

are

_presented

by

the

sub-jecti9).

The

majority oi

_preceding

studies emphasize strengthening and stretching exercises

to

improve

balance

and coerdination, and neglected

to

address

the

three

senso-ry systems

for

balance

(visual,

somatosensory,

vestibu-lar)14}22)24'2s).

Recent

studies

have

shown

that

amulti-dimensional

inter-vention

targeting

balance

and mobility may reduce

fall

risk

in

COMmuntty-dwelling elder adults2)]3']6)22)25)29'33).

Furthermore,

_group-based

_programs

with multi-dimensional

interventions

have

been

shown

to

be

effective

in

the

reduc-tion

in

falls

and

improvement

in

balance

with the elderly

population25).

Province

et al.3i) used a meta-analysis of

the

Frailty

and

Injuries:

Cooperative

Studies

of

Intervention

Techniques

studiesa4) and

found

that treatments

including

exercise with

balance

training

could reduce

the

risk of

fa11s

by

ten

percent

However,

research

is

tacking

regarding

the

integration

of

the

three

sensory systems which

play

impor-tant

reles

in

maintaining static and

dynamic

postural

con-tro12)29)'

The

key

cornponents needed

to

improve

an

indi-vidual's

bodily

orientation are

integration

of

three

etements:

the

environment,

the

goals

of

the

task,

and

the

abilities of

the

individua12)9),

Dr.

Debra

Rese

frem

the

Center

for

Successful

Aging

at

California

State

University,

Fullerton

has

recenuly

designed

a community

based

multi-dimensional program

for

persons

at medium te

high

risk

for

falling:

FallprooftTM,

She

has

multiple

_years

of experience working with olcler adults with

balance-related

impairments

and

has

successfully started

these

comrnunity-based

programs

in

various

facilities

throughout

Orange

County,

CA.

The

thgiproqffTM

_program

integrates

the

three

balance

systems

by

manipulating the

task

and environment, along with educating

the

_participants

regarding

intrinsic

and extrinsic

factors.

The

level

of

inten-sity ef

the

program

specifically addresses

the

balance-relat-ed

impairments

identified

during

the

initial

screening.

Thus,

persons

with

both

high

and

low

physical

function

can

par-ticipate,

Peer

mentors are

trained

to

assist

the

lower

func-tionTng

participants

and

thus

ensure safety

in

a

greup

class.

However,

no study

has

specifically compared

lower

func-tioning

and

higher

functioning

participants.

Participants

engage

in

activities

that

are

designed

by

certified

balance

and mobllity

instructors

to

progressively

challenge

the

bal-ance systern,

The

ebjective of our research was

to

substantiate a

sim-Comparing

High

and

Low

Functioning

Participants

317

ilar

program

in

the

Fresno,

CA

area and

to

answer the

lowing

three

questions/

1)

will oLder adults

(over

the

age of

50}

at medium

to

high

risk

for

falling

improve

their

balance

after

taking

an eight-week

FZiliprooffTM

class:

2}

are

there

any

diiferences

in

outcome measures

between

individuals

who are

functioning

at a

lower

physical

tevel

and

those

tioning

at a

higher

_physical

level;

and

3)

what

is

the

mal number of sessions, out of a

total

of

16

sessions,

that

is

required

to

show

improvement?

To

answer

these

tions,

we

hypothesized:

1)

an eight-week

balance

tion

program

following

the

FaleproofS'i'M

model wou]d

duce

significant

imprQvement

in

persons

who are at

um

to

high

risk

for

falls:

2)

the

older adults who are

tioning

at a

lewer

physicaHevel

would make comparable

improvements

to

the

older adults who are

functioning

at a

higher

physical

level:

and

3)

individuals

who

_participated

in

75-100%

of

the

Fkxliproof,rTM

classes

(at

least

12116

sessions)

weuld

demonstrate

significantly

better

results

than

those

who

_participated

in

56-74%

of

the

classes

(9-11

sessions).

Therefore,

the

purpose

of

this

study was

to

assess

the

tiveness of

the

eight-week

Fallproof!TM

Balance

and

Mobility

classes on comrnunity-dwelling older adults

tioning

at

different

physical

activity

levels

through

lheir

formance

on selected

balance

activities and

tests.

Selected

balance

activities

included

an exercise-based rehabilitation

program

with

the

fellewing

components:

bone

loading,

gait,

dynamic

posture,

balance,

reaction, and co-ordination

ing

intended

to

improve

balance

and mobility and reduce

or

prevent

falls,

The

tests

included

impairment

and

mance-based

balance

assessnnents.

By

answering

the

three

_questions

_posed,

we can

mine

if

the

Fallproof!TM

class

is

effective

for

reducing

the

risk of

falls

in

both

1iigh

and

low

functioning

older adutts.

Falls

continue

te

be

a slgnificant source of morbidity and

mortality among older adults,

despite

the

medical

nity's extensive

preventative

efforts32)35)3S).

According

to

the

California

Department

of

Health

Services,

`unintentional

fall'

was

the

number one

leading

cause of

hospitalized

nonfatal

injuries

in

older adults ages

55

and abeve

in

200135).

Falls

often

lead

to

serious

injuries

such as

hip

fractures,

talizatien,

and

death,

and

the

average cost of a

total

hip

replacement

is

$21,ooo32)35'3B).

Our

goal

is

to

determine

if

a

cemmunity-based

fall

prevention

class, at a cost ef

$75

per

persoll,

can significantly

improve

an older adult's sense of

balance

and

]evel

of cenfidence,

if

se, we can

help

avoid

the

significant sociar and economic ramifications

by

_providing

older adults a cost-effective, accessible method

to

address

318

-eutifte

Methods

Subjects

The

study

population

consisted of older adults

living

in

the

communTty and retirement centers within the

Fresno,

CA

region,

Recruiting

consisted of

posting

flyers

at senior

centers,

placing

an ad

in

the

local

newspaper, soliciting

_prior

participants

from

the

Gait,

Balanee

and

Mobility

Center

at

California

State

University,

Fresno

and contacting

als

from

the

gelleral

community

in

the

Central

Valley

of

California,

Over

a period of one year,

203

panicipants

were contactecl, of whom

132

were scheduled

to

be

tested.

The

71

participants

that were not

scheduled

for

_testing

either

did

not meet

the

criteria

for

the

class, were unable

to

pay

the

$75

fee,

or were not

interested

in

taking the class.

Of

the

132

scheduled, only

97

were

tested

and

the

remaining

35

participants

were not

tested

because

of

illness,

conflict

in

schedule,

personal

reasons, or

locatien.

Of

the

97

tested,

15

subjects

did

not enroll

in

a class

because

ef confiict

in

time,

locatien,

health

status, and

personal

reasons

leaving

82

jects

who enrolled

in

rhe class,

Thirty

did

not attend nine

or more classes or were not

post-tested

and were not

ed

in

the

study.

Reasons

for

not completing

the

study

ed:

death

(1

participanO,

relocation

(1

participanO,

drop

out

due

to

illness

or

driving

distance

(10

participants),

and

poor

attendance

(13

parzicipants),

A

total

of

52

_participants

eclnine or mere classes, completed

_pre

and

_{post-testing,}

and

were used

for

data

analysis.

This

information

is

presented

in

Fig.

1.

Baseline

characteristics of the socio-demographic and

health

status

data

for

the

52

_participants

are shown

in

Table

1,

The

age range of

the

subjects was

53

to

91

years

{mean

=

78.6).

Seventy-zhree

percent

of

the

participants

were

categorized as

having

a

high

physical

aetivity

level,

with a

physical

compesite score ef

11

or abeve, whereas

27%

were

grouped

as

having

a

low

physical

activity

level.

Females

resented

79%

of

the

participants,

and

the

majority of

the

participants

in

this

study were older

than

70

years of age,

The

mosz common medical conditions reported among

ticipants

were numbness

in

the

ieet

(25%),

heart

_problems

(24%},

and arthritis

(18%),

The

majority of older adults

did

not use an ambulatory

device

_(54%).

In

the year

before

the

intervention,

63.5%

of

the

participants

reported

falls

and

53.85%

were using more

than

five

_prescription

_drugs.

Prior

to

_{participating}

in

the

study, allsubjects met

the

following

inctusion

criteria:

1)

age

50

or older,

2)

able

to

move

from

sitting

in

a chair

to

standing

independently,

3)

walk at

least

50-feet

without an assistive

device,

4)

have

a

ed

balance

deficit

that

limits

functional

actlvities, or

have

a

history

and/or

fear

of

falls,

5)

pay

a non-refundabte

fee

of

$75

for

the

eight-week e]ass and

6)

obtain a

physician's

med-ca34tsrg8e

FAI12001toFalLID03 TotntContEctedN=203

t

t

-w tptt b'otSeheduled<Reasons/time Sehod-tedforPre-Testing

.N.-ISI

'

iconficts,personat,notinterested

Endhealth)X"1 th

ttam.

DidNotAttendPrc-Test aseaso]ls/imeconfiiets, persoflnl,n]dhealth)N4i

,AtteodedPre-Tcst

/N;97

lC5P=fat120DlrspringlO03

//SS=fmlt2003)' NotEnrolted(Reasens/ttmeconMets, vaeatlen,lttnessillN!IS]ocAtion,femily)personal,heAtth,

tt

'

tt

1

E"roued 1 N=Sl l{i3=fAIL!O021sptingleO]1"=rEUIO03} DidNotCempteteStudyMeaso]s/didnotattepd netmeetinclvs;oncriteriu,

IPost-Test,didstudy]

liL-30 repeated C"mpletedStudyN=S2C3L-fslnOO!lspringlOO] 11=ffi1110D3)

F-g.

1

Study

design

-

Flow

of

_participants

through

the

study.

ical

clearance.

Subjects

were excludecl

if

they were:

1)

diag-nosed with

dementia

or

Alzheimer's

disease,

2}

diagnesed

with a cardiepulmonary cendition that

limited

their

ability to exercise, or

3)

were receiving

format

physical therapy concurrent to

the

class.

After

meeting

the

inclusion

criteria, the subjects were

then

ellrolled

in

one of eight

cemmunity-based

FkellproofYTM

balance

and mobility

_group

classes

offered

in

the

FresnofClovis

area

during

September

2002

to

November

2003.

Each

subject was

tested

one week

prior

to

and one week

fellowing

the

eight-week

FallprooftTM

class,

Subject's

demographic

information

is

included

in

Table

1.

Design:

This

study was a repeated measure,

quasi-experimental

study

that

analyzed

the

effect of an eight-week rmulti-dimen-sional

Greup-Structured

Balance

and

Mobility

Class

<GBMC)

on selected

balance

ancl mebility measures oyer

time.

We

examined eight classes that were

held

in

the

falt

alld spring of

2002

through

2003.

In

all examined'classes, each

partici-pant

underwent

_pre-teszing,

GBMC

intervention,

and

post-testing.

Instrumentation

Each

participant

completed

two

subjective

tests

and

five

objective

tests

to

determine

balance

innpairments,

Subjective

Tests:

Balance

Etficacl,

Scale

The

Balance

Ei7icacy

Scale

{BES)

was

developed

by

Rose

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysical Therapy Association

The

Effects

of an

Eight

Week

thllproofvTM

Table

1

Demographic

Characteristics

Class

Comparing

of

Subjects

at

the

High

and

Low

Functioning

Participants

Beginning

ef

Intervention

(n=52)

319

Baseline

characteristicsHigh-level n=38

%

ofHigh-levelLow-Level n=14

%

ofLow-tevel# of

patients

total

%

of

total

Age:

51-60

61-70

71!80

81-90

91-100

3415151

7.910,539,539,5

2.6

1o373

7,1o2L455021,45

4318224

7.7

7.734.642.3

7,7

Gender:

Male

Female

1127

28.97Ll

o14

o100

1141

21,278,8

Diabetes

8

21,05

1

7,1

9

173

Heart

_problems

22

57.9

7

50

29

55.8

Osteoporosis

8

21.05

4

28.6

12

23,1

Arthritis

16

42,1

6

42,9

22

42.3

Stroke

2

5.3

3

21,4

5

9.6

Parkinson's

5

132

1

7,1

6

IL5

Numbness

in

feet

22

57,9

9

64.3

31

59,6

Jeint

replacerment

6

15,8

3

21,4

9

17,3

Use

of assistive

device

10

26.3

14

100

24

46.15

Falls

in

the

previous

year

23

60,5

10

71,4

33

63,5

Prescription

medications/

O-5

6.15

1622

42.157.9

86

57.142.9

2428

46.1553,85

Pathelogies

are

per

self report.

the

individual

while

_perferming

activities of

daily

living

that

require

balance.

Subjects

answered

18

questions, rating on a scale of

O

to

100%,

their

level

of confidence

in

_performing

a

given

task

_(e.g.

rise

from

a chair).

The

totalscore eblained

was

divided

by

1800

and multiplied

by

100

to

_get

a

per-centage.

The

percentage

determined

the

individual's

confi-dence

in

maintaining

their

balanee

during

activities of

daTly

living,

Subjects

who scored

less.

than or equal

to

50%

were

considered

to

have

low

self-confidence while

performing

var-ious

activities requiring

balance3).

Composite

Pdysical

Furection

Scale

The

Conrposite

Physical

Funetion

(CPF)

Scale3)39)

consists

of

12

questions

addressing a

person's

ability

to

cemplete

daily

activities, such as

heusehold

chores and shopping, with

or without

difficulty.

The

maxirnum score

is

24,

Objective

Tests:

Berg

Balance

Scale

anal

Fullerton

Advanced

Balance

71ests

Functional

balance

was assessed using one of

twe

tests:

the

Berg

Balance

Scale

_(BBS)4e)

of

14

items

or

the

Fullerton

Advanced

Balance

_(F)IB)3)

Scale

of

10

items.

Both

the

BBS

and

FAB

Scales

have

demonstrated

_good

test-re-test

relia-bility

and

inter

and

intra-rater

reliability5}40),

The

BBS

has

an excellent

inter-rater

reliabiUty of

O.96i4).

The

FAB

Scale

was

developed

as an alternative measure of

functional

limi-tations,

due

to

the

tendency

of the

BBS

to

_produee

ceiling

effects3).

Higher

functioning

adults with

balance

impairments

wM score

higher

on

the

BBS,

which may

be

interpreted

as

having

normal

balance.

An

individual

who scored

14

or

below

on the

CPF

was

defined

as a

lower

functioning

individual

and

the

BBS

was administered.

A

score aboye

14

on

the

CPF

xvas

defined

as a

higher

functioning

individual

and

the

FAB

was administered.

Both

tests

were scored using a

O-4

ordinal scale

for

each

item,

The

BBS

has

a maximurn score of

56.

A

score of

45

or

below

is

associated with a

high

risk

for

falls3).

The

items

on

the

test

progressively

challenge

the

individual:s

balance

while

performing

narrew

bage

of support activities

begin-ning

in

the

silting

positien

and ending with a one-legged stance

position,

The

test

additionally measured weight

shift-ing.

turning,

and reaching,

Materials

used

to

administer

the

BBS

include

the

following:

a stopwatch:

two

straight-backed chairs:

_(one

with armrests and one without armrests); a yard-stick; a slipper: and a

6-inch

bench.

The

FAB

is

also a

functienal

test

with a maximum score

of

40.

Unlike

the

BBS,

it

challenges sensory

integration

with

tasks

such as standing on

foam

with eyes closed and

waik-ing

with

head

turns,

Other

items

include

stepping up and

over an ebstacle,

jumping

for

distance,

and

tandem

walkTng.

Scores

on

the

FAB

Scale

also correlate with scores obtained using

the

BBS3).

According

to

Dr.

_Debra

_Rose

at

California

320

re\rkta\

State

University,

Fullerton,

a

F)IB

score ef

30!40

places

the

individual

at risk

for

falls

{personal

communicatien),

Materials

used

to

administer

the

FAB

include

a stopwatch, a

stick, a

12-inch

ruler, a

pen

or

penciL

a

6-inch

bench,

a

metronome, masking

tape,

two

stacked

AirExe

balance

foam

pads,

and one or more

12-inch

lengths

of non-slip material.

Modified

Clinical

71est

of

Sensory

Jnteraction

in

Balance

CrsIBJ

The

purpose

of

the

M-C71SIB7)

Ts

to

identify

whether

the

use of sensory

information

in

different

sensory environments

are normal or abnormal,

Subjects

were required

te

stand

quietly

for

30

seconds. with

feet

shoulder width apart and

arms

folded

across

their

chest

during

each of

the

following

four

conditions:

1}

eyes open,

firm

surface,

2)

eyes c}osed,

firm

surface,

3}

eyes open,

foam

surface

(two

stacked

AirExO

balance

foam

pads}

and

4)

eyes closed,

foam

surface.

The

individual

was scored

by

the

sum of the

four

collditions,

with

the

maximum score

being

l20

seeonds,

50-Fbot

Wdlk

71est

The

50-}7bot

IVdlh

flest

is

used to

identify

functional

itations

of

gait

by

measuring variability of velocity3).

Each

subject was asked

to

walk a

total

distance

of

70

feet,

first

at a

_preferred

speed and

then

at a

fast

speed.

The

distance

between

the

10-foot

and

60-feot

markers was timed.

The

purpose

of

this

test

is

to

determine

if

the

subject

is

able

to

adapt

hisfher

gait

speed

to

the

change

ln

task

demands3),

It

has

been

well

documented

that

low

or slow

gait

speeds

are associated with an

increased

risk

for

falls3)4i),

"Wttlleie-71ilhie"

_712st

The

"Wtxlkie-Talhie''

Test

is

used

to

measure

the

subject's

ability

to

divide

hisfher

attention

between

tasks3).

This

test

was

perforined

as

the

investigator

walked with

the

subject

to

the

location

of the

50-17bot

Wdlk

flest.

The

subject was

asked an epen-ended

_question

that required more than a

"yes''

or `'no" answer.

A

_positive

score was recorded

if

the

subject

stopped walking

to

answer

the

question.

Conversely,

a negative score was recerded

if

the

subject couid

ue walking while

he/she

answered

the

question.

Senior

Fitness

7lest

The

Senior

Fitness

Test,

developed

by

Rikli

and

Jones42),

consisted of a six-test

battery

that

incLudes

testing

upper

and

lewer

bedy

strength,

flexibillty,

aerobic endurance, and

dynamic

balance

and agility.

Materials

used

during

testing

include

a stopwatch, masking

tape,

a standard straight-back

chair without arms,

five

or eight

pound

dumbbells,

a

36-inch

measuring

tape,

and a eone,

This

assessment

has

strated reliability and validity42) and was

developed

to

test

underlying

_physical

impairments

associated with

functional

mobility.

The

results

from

these

tests

were compared

to

norm-referenced standards

based

on a sample ef

7,l83

munity-dwelling elder adults ranging

from

60-94

_years

of

age3)42),

Proeedures

Subjeets

were scheduled

fer

pre-testing

one week

prior

te

the

start of their

Fagiproof7TM

class,

Testing

toek

place

at

3

different

sites

in

the

Fresno

community where

the

Fallproof!TM

classes were

held.

Subjecis

were scheduled according

to

time

and convenience of

location.

Prior

to

testing,

allsubjects signed an

informed

consent

document

that

was approved

by

the

University

Committee

on

the

Protection

for

Human

Subjects.

Next,

each subject

filled

out a

Health

Activity

Questionnaire

that

consisted of

general

health

questions,

any

diagnosed

medical conditions,

a

histery

of

falls,

the

CPF

Scale,

as well as activity

leveL

In

addition

to

completing

the

Health

Activity

Questionnaire,

each subject completed

the

BffS.

Then,

an

investigator

who

was a

Certified

Balance

and

Mobility

Instructor

(CBMI}

per-formed

a comprehensive assessment of

balance

and

mobili-ty

skills,

The

CBMI

used the

FAB

or

BBS,

50-Foot

Walk

7lest,

''Wdlhie-7lrlhie"

_flest,

_Senior

_Fitness

_Test,

and

M-C71SiB

to

complete

the

balance

assessment

for

each

indi-viduaL

Each

CBMI

underwent

130

hours

of

theoretical

coursework and examinations, along with

50

heurs

ef

total

contact time

through

distance

learning

at

California

State

University,

Fresno

and was sponsored

by

California

State

University,

Fullerton

in

order

to

become

a

Certified

Balance

and

Mobility

Instructor.

The

pregram

collsisted of

the

the-oretical

basis

for

balance

and mobility,

the

rationale

for

develeping

a multidimensional

fall

risk reduction

program,

analyzing

the

role of

intrinsic

and extrinsic

factors

that

are associated with

falls,

and assessment of

balance

and

mobili-ty,

During

the

certification

process,

each

investigator

was

evaluated and

tested

by

the

course's

instructors

to

ensure

proper

administration and

interpretation

of assessment

tests,

The

order

for

testing

subjects was unsystematic and

based

on

the

availability

of

equipment.

Data

was recorded on a score sheet as each test was administered.

Ifa

subject scored

14

or

below

on the

CPF

Scale,

the

BBS

was conductecl,

During

the

BBS

the

subject was asked

to

_perform

the

fol-lowing

fourteen

items:

standing

from

a seated

_position,

stand-ing

unsupported, sitting unsupported, standing

to

sit,

trans-fers,

standing with eyes ciosed: standing with

feet

together;

reaching

forward

with outstretched arm;

picking

up a

slip-per

from

the

floor;

turning

to

look

behind

ever

left

and right

shoulders;

turning

360

degrees:

toe

tapping

on a six

inch

step-stool:

tanclem

stance; and standing on one

leg.

Conversely,

if

the

subject scored above

14

en

the

CPF

Seale,

the

FAB

was administered

in

pLace

of

the

BBS,

During

the

FAB

the subject was asked

to

perform

the

fol-lowing

10

items:

standing with

feet

together, eyes cLosed: reaching

ferward

to retrieve all object

held

at shoulder

Japanese Physical Therapy Association

NII-Electronic Library Service

Japanese _Physical Therapy Association

The

Effects

of an

Eight

Week

FaliproofrTM

CIass

height

with outstretched arm; a turn

360

degrees

in

a right

and

left

direction;

stepping up and over a six

inch

bench:

tandem

walking; standing

on

one

leg:

standing on

4-inch

foam

with eyes closed; a

two-foQted

jump;

walking with

head

turns; and reactive postural controL

The

M-CTSIB

was

_performed

by

having

the

subject stand

quietly

for

30

seconds with

feet

shoulder width apart and arms crossed over

their

chest

during

each of

the

follewing

four

conditions/

1)

eyes open,

firm

surface,

2}

eyes closed,

firm

surface,

3)

eyes open,

foam

surface, and

4)

eyes closed,

foam

surface,

Each

condition consisted of

three

trials.

If

the

subject was able

to

maintain

hislher

balanee

for

the

full

30

seconds

in

the

first

triaL

the

investigator

proceeded

to

the

next sensory cendition.

If

the

subject

lost

hisfher

balance,

lifted

the

arms or opened

the

eyes, then an average of all

three

trials

was recorded.

The

individual

was scored

by

the

sum of

the

four

conditions. with

the

maximum score

being

120

seconds.

The

50-Fbot

Wdlk

11est

and

the

"Wdlhie-fkelkie"

11est

were

performed

as

previously

described.

All

six

items

included

in

the

Senior

Fitness

Test

were

administered

in

accordance

to

the

protocols

outiined

in

the

Senior

Fitness

Manua142}.

Upper

extrernity strength was

assessed

by

performing

the

Arm

Curt

7lest.

The

subject was allowed

to

practice

one

to

two

bicep

curls

to

check

for

cor-rect

form

prior

to

performing

the

test.

A

score was

given

by

counting

the

number of

bicep

curls cempleted

in

thirty

seconds with

females

using a

five-pound

durnbbe]1

and males using an eight-pound

dumbbell.

Lower

extremity strength was measured

by

_performing

the

Chair

Stand

flest.

A

score was

_given

by

counting

the

number of

times

the

subject steod

from

an armless chair with

hands

crossed over

hisfher

chest

in

30

seconds.

The

subject was allowed

to

practice

standing up one

time

before

the

test

triaL

Upper

extremi-ty

flexibility

was evaluated

by

performing

the

Back

Scratch

Test.

The

subject was asked

to

reach one

hand

over

the

ipsilateral

shoulder and

down

the

back;

the

other

hand

reached around

the

back

and up

towards

the

other

hand

in

an attempt

to

touch

or overlap

the

extended

third

digits

of

both

hands.

The

subject

practiced

with eaeh arm

to

deter-mine

hislher

preferred

arm.

After

praeticing

zwo times using

the

preferred

arm,

two

test

trials

were

performed.

The

score was

then

recorded

to

the

nearest ih

_inch

_measuring

_the

dis-tance

of overlap er

distance

between

the

tips

ef

the

3rd

dig-its.

A

minus

O

score was recerded

if

the

3id

digits

did

not

teuch

ancl a

_plus

<+)

seere recorded

if

they

everlapped.

The

better

score of

the

two

trials

was circled.

Lower

extremity

ftexibility

was assessed

by

performing

the

Chair

Sit

and

Reach

Test,

Seated

in

a chair,

the

subject reached

for

one

foot

keeping

the

knee

fully

extended while the opposite

leg

was

kept

in

a

fiexed

position.

The

subject

practiced

the

test

Comparing

High

and

Low

Functiening

Participants

321

on

both

legs

to

deterrnine

which was

the

_preferred

leg,

Once

determined,

the subject

_practiced

two

times

to

warm-up,

then,

two

test

trials

were

performed,

The

distance

(inches)

between

the

tip

of

the

toe

and

tips

of

the

3'd

digits

were

measured and recorded,

The

midpoint at

the

toe

represented

the zero

_point.

If

their

reach was short of

this

point,

the

distallee

was recorded as a minus

(-)

score;

if

the

middle

gers

touched

their

toe,

a score a zero was recorded; and

if

the

subject reached

past

the

midpoint of

their

toe,

the

tance

was recorded as a

plus

(+)

score.

Aerobic

endurance

was ascertained

by

administering

the

2-minute

Stqp

11est,

The

step

helghz

was established

for

each

individual

by

ing

the

subjects stand sideways next

to

the wall with arms

resting

by

their sides.

The

wall was marked with a

_piece

of

tape

at

the

height

of

the

tip of the middie

finger.

The

tape

represented

the

minimum

knee-stepping

height

for

the

subject.

The

subject was asked

to

march

in

place

liftTng

the

knees

above

the

tape

for

two

minutes.

The

score was

the

number of

full

steps completed

by

one

lower

extremTty

in

two

minutes.

Dynamic

balance

and agility was

determined

by

the

subject's

performance

on

the

8-Fbot

VP

and

Go

Tlest.

Subjects

were

timed

to

see

how

quickly

they could stand

from

an armless chair, walk around a cone

_placed

8

feet

away, and return

to

the

originat

_position.

The

subject was

allowed one

practice

trial

fo11owed

by

two

test

trials,

The

better

score of

the

two

test

trials

was

circled.

The

nents of

the

Senior

Fitness

Test

were modified and

ed

if

the

subject was

incapable

of

performing

the tesz

_per

protocol

(i.e.,

using

hands

to

push

up

from

the chair

for

the

Chair

Stand

7kest,

or

holding

onte

the

wall!chair

for

the

minute

Step

7lest).

After

pre-testing,

the

results of

the

senior

firness

tesr

zvere

discussed

with each subject, comparing

hislher

scores

to

normative

data.

In

addition,

the

EAB

or

BBS,

50

17bot

Wdlle

Test,

'tWttlkie-7kelfeie"

Test

and

M-CTSIB

were analyzed

by

each

CBMI

to

determine

any

balance-related

impairments

and

the

results were recorded on an

individualized

Fal(proof.tTM

report card.

Prior

te

the

intervention,

cian's clearance was obtained

for

each subject

that

gave

mission

for

participation

in

the

Fal(proof!TM

class.

Following

the

eight-week

inzervention,

subjects were

tested

adhering zo

the

same

procedures

deserlbed

above.

Intervention

Subjecls

who met

the

inclusion

crlteria were

placed

in

one of eight

FtzllprooffTM

classes

that

were

held

from

spring

2002

through

fall

2003.

The

primary

instructor

for

the

week

_group

class was a

CBMI.

In

addition

to

the

CBMI,

graduaze

physical

therapy students, as

part

of

the

graduate

curriculum, underwent

12

hours

of

training

to

assist

in

ance re-training techniques

taught

_by

a

faculty

member of

322

ve#fith7

California

Sate

University,

Fresno,

who

is

also a

CBMI,

Based

on

the

impairments

identMed

through

the

pre-testing

sions,

the

primary

instructor

for

the

class

developed

priate

lesson

plans

for

each class sessien,

The

lesson

plans

were

based

on

the

theory

and applications

taught

in

the

Balance

and

Mobility

Certification

course.

The

CBMI's

ated a struetured and

progressive

program

of activities

specifically

designed

to address

the

multiple

dimensions

that

contribute

to

balance

and mobility.

The

Fallproof!TM

cere

program

components consTsted of center of

gravity

control

training,

mulitsensory

training,

proactTve

and reactive

tural

strategy

training,

gait

pattern

enhancement

traTning,

and strength and

flexibility

training,

These

elements were

systematically

introduced

and

_progressed

from

a

low

to

high

level

of

balance

challenge

by

manipulatien of

the

ment and

task

demands.

Environmental

changes

included

decreased

availability of vision and altered support surfaces.

Task

demand

changes

include

decreasing

the

base

of

port,

varying arm

positions,

and adding cognitive

tasks.

Each

subject

in

the

class

performed

the

activity at an

ate

level,

based

on

their

individual

impairments

as

mined

by

the

CBMI,

The

class met

two

times

a week

for

eight weeks with

each sessioll

lasting

for

one

hour.

For

the

first

10-15

utes,

the

instructor

Ied

the

class

in

a warm-up

that

porated

gait,

range of motion, strength and coordination,

Throughout

the

intervention,

the

subjects

perfermed

ties

as a

group

and

then

divided

up

in

to

sub-groups

to

ticipate

in

specific

balance

activities.

Each

balance-related

activity was

demonstrated

along with

the

rationale of

how

it

can maximize an

individual's

sensory

Tntegration

ness within

the

home

and community.

The

classes ended

with a

10-minute

coel-down

that

consisted ofstretching,

cleep

breathing

and a review of activities.

Throughout

the

vention,

both

the

CBMI

and

physical

therapy

graduate

dent

helpers

provided

assistance and

guarding

to

ensure

the

safety of

the

subjects at all

times.

The

ratios of

helpers

to

subjects ranged

from

1:1

to

1/3

among

the

eight

FZillproofYTM

classes.

In

this

multi-dimensional approach

to

balance,

extrinsic and

intrinsic

factors

were addressed with each subject

ally,

During

the

second

to

third

week, the subjects were

given

a

home

safety check effsheet

in

order

to

assess

their

heme

conditiens

for

extrinsic

facters,

which could contribute

to

falling.

The

home

safety check off

list

provided

ness of

_potential

hazards

throughout the

home

that

eould

creaze a

fall,

Suggestions

were

_given

for

modification

to

ate a safer environment,

At

the

fourth

ancl

fifth

week,

the

subjects were

given

an

individuaEized

home

exercise

gram

(HEP)

that

consisted of upper and

lower

extremity

stretching and strengthening with a

theraband,

head-eye

eg34#eg8e

ceordmalion exercises, and aczivities

that

challenged multi-sensory systems.

Data

analysis

The

scores of

the

fifty-two

subjects who met

the

inclu-sion criteria were used

for

data

analysis,

Repeated

measures

two-way

analysis of variance

(ANOVA}

was

performed

on

ten

outcome variables

(BES,

M-CTSIB,

50-Foot

Wdlk

lpre･

ferred},

Chair

Stand

7lest,

Arm

Curl

71est,

2

Minute

Step

71!st,

Chair

Sit

and

Reach

7lest,

Baefe

Scratch

flest,

8-Foot

UP

and

Go

11?st,

and

FAB

or

BBS.)

using

Statistical

Package

for

the

Secial

Sciences

{SPSS,

Microsoft

Windows

version

11.0a}.

The

"Wdlfeie-lhlkie"

_71?st

was not used

for

data

analy-sis

because

51

of

the

52

subjects received a negative score

leaving

no room

to

demonstrate

change.

Descriptive

data

are reported

for

variables of

interest

{mean,

standard

devi-ation, and

95%

confidence

interval)

using

Microseft

Excel

2000e.

_The

twe

independent

variables

in

this study were

time

(pre-post)

and

group

(high

or

low).

The

between-groups

variance explains

the

independent

variable effects, and

the

error variance accounts

for

all sources ef variation

unex-plainecl

by

treatment.

Because

this

design

incorperates

two

indepelldent

variables, we were able

to

ask

three

questions

of

this

data:

1,

Factor

A

(time):

What

is

the

effect of

Tnter-vention on subjects regardless of

their

status?

2.

Factor

B

{group):

Was

there

a

difference

in

perfermance

between

low

level

and

high

level

subjects?

3.

Interaction:

Did

the

inter-vention effect

depend

on status of subjects?

Results

Table

2

_presents

two-factor

repeated measure

ANOVA

fer

two

independent

variables:

time

(prepost)

and

group

(high

level-low

leveb.

There

was a significant

imprevement

over

time

in

alleutcome measures except

Chair

Sit

and

Reaeh

712st.

There

was a significant effect on

group

status

for

BES

(Fig.2),

M-C71glB

(Fig.3),

BBSfFAB

(Fig,4),

Chair

Stanel

Tlest

(Fig.

5),

2-minute

Stqi)

71est

(Fig.

6),

and

8

Fbot

tlp

and

Go

71est

{Fig.7).

There

was an

interaction

of

time

by

group

for

the

M-C7SIB

and

8-Fbot

Clp

and

Go

71est

with

the

low

level

group

demonstrating

greater

improvements

(Fig.

3

and

7).

Results

frem

the

FAB

and

BBS

tests

are

presented

in

Table

2,

which shows significant main effect

from

the

inter-ventien;

however

there

was ne

Tnteractien

between

groups

(Fig.4}.

The

majority of

the

partTcipants

(88%)

participated

in

75%

or more of the classes

_(Table3).

Statistical

analysis,

two-factor

repeated measure

ANOVA,

indicates

no signifi-cant

difference

in

the

outcome measures

based

on

the

num-ber

of classes

in

which

the

subjects

participated

<p>O.05).

Discu$sion

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysicalTherapy Association

The

Effects

of an

EightWeekFZillproofVTM

CIass

ComparingHigh

and

LowFunctToningParticipants323

Table

2Two-wayRepeated

MeasureANOVA

forTen

OutcomeMeasures

OutcomeMeasures

Mean

Pre-Test

n=38High

level

(

±

SD}

MeanPost-Test

n=38High-level

{

±

SD)

MeanPre-Test

n=14Low

level

(

±

SD)

MeanPest-Test

n=14Low

level

(

±

SD)

MInain

Effect

M

terventlonain

EffectStatusMain

Effect

Stalus

X

Intervention

p

value

BES

66,91

±

18.472.53

±

16.6

43,29

±

14.653.38

±

23.1O.O02

S

o.ooo

s

O.349

NS

M.CTSIB

I04,23

±

16.1103,91

±

15.6

82.42

±

13.193,28

±

12,4O,O14

S

o.ooo

s

O,O09

S

50-Foot

Walk

PreferredTest

3.17

±

3.142,30

±

L94

5,54

±

8.263,42

±

3.05O,O19

S

O.I03

NSO.321

NS

ChaTrStand

Test

8.84

±

3,229,47

±

3.76

5,71

±

3.05Z32

±

3.04O,O13

S

O,O09

S

O.269

NS

ArmCurl

Test

11,50

±

4.7813.08

±

4.94

10.64

±

3.1811.57

±

1.51O.024

S

O.350

NSO.550

NS

2-pt(inuteStep

Test

62.61

±

2L273.89

±

21,O

46,50

±

17.951.79

±

14.4O,OOI

S

O.O02

S

O.208

NS

Chair

Sit

Testand

Reach

_-4.13

±

5.58-3.85

±

5.18

-5.54

±

4.57-5.14

±

5.69O.509

NSO.400

NSO.909

NS

BackScratch

Test

.6.53

±

5.68-6,331

±

5,77

-6,64

±

5.44-4,157

±

6.41O,048

S

O,545

NSO.090

NS

8-FootUp

and

Go

Test8.81

±

2.308.65

±

2.88

12.93

±

3.01IL21

±

2.34O.O02

S

o,ooo

s

O,O07

S

#BBSbinedand

_FAB

com-52.7

±

16259.87

±

17,5

59,74

±

16.572.14

±

l3.7o.ooo

s

O,047

S

O.190

NS

p<O.05"%ofstatistically

significant. maximuln,

1OO

90

80ge

70U

6o]fi

50>E

40g

3o

20

10

o

Fig

High

level

Low

level

Total

.2

Mean

percentage

value ef

BES

between

low

level

groups,

*

Indicates

a significant

ment of confidence

level

(p<O.05)

in

the

and overall tetal

_post-test

scores.

140120100m

80v88

6oco4020

Fig

o

high

andimprove-low-levet

High-level

Low-level

Tetal

.

3

Mean

M-CTSIB

scores comparing

high-level

and

low-level

subjects.

Error

bars

represent

subjects standard

deviation,

'

Indicates

a

significant

difference

(p<O.05)

in

the

low-Ievel

and overall

total

post-test

scores.

100

90

80gE

70'G'

6oE6

50ge

40

30

20

"o

o

Fig.

4

14

12

dOv=es

8se6--.co

4

2

o

BBS

FAB

Total

BBS

and

FAB.

Low

level

_group

took

BBS

and

high

level

group

took

FAB.

*'

Indicates

_{a significant}

improvement

{p<O,05)

in

the

BBS

and

FAB

post-test.

Error

bars

represent

between-subjects

stan-dard

deviation.

Fig.

5High-levelLow-levelTotalNormreference

Comparison

of

Chair

Stand

Test

between

high

and

low

level

groups.

"

Indicates

a significant

improve-ment

(p<e.05)

in

the

low-level

and overal1

post-test

scores.

##

Indicates

nermative referenee standard

for

women

between

7579

years within

50th

_percentile.

Error

bars

represent

between-subjects

standard

devi-ation.