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Balance Training in Elderly Women Using Public Parks a

Raquel Leiros-Rodríguez & José L. García-Soidan a


College of Physical Therapy, University of Vigo, Pontevedra, Spain


Faculty of Education and Sport Sciences and College of Physical Therapy, University of Vigo, Pontevedra, Spain Published online: 11 Jun 2014.

To cite this article: Raquel Leiros-Rodríguez & José L. García-Soidan (2014) Balance Training in Elderly Women Using Public Parks, Journal of Women & Aging, 26:3, 207-218, DOI: 10.1080/08952841.2014.888220 To link to this article:

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Journal of Women & Aging, 26:207–218, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0895-2841 print/1540-7322 online DOI: 10.1080/08952841.2014.888220


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Balance Training in Elderly Women Using Public Parks RAQUEL LEIROS-RODRÍGUEZ College of Physical Therapy, University of Vigo, Pontevedra, Spain

JOSÉ L. GARCÍA-SOIDAN Faculty of Education and Sport Sciences and College of Physical Therapy, University of Vigo, Pontevedra, Spain

This study evaluates the effects of a balance training program developed in public parks on functionality and general state of health in elderly women. It was a randomized controlled trial. Women older than 65 years ( n = 28; 68.5 ± 2.9) participated in a balance training program that lasted 6 weeks, with sessions taking place twice a week (12 exercises/session, 50 min). Balance was analyzed by the Berg Balance Scale and Timed Up & Go Test. The generic health status was measured by the SF-12 Health Survey. These tests showed statistically significant differences in the experimental group ( p < .05). Public parks are adequate installations for developing balance. KEYWORDS postural balance, elderly women, exercise therapy

BACKGROUND Earlier studies on the prevention of falls have presented diverse results, due to the lack of specially applied treatments. These programs should respect the basic principles of the guidelines about the falls of the aged and should develop a proper means of the same (Feder, Cryer, Donovan, & Carter, 2000; Skelton, 2001). Address correspondence to José Luis García-Soidan, University of Vigo, Faculty of Physical Therapy, Campus a Xunqueira, 36005-Pontevedra, Spain. E-mail: [email protected] 207

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R. Leiros-Rodríguez and J. L. García-Soidan

In recent years, more investigations have shown that doing physical activity during free time can improve the state of physical health and the social integration of elderly people (Ebrahim, Wannamethee, Whincup, Walker, & Shaper, 2000; Ferraro, Su, Gretebeck, Black, & Badylak, 2002; Hassan, Joshi, Madhavan, & Amonkar, 2003; Stuck et al., 1999), including those who suffer from chronic diseases or reduction of their mobility that cause disability and/or fragility (Chen, Bermudez, & Tucker, 2002; Mather et al., 2002; Skelton, 2001; Spirduso & Cronin, 2001; Stuck et al., 1999). Thus, doing physical activity in moments of free time can act against the three main risk factors related to disability: the biological risk, the psychological risk, and the social risk (Stuck et al., 1999). Applying ecological models to promote physical activity has shown that surroundings influence exercise habits (King et al., 2005; Sallis et al., 2006). Indeed, certain areas and installations produce a positive effect on some behavioral traits of the population, increasing their participation in physical exercise (McCormack et al., 2004; Wendel-Vos, Droomers, Kremers, Brug, & Van Lenthe, 2007). Therefore, open public spaces, like parks, represent a potential social and health resource that is often not recognized as such and even less since the last decade has been the subject of investigations (Maller et al., 2009; Sallis, Bauman, & Pratt, 1998). This has his origin by a changing conception of public parks as a natural, accessible, and available space for every group of the population (whether it is by age, ethnicity, cultural, and or socioeconomic; Prüss-Üstün & Corvalán, 2006). Thus it is clear that public parks can be used by elderly people for recreational activity and social interaction (Giles-Corti et al., 2005; Godbey, Caldwell, Floyd, & Payne, 2005; Owen, Humpel, Leslie, Bauman, & Sallis, 2004; Sallis et al., 2006). Different investigations from many disciplines have promoted an increase in using public parks for exercise (Godbey et al., 2005; Sallis et al., 2006). The aim of this investigation was to analyze how a program of specific balance training conducted on the equipment of a public park can influence the state of balance and general health in the elderly female participants.

METHOD Study Design and Sample For the selection of the participants, a randomized controlled trial was carried out in senior centers in the city of Ourense (Spain), with the following inclusion criteria: women older than 65 years old with a deteriorating sense of balance who are able and willing to participate. Exclusion criteria included: participants diagnosed with a neurological, sensorial, or vestibular disorder or cognitive impairment; those who need external devices to aid walking;

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Balance Training in Elderly Women


FIGURE 1 Flow diagram.

those with medical contraindications for exercise or without having obtained informed consent; and those who exceeded the Berg Balance Scale (BBS) and/or Timed Up & Go test (TUG). Forty-two healthy women (68.5 ± 2.9 years) participated in the study. All subjects signed informed consent prior to participation in the study, in accordance with the Helsinki declaration; this investigation was approved by the Research Committee (exp.12/2011). The assignment of the participants to either the experimental (EG) and controlled group (CG) was based on a randomization process that can be observed in Figure 1.

Measurement Procedure A personal interview and a health check were completed by the doctor for each participant. Personal information collected in the interview and possible risk factors of the contraindications for exercise were identified using a Physical Activity Readiness Questionnaire (PAR-Q; Balady et al., 1998) and the cognitive state assessed with the Mini Mental State Examination Test of Folstein (Crum, Anthony, Bassett, & Folstein, 1993). The evaluation of the


R. Leiros-Rodríguez and J. L. García-Soidan

participants done by a qualified physical therapist included the state of functional balance quantified on the Berg Balance Scale (BBS; Bogle Thorbahn& Newton, 1996; Riddle & Stratford, 1999; Wang et al., 2006), the Timed Up & Go test (TUG; Mathias, Nayak, & Isaacs, 1986; Shumway-Cook, Brauer, & Woollacott, 2000), and evaluation of the quality of life related to health taken from the SF-12 Health Survey (Jenkinson et al., 1997; Ware, Kosinski, & Keller, 1996; Ware, 2000). The tests that assessed balance and quality of life were repeated at the end of the intervention.

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Balance Training Program The program was completed in a public central park near the participants’ residence. The training program had a duration of 12 sessions, with a frequency of two days a week. Before the beginning of the program, the physical therapist and the doctor analyzed the equipment in this park, and then they adapted the balance exercises that should be performed on each apparatus (Figure 2). Each session lasted for 50 minutes, and the training was conducted by a qualified physical therapist. The first 10 minutes were dedicated to warming-up exercises. The following 30 minutes were spent completing specific exercises to train balance, and the remaining 10 minutes were devoted to cooling down. The sessions were performed in groups for each exercise circuit so that participants interacted with each other and with the instructor. On rainy days (there were only two), the sessions were done in a covered pavilion near the park, using the same protocol and duration, except that the dynamic- and static-form balance exercises used the help of a companion for support. Each of the 12 exercises included in the balance training program had a specific objective: to expose the participants to situations in which they might be unsure of their stability and to demonstrate problems with movement that could restrict them in daily life or in combined tasks. The program was applied in a safe and specified way to improve the static and dynamic balance necessary for adequate functionality of the elderly by using all the equipment that we found in the public park in which this intervention was conducted. The women of the CG continued with their normal life and did not participate in any balance program. The exercises can be observed in Figure 2. All the exercises were done in a slow and controlled way to improve the sensory consciousness of the movements, coordination, and transfer of weight. Each exercise had a duration of 60 seconds, followed by a 60-second break (which the subject used to change position for the next exercise), and the whole circuit was repeated twice. When the required tasks were completed successfully, they evolved in complexity by challenging the body position through the modification of the size and characteristics of the base support surface.

Balance Training in Elderly Women


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Balance exercises

Exercise 1. Dynamic balance

Exercise 4. Static balance

Exercise 7. Static balance

Exercise 10. Static balance

Exercise 2. Dynamic balance

Exercise 3. Static balance

Exercise 5. Dynamic balance

Exercise 6. Static balance

Exercise 8. Dynamic balance

Exercise 9. Dynamic balance

Exercise 11. Dynamic balance

Exercise 12. Dynamic balance

FIGURE 2 Exercises performed with the experimental group (dynamic and static balance).


R. Leiros-Rodríguez and J. L. García-Soidan

Statistical Analysis

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The description of each of the variables was performed separately using the calculation of the mean and standard deviation (SD), and the variables were tested for normality and homoscedasticity. The covariance values and the Pearson statistic were calculated. ANOVA analysis and Games-Howell tests were done to compare means pre- and posttreatment, intragroup and intergroup. The differences were considered significant for p < .05. All data were analyzed with SPSS 19.0 software.

RESULTS The average number of sessions attended by participants in the experimental group was 10.57 ± 1.6. Throughout the course of the study seven participants dropped out, representing a rate of adherence to the program of 66.7%. First, we made sure that no significant differences were observed in pretreatment between the CG and the balance training group for age variable, the initial test measurements of balance, and SF-12 Health Survey. The results of contrast analysis between and within groups (Table 1) of the valuations of the BBS, the TUG test, and the SF-12 showed statistically significant differences for the EG. In addition, the SF-12 Health Survey identified changes in the different dimensions of overall health (total score). Thus, significant improvements were seen posttreatment in EG in the SF12 subscores for: bodily pain (p = .007), vitality (p = .002), general health (p = .02), physical function (p = .006), mental health (p = .009), and physical role (p = .001). By contrast, no significant differences were found for social functions (p = .2) or emotional role (p = . 07). The correlation of pretest assessments identified at the beginning of the intervention program was a negative relationship between age and the result in the BBS (p = .02) and between the BBS and the TUG test (p = .004). TABLE 1 Assessments of Balance State Group Balance group (n = 14): Age (69 ± 3.2) Pretreatment Posttreatment Controlled group (n = 14): Age (68 ± 2.7) Pretreatment Posttreatment




45.86 ± 2.91 54.07 ± 1.98

11 ± 1.3 6.71 ± 0.73

49.36 ± 3.2 54.93 ± 1.8

47.79 ± 3.38 47.71 ± 2.89

11.14 ± 1.68 10.93 ± 1.49

50.29 ± 2.5 50.79 ± 2.3

Note. Values are mean ± SD; BBS: Berg Balance Scale; TUG: Timed Up & Go; SF-12: SF-12 Health Survey (total score).


Balance Training in Elderly Women TABLE 2 Correlations Between Assessment Tests

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Pretreatment evaluation: Berg Balance Scale Age Timed Up & Go Timed Up & Go SF-12 Posttreatment evaluation: Berg Balance Scale SF-12 Timed Up & Go Timed Up & Go SF-12

−.426∗ −.532†


p Value

−8.028 −2.098

.024 .004




.526† −.881†

242.874 −8.687

.004 .000‡




Note. Those variables that were significantly related to the stride line variability are listed. The r value is the Pearson product-moment correlation coefficient. The cov value is covariance. SF-12 is the total score. ∗ correlation is significant at the .05 level. †correlation is significant at the .01 level. ‡p < .001.

TABLE 3 SF-12 Subscores Variations pre posttreatment in EG Subscore


Bodily Pain Vitality General Health Physical Function Mental Health Physical Role Emotional Role

.007 .002 .02 .006 .009 .20 .70

In turn, the TUG test showed negative correlation with a previous selfassessment of the participants in their “Physical Role” in the SF-12: the longer (in seconds) needed to complete the TUG test, the worse the score for their physical abilities). At the end of the program, in the analysis of posttest assessments, positive correlations related to balance were found between the results of the SF-12 Health Survey, the BBS, and the TUG test. However, the test results between the TUG test and BBS, continued interacting in reverse at the end of the experimental intervention (Table 2).

DISCUSSION Firstly, it should be pointed out that there was a significant rise in the functional state of balance: an improvement by 8 points on the BBS, and a reduction by 4 seconds on the TUG test. This shows that the efficiency of the intervention program was acceptable, and the activities were well tolerated.

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R. Leiros-Rodríguez and J. L. García-Soidan

With respect to the prevention of falls, it is necessary to take into account that the exercises completed during the sessions increased balance significantly, as shown by the TUG and BBS results before and after the intervention program. The program also improved other capacities that are useful for daily activities, as shown in the increase of the physical role (SF-12) score posttreatment (p = .001) and the general health score (p = .02). Our results agree with those obtained by Barnett et al. (2003), who demonstrated that programs that improve balance decrease the risk of falls in older people. Therefore, we think that a safe and sustainable health-promoting program like ours can be developed in a public park in a practical setting; therefore policy makers can encourage elderly people to use public parks to improve their health. In addition, this program, as a recreational activity for the elderly, has shown to have positive effects in the general state of health, especially in some of the aspects of well-being estimated by the SF-12 questionnaire: vitality (p = .002), general health (p = .02), physical function (p = .006), mental health (p = .009), and physical role (p = .001). Above all, the questions that refer to the benefits of health and physical condition have important consequences and confirm the ideas shown before through other studies of the necessity to promote physical activity as a measure to prevent disability. Some of the authors of these studies pointed this out as an effective improvement for functional difficulties if moderate or intense exercise is done at least two times a week (Barnett, Smith, Lord, Williams, & Baumand, 2003; Lampinen, Heikkinen, Kaupinnen, & Heikkinen, 2006; Simoes et al., 2006). The effects of our intervention program aren’t limited to the field of physical health; they also produced significant changes in vitality and mental health (vitality p = .002; mental health p = .009), which reduced the impact of depression and anxiety in the elderly who participated in physical activities (Lampinen et al., 2006; Zaitune et al., 2010). As for improving the program, we found no differences in social function (p = .2) and emotional role (p = .07) before and after the program, which might be because the designed program was of short duration (12 weeks); emotional and social aspects need a longer period of contact between the participants to produce significant improvements, and age group comparisons of social function and emotional role can be affected by differences in education, as well as age and economic level, aspects that are detailed in the work conducted by Fleishman and Lawrence (2003). Further study is required to understand demographic factors that give rise to social and emotional differences in reported SF-12 subscores. We have to consider the higher life expectancy of women to design health-promoting programs in public parks for the last decades of their lives. In this intervention, the total dropout rate was 33% (participants who left the program and/or missed more than half of the sessions). This implies a high but relative percent, as some of the excluded participants in the analysis were willing to return to the program after missing various training sessions

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Balance Training in Elderly Women


(for health or personal reasons). In addition, taking into account the high dropout risk during the first few weeks of the start of the program, the adhesion rate will be more positive. Regarding this point, the recommendations included in this program have been described previously in other publications (Lampinen et al., 2006; Zaitune et al., 2010)—such as including group-based activities, which have improved the motions and efficiency of the elderly in their daily activities that need stimulus and positive feedback from the instructor. Among others, we also found it necessary to individualize and adapt the exercise program to the capacities and limitations of each participant, according to their health. This helped to increase their confidence in performing practical activities, alleviating anxiety and associated pathologies that limit them functionally and socially. With regards to the inclusion of parks where the intervention takes place, it should be pointed out that these installations proved safe to carry out experiments in how to promote physical activity in the elderly. This is a fundamental premise for any intervention and particularly for this one, which developed activities that challenged the balance of participants; each apparatus of every park should be analyzed for balance exercises. We should also point out that the main limitations of this study were related to the small size of the sample, and that it was formed solely by women. Moreover, the difficulty in evaluating long-term effects must be taken into account in future investigations. Therefore, the results obtained in this study indicate that public parks have adequate equipment for developing intervention programs related to balance and make the practice of regular exercise easier. Hence, the design of the installations of these spaces provide safe and accessible use for the elderly. Thus, this article proposes a further step in the use of communal spaces like public parks for development of public health interventions, which has been suggested by various scientific studies (Bedimo-Rung, Mowen, & Cohen, 2005; Buchner & Gobster, 2007; Di Pietro, 2001; Humpel, Owen, & Leslie, 2002). After analyzing and discussing the results, we can declare that this program developed in public parks has been efficient for elderly women; it has contributed to an increase in their balance and an improvement of their general health. Policy makers can encourage elderly people to use public parks to improve their health. This can diminish the number of falls and the resulting consequences for this population of elderly women. Furthermore, the program has achieved an improvement in the general health of the participants, which includes physical and psychosocial aspects of great importance for healthy and successful aging.

ACKNOWLEDGEMENTS We thank the elderly women who participated in this investigation for their time and effort.


R. Leiros-Rodríguez and J. L. García-Soidan

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Balance training in elderly women using public parks.

This study evaluates the effects of a balance training program developed in public parks on functionality and general state of health in elderly women...
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