Disability and Rehabilitation
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20
Short stick exercises for fall prevention among older adults: a cluster randomized trial Katsushi Yokoi, Kouichi Yoshimasu, Shigeki Takemura, Jin Fukumoto, Shigeki Kurasawa & Kazuhisa Miyashita To cite this article: Katsushi Yokoi, Kouichi Yoshimasu, Shigeki Takemura, Jin Fukumoto, Shigeki Kurasawa & Kazuhisa Miyashita (2015) Short stick exercises for fall prevention among older adults: a cluster randomized trial, Disability and Rehabilitation, 37:14, 1268-1276, DOI: 10.3109/09638288.2014.961660 To link to this article: http://dx.doi.org/10.3109/09638288.2014.961660
Published online: 22 Sep 2014.
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Date: 05 November 2015, At: 16:32
http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(14): 1268–1276 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.961660
RESEARCH PAPER
Short stick exercises for fall prevention among older adults: a cluster randomized trial
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Katsushi Yokoi1,2, Kouichi Yoshimasu2, Shigeki Takemura2, Jin Fukumoto2, Shigeki Kurasawa1, and Kazuhisa Miyashita2 1
Department of Rehabilitation Sciences, Kansai University of Welfare Sciences, Osaka, Japan and 2Department of Hygiene, School of Medicine, Wakayama Medical University, Wakayama, Japan Abstract
Keywords
Purpose: To investigate the effects of short stick exercise (SSEs) on fall prevention and improvement of physical function in older adults. Methods: A cluster randomized trial was conducted in five residential care facilities. The intervention group (n ¼ 51) practiced SSEs for six months, followed by routine care for six more months. The control group (n ¼ 54) received ordinary care for 12 months. The primary outcome measure was the number of fallers, taking into account the time to first fall using the Kaplan–Meier method. The secondary outcome measures were physical and mental functions. Results: The number of fallers was significantly lower in the intervention group (n ¼ 6) than in the control group (n ¼ 16) during the 12 months. The adjusted hazard ratio for a first fall in the intervention group compared with the control group was 0.15 (CI, 0.03 to 0.74, p ¼ 0.02). The fall-free period was significantly longer in the intervention group than in controls (mean ± SD, 10.1 ± 3.0 versus 9.0 ± 4.1 months, p ¼ 0.027). The functional reach and sit and reach tests were significantly improved at three and six months. Conclusion: The SSEs appeared effective for fall prevention and improvement of physical function in older adults.
Exercise, falls, older adults, residential care History Received 22 December 2013 Revised 21 August 2014 Accepted 1 September 2014 Published online 22 September 2014
ä Implications for Rehabilitation
The newly developed short stick exercises appear an effective means of reducing falls among older adults in residential care facilities. The short stick exercises seem to have an immediate effect on improving physical functions. Effects gained by performing the short stick exercises, such as static balance, flexibility and agility may last for six months. The short stick exercises were found to be easy for older adults to practice continuously in residential care facilities.
Introduction Falling may shorten the duration of healthy life and decrease the quality of life (QOL) [1]. The annual cumulative incidence of falling has been reported to be approximately 30% among older adults in the community and as high as 50% among residents living in institutions [1]. Therefore, there has been a need to collect and examine evidence for the effectiveness of fall prevention programs in institutional settings [2]. The most commonly identified risk factors for falls in older adults are loss of muscle strength and flexibility and impaired balance and reaction time [3,4]. Balancing ability is affected by the visual system, vestibular system, somatesthetic system,
Address for correspondence: Katsushi Yokoi, MS, Department of Rehabilitation Sciences, Kansai University of Welfare Sciences, 3-11-1 Asahigaoka, Kashiwara, Osaka 582-0026, Japan. Tel: +81-72-978-0088. Fax: +81-72-978-0377. E-mail: [email protected]
muscular strength and reaction time [5–7]. Not only impaired dynamic balance but also impaired static balance increases the risk for falls [8]. It should be noted that these functions deteriorate with age. A study that analyzed rapid steps to regain balance during a forward fall showed that older adults have longer reaction times for taking steps than younger adults [9]. An effective method to prevent older adults from falling needs to be established. Certain multifactorial approaches, including individual risk assessment of falls and exercise interventions, have been shown to be effective [10,11]. Regarding other exercise interventions, balance training and tai chi were also found to be effective [2,12,13]. In particular, the Otago Exercise program [14] and the LIFE study [15] showed concrete exercise methods. However, few studies have thoroughly described the frequency, types and details of exercises in care facilities. In addition, a majority of interventions require special equipment, space and complex protocols. Effective activity programs must be safe for older adults to practice.
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DOI: 10.3109/09638288.2014.961660
Therefore, we developed short stick exercises (SSEs) that involve the throwing and catching of a short stick while sitting in a chair to accustom older adults to postural imbalance, thus preventing their falling and stumbling. The SSEs could be a fall prevention exercise focused on the modifiable risk factors of physical functions for falls. The SSEs consisted of six steps. Step one was for warming up, and steps two through six included throwing, catching, keeping, flipping and dropping a short stick. Movements that combine two or more physical functions were found to be effective for fall prevention in a previous study [10]. The SSEs combine movements with balance, flexibility and agility during the throwing and catching of a stick. Furthermore, the SSEs involve the shifting of body weight and rotation of the trunk required in tai chi [16]. The balancing action in combination with rapid reaching movements is critical for fall prevention [17]. The SSEs include the frequent reaching for the short stick task, which may enable older adults to achieve a quick response to their environment even from a seated position. In our pilot study in a local community, performance of the SSEs decreased the number of older adults experiencing falls [18]. We randomly assigned 62 older adults from four municipalities to the intervention group (SSEs twice per week for six months) or the control group (a routine daily schedule for six months). The number of fallers was significantly decreased in the intervention group (n ¼ 2) compared with the control group (n ¼ 9) during the six months. Furthermore, the performances of the functional reach and sit and reach tests in the intervention group were significantly improved. We hope that the benefits gained from exercising in a relatively safe position will lead to improving independent, free-standing, locomotor control and thus prevent future falls. In the current study, the effects of the SSEs on fall prevention were investigated among older adults in residential care facilities. We hypothesized that performing the SSEs for six months would reduce the number of fallers and improve physical function, particularly balance, in institutionalized older adults. This hypothesis was based on our pilot study involving community-dwelling older adults.
Methods Subjects and study protocol As clusters for the study, the residential care facilities with 50 beds in the Kinki area in Japan, where no intervention for fall prevention was conducted, were recruited. Five residential care facilities (n ¼ 240; 10 beds were unoccupied at the time of recruitment) met the criteria and were enrolled in the study. Clustering was conducted to protect the control group from contamination. A sequence was not generated, because the number of recruited residential care facilities was limited. Randomization was performed by lottery using envelopes by a researcher not involved in the study. The subjects were not notified of group assignment at the time of recruitment. Subjects who met the criteria were able to walk without assistive devices and take care of themselves without assistance, had sufficient cognition to follow directions, had never performed an SSE before, and were allowed by their chief physician to exercise. Furthermore, individuals with dementia or severe cardiac, pulmonary or musculoskeletal disorders that are associated with a higher fall risk were excluded. Thus, 106 subjects were regarded as eligible participants and were enrolled in the study. One person did not provide written consent to participate in the study, so that a total of 105 subjects remained. At the time of recruitment, there were no significant differences among residential care facilities or in the sex, age and underlying diseases of the residents (data not shown). A total of 51 individuals in two residential care facilities (18 males and 33 females) were assigned to the intervention group.
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These individuals practiced the SSEs twice per week for six months and were then followed-up for an additional six months after the intervention was completed. In contrast, 54 persons in the three other residential care facilities (24 males and 30 females) were assigned to the control group and followed their usual routines for 12 months. None of the excluded residents within the intervention facilities performed the SSEs. Basic attributes, physical functions, cognitive functions and health-related QOL were investigated at baseline. Physical functions were re-evaluated 1, 3, 6 and 12 months after the initiation of the study, and the other items were re-evaluated at 6 and 12 months. This study was approved by the Ethics Committee of Wakayama Medical University. Oral and written consent of the study participants was obtained after they were given thorough explanation of this study. Outcome measures Primary outcome measures The primary outcome measures were the number of fallers and the time to first fall. Fall incidents were confirmed by research assistants through interviews with the staff and by reviewing medical records. The staff and nurses in the facilities were asked to report the state of falls when they found the participants had fallen. During the 12 months, research assistants checked the participants’ medical records every month and confirmed falls with both the participants and the staff. A fall was defined as an unintentional coming to rest on the ground, floor or other lower level, excluding coming to rest against furniture, walls or other structures [12]. Prior to the study, staff members at the residential care facilities were assessed to ensure that they could report falls based on this definition. Six typical types of falling were videotaped and shown to the staff. It was ensured that the staff regarded the falls defined above as ‘‘outcomes’’. Research assistants were not informed of the results of the randomization. The staff was asked not to tell the research assistants about which group was undergoing the intervention. Secondary outcome measures The secondary outcome measures were physical functions that are generally considered to be ‘‘internal’’ factors for falling. Grip strength was measured twice, and the higher of the two measurements was used, based on a previous study [19]. The 30-second chair-stand test (CS-30) [20], timed up and go (TUG) [21], and five-meter walk [22] were each measured once. The sit and reach test [23], the one leg balance with eyes open (OLB) [24], and the bar-gripped reaction test were performed twice and the average values computed. In the bar-gripped reaction test, subjects were asked to catch a 700-mm-long plastic bar as soon as possible after it was dropped. The functional reach (FR) was measured three times to calculate the mean [25]. Additionally, MMSE [26] and SF-8 were measured in a private room. SF-8 is a comprehensive scale that assesses the physical and mental components of health-related QOL through eight questions. These components were computed using the standard formula in the SF-8 manual [27]. A higher value is indicative of superior health-related QOL. The evaluation was conducted by the research assistants in the same place under the direction of one occupational therapist. Intervention program Subjects in the intervention group practiced the SSEs twice per week for six months with strictly recorded attendance, under the instruction of the same staff member at each site. To ensure the
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uniformity of instruction, staff members were provided with a poster and an explanatory leaflet to show them the SSE procedure before the initiation of this study. The stick used in the exercise was a Japanese newspaper rolled in a stick shape with red adhesive tape around the center and at both of the ends (21.5 inches in length, 1.0 inch in diameter, 200 g in weight). The exercises consisted of the following six steps: (1) warming up, (2) throwing the stick with one hand, (3) throwing the stick with both hands, (4) balancing the stick, (5) spinning the stick and (6) dropping the stick (Figure 1). The exercises were conducted in the sitting position and took approximately 25 min in total. The exercise sessions were conducted on a group basis. Details of the exercises are shown in the Appendix. The staff was asked to check the vital signs of participants before and after the SSEs and to carefully observe them to prevent them from falling from the chair during the SSEs. No other intervention was conducted for fall prevention, such as other exercises and environmental modification in the facilities, in both groups during this 12-month study period. Usual care Daily housekeeping, hobbies and work were continued as usual in both the control and intervention groups throughout the study period. In the control group, 10-minute group stretching exercises had always been conducted as usual care every morning. No other alternative exercises were conducted in the study. Analysis methods Sample size As mentioned above, the annual cumulative incidence of falls by residents in residential care facilities was reported to be more than 30% [1]. Because the annual cumulative incidence of falls with an
Figure 1. Performing the short stick exercises.
Disabil Rehabil, 2015; 37(14): 1268–1276
intervention was estimated to be approximately 5% in our previous study [18], an effective goal of a 25% reduction in falls was set, and the sample size was calculated as 43 in each group (a ¼ 0.05 [two sides], b ¼ 0.20). To calculate the clusterbased sample size, the intra-cluster correlation coefficient was set to 0.02, the design effect was set to 1.38, and the necessary sample size was calculated to be 55 in each group. Statistical analysis First, to investigate the fall prevention effects of the SSEs, the time to the first fall was compared between the intervention and control groups using the Kaplan–Maier log-rank test and the Cox regression method, adjusting for baseline characteristics. Second, changes in the physical function measurements at baseline and at one, three and six months were compared using repeated two-way analysis of variance with a linear mixed model. Third, changes in cognitive functions and health-related QOL were compared at baseline and at six months. In addition, the physical function measurements at one, three and six months were compared with the baseline values in the intervention group, using Bonferroni’s multiple comparison test to clarify the timing of physical function improvement. Moreover, to estimate the duration of effects after the SSE intervention was completed, variables at the completion of the SSE period were compared with those measured six months after the completion of the intervention using paired t-tests. An intention-to-treat analysis was adopted based on the initial intervention assignment to analyze the number of fallers and the time to first fall. The analysis of physical and mental functions included only the subjects with complete data. The adherence rate in the intervention group was defined as the number of subjects who attended all of the twice-a-week SSE sessions for six months divided by the number of subjects who completed the SSEs for six months. SPSS version 19 (SPSS, Inc., Chicago, IL) was used for
Prevention of falls in residential care facilities
DOI: 10.3109/09638288.2014.961660
all statistical analyses, and a significance level of less than 0.05 was adopted.
Results
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During the study period (from January 2010 to January 2011), 10 individuals in the intervention group and 12 individuals in the control group were lost to follow-up. Consequently, 41 (15 males and 26 females) and 42 individuals (18 males and 24 females) formed the intervention group and the control group, respectively, at the end of the study (Figure 2). There were no significant differences between the intervention and control groups at baseline, except that body mass index (BMI) was higher in the control group (Table 1). No significant differences were found in physical functions, cognitive functions and health-related QOL between the intervention and control groups. Number of fallers and time to first fall During the first six months, three members (5.9%) in the intervention group and 11 (20.0%) in the control group fell. The adjusted hazard ratio for a first fall in the intervention group compared with the control group was 0.21 (95% CI 0.04–0.98). In addition, there were fewer fallers in the intervention group than in the control group throughout the follow-up period (6 versus 16).
Figure 2. Flow chart of study participants.
Recruitment
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The fall-free period was significantly longer in the intervention group than in the control group (mean ± SD, 10.1 ± 3.0 months versus 9.0 ± 4.1 months, p ¼ 0.027). The adjusted hazard ratio for a first fall in the intervention group was calculated to be 0.15 (95% CI 0.03–0.74). These findings were supported by the Kaplan–Meier method with the log-rank test, which showed that the number of accumulated non-fallers was significantly greater in the intervention group (p ¼ 0.026 at 6 months; p ¼ 0.019 at 12 months; Figure 3). The number needed to treat was calculated to be 5.62. Physical function, cognitive function and health-related QOL Interaction of physical function measures between the groups and time was observed in the CS-30 (p50.01), FR (p50.01), bargripped reaction test (p50.01), TUG (p50.01), OLB (p50.01), and the sit and reach test (p50.01). In these measurements, improvements were observed in the intervention group that were not observed in the control group. Given that BMI differed between the two groups at baseline, BMI was adjusted in the relevant statistical analyses (Table 2). Significant time-and-group interactions were observed in the MMSE (p50.01) and the Mental Component Summary of the SF-8 (p50.01), but the effect size was small (Table 2).
Recruited from 5 residential care facilities (n = 240) Excluded (n =134) No eligibility
Registration 106 applicants for participation Baseline Assessment
Excluded (n=1) No interest
105 persons included in the study
Randomization Intervention for 6 months
Intervention group
Control group
(2 residential care facilities, n=51)
(3 residential care facilities, n=54) Lost to follow-up (n = 1) Low back pain
Lost to follow-up (n = 1) Refusal
Assessment at 1 month
(n = 50)
(n = 53)
( = 46) (n
( = 48) (n
Lost to follow-up (n = 4) 1: Health problem 2: Hospitalization 1: Death
Assessment at 3 months
Lost to follow-up (n = 2) 1:Hospitalization 1: Low back pain
Lost to follow-up (n = 1) Low back pain
Assessment at 6 month and follow-up for 6 months
(n = 45)
(n = 46)
Lost to follow-up (n = 4) 1: Transfer to another nursing home 2: Hospitalization 1: Death
Completion of 12-month follow-up
Lost to follow-up (n = 5) 1: Refusal 1: Low back pain 2: Hospitalization 1: Death
Lost to follow-up (n = 4) 1: Refusal 1: Hospitalization 2: Death
Intervention group Total follow-up (n = 41)
Control group Total follow-up (n = 42)
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Table 1. Baseline characteristics of participants.
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Characteristics Age (yrs) Male Body mass index (kg/m2) Past fall Multiple fall Previous fracture Alcohol intake Disease Hypertension Ischemic heart disease Diabetes Bone and joint disease Cerebrovascular disease Cataract No. of medications used Tranquilizer Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Pulse rate (counts/min) Use of slippers for indoor movement Living room structure First floor Second floor Room type Single room Double room
Intervention group (Short stick exercise) n ¼ 51 80.2 18 21.0 19 9 6 1
(7.9) (35) (3.4) (37) (18) (12) (1.9)
19 12 8 19 1 17 7.0 21 133.0
(37) (24) (16) (37) (2.0) (33) (3.4) (41) (18.0)
Control group (Usual care) n ¼ 54 78.5(5.2) 24 (44) 23.8 (4.1) 20 (37.0) 14 (26) 4 (7.4) 1 (1.8) 27 15 9 21 0 13 7.8 18 138.1
(50.0) (28) (17) (39) (0.0) (24) (4.7) (33) (16)
p value 0.22 0.34 50.01 0.98 0.31 0.46 0.74 0.22 0.62 0.89 0.86 0.49 0.29 0.30 0.41 0.13
70.8 (12)
74.3 (9.1)
0.09
69.9 (12) 46 (90.0)
70.5 (9.5) 49 (91.0)
0.78 0.61
35 (69.0) 16 (32.0)
35 (65.0) 19 (35.0)
0.68
25 (49.0) 26 (51.0)
23 (43.0) 32 (57.0)
0.51
Age, body mass index, medication, systolic blood pressure, diastolic blood pressure and pulse rate values are mean (SD), and other values are n (%).
Timing of improvement in physical function Multiple comparisons of each measurement with the baseline values in the intervention group showed significant improvements at one, three and six months in the bar-gripped reaction test, at three and six months in the FR and sit and reach test, and at three months in the CS-30. The other measurements did not show any significant improvements (Table 2).
Figure 3. Survival curves for time until first fall among residents in the intervention and control groups. Survival curves were determined by the Kaplan–Maier log-rank test. Using multiple Cox proportional hazard analysis adjusting for age, sex, body mass index, past history of falls, alcohol intake, chronic disease, medication, blood pressure, pulse rate, use of slippers, room structure, and room type, the hazard ratio at six months was calculated to be 0.21 [95% CI, 0.04 to 0.98, p ¼ 0.048], and that at 12 months was 0.15 [95% CI, 0.03 to 0.74, p ¼ 0.02]). The solid line denotes the intervention group; the dotted line denotes the control group.
was conducted. The intervention program significantly reduced the number of residents who fell and prolonged the time to first fall. The SSE program was found to improve physical functions, which are the internal factors associated with falling. Improvements in static balancing and flexibility were found to continue for at least six months after the intervention was completed. This study showed that exercising in a seated position improved independent free-standing locomotor control and, thus, prevented future falls. In addition, although the SSE program is a single-exercise intervention, it proved nearly as effective as multifactorial interventions among older adults with intact cognitive function in nursing homes with respect to the hazard ratio for falls [28].
Duration of effects Compared to six months after initiation of the study (when the SSE period was completed), the intervention group at 12 months showed a significant decrease in the CS-30 (p ¼ 0.04) and the TUG (p50.01), whereas no significant differences were observed in the FR, bar-gripped reaction test, OLB, and sit and reach test. Adherence Thirty-six of the 41 subjects who completed the six-month intervention program attended all of the twice-a-week SSE sessions, resulting in an adherence rate of 87.8%. Five subjects missed at least one SSE session due to poor health conditions or private business. Low back pain was reported by one participant during the intervention, though its relationship with the SSEs was unclear. No participant reported shoulder pain.
Discussion An interventional study in which elderly residents in residential care facilities performed SSEs twice per week for six months
Fall-prevention effects Traditionally, the causes of falling have been attributed to internal factors, such as motor or cognitive disturbances, and external factors, such as slippery floors and dim lighting in the living environment [29]. The beneficial effects on fall prevention might be attributed to changes in internal factors related to falling, which are balancing ability, reaction time, muscle strength and flexibility, because no change was observed in external factors, such as the living environment. SSEs can help simulate three strategies by which balancing while standing is maintained: ankle, stepping, and especially hip strategies [30,31]. The SSE in the seated position includes many elements of movement, such as the slow and rapid movements of the pelvis and trunk to maintain balance of the stick, the reach of the hand while picking up the stick from the floor, and the agility to catch a falling stick. Furthermore, the limits of stability [32] in the standing position may be accomplished in the sitting position during SSEs, and it was found that the range of reaching was improved.
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Table 2. Changes in physical and mental function during 6 months. Intervention group (short stick exercise) n ¼ 41
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Variables Physical function Grip strength (kg) Right Left CS-30 (times) FR (cm) Bar-gripped reaction test (cm) TUG (s) Five-meter walk (s) Comfortable speed Maximum speed OLB (s) Sit and reach (cm) SF-8 PCS (points) Mental function MMSE (points) SF-8 MCS (points)
Baseline
18.9 19.7 10.8 24.1 40.9
(7.5) (8.6) (4.4) (7.9) (12.6)
1 month
19.8 19.9 12.5 27.8 32.6
(8.1) (8.5) (4.2) (7.2) (9.7)**
3 months
19.6 20.0 13.4 31.2 28.6
(8.0) (8.4) (4.5)* (6.7)** (7.6)**
Control Group (Usual care) n ¼ 42
6 months
19.0 18.6 13.0 30.7 30.0
(8.0) (8.2) (4.8) (7.9)** (10.4)**
Baseline
19.1 19.3 10.1 24.6 38.9
(6.8) (6.2) (3.5) (7.1) (9.7)
1 month
19.7 18.9 10.8 23.7 36.2
(7.0) (7.1) (3.7) (6.5) (10.9)
3 months
18.5 18.1 9.6 22.5 37.4
(6.8) (6.8) (4.7) (6.5) (2.5)
p value 2-way ANOVA*** with Effect 6 months mixed model Size
18.9 17.6 10.1 22.9 34.9
(7.2) (6.9) (3.5) (6.3) (11.3)
0.06 0.28 50.01 50.01 50.01
0.00 0.01 0.04 0.21 0.10
12.6 (4.4)
12.7 (3.8)
11.8 (3.9)
11.6 (4.0)
12.2 (4.2) 12.3 (5.5)
12.3 (5.8) 12.8 (5.0)
50.01
0.01
7.3 5.2 4.5 22.2 48.5
7.4 5.3 5.7 24.9
6.7 4.9 8.1 26.5
7.1 5.0 6.4 28.8 49.4
7.3 5.4 5.2 21.2 48.2
7.5 5.5 3.2 19.8
(2.6) (1.9) (2.6) (7.6) (6.1)
0.06 0.07 50.01 50.01 0.36
0.00 0.00 0.04 0.32 0.00
24.6 (2.5) 46.6 (5.8)
50.01 50.01
0.00 0.01
(2.5) (1.8) (4.5) (6.4) (5.8)
25.2 (2.0) 49.2 (2.0)
(2.1) (1.8) (5.4) (6.6)
(1.8) (1.8) (11.7) (7.5)*
(2.0) (1.7) (6.8) (7.5)** (5.3)
25.7 (2.3) 49.7 (4.7)
(2.4) 7.4 (2.0) 5.4 (7.5) 3.2 (6.2) 19.1 (5.5)
(3.0) (1.9) (4.5) (7.1)
25.4 (2.6) 49.8 (5.0)
(2.5) 7.7 (2.0) 5.6 (8.1) 2.1 (7.0) 19.8 47.9
Values are mean (SD). CS-30 ¼ 30-Second chair-stand test; FR ¼ functional reach; TUG ¼ timed up and go; OLB ¼ one leg balance with eyes open; PCS ¼ Physical Component Summary; MMSE ¼ Mini-Mental State Examination; MCS ¼ Mental Component Summary. *p50.05, **p50.01. ***Analysis of covariance for physical function measurements adjusted for baseline characteristics.
Fall-prevention effects could be due to the unbalanced physical conditions experienced during SSEs. The actions to throw or catch the stick in the SSEs could improve the reaction time for reaching of the upper limbs and step reaction. In addition, this exercise program could prevent multiple steps following motordriven waist-pull perturbations, which could cause falls [33]. One intervention study reported methods to induce a disturbance with a bilateral separated treadmill [34]. The treadmill exercise significantly improved static balance and reaction time compared with usual exercise. The SSE program has been shown to improve sit to stand abilities, even though it is a seated exercise. Antigravity muscles are constantly contracting to control the posture in the standing position [35]. The SSEs enable the participants to experience resistance training without weights. The ability to shift body weight may also be improved. In a previous study, seated exercise through resistance training reduced the fall risk score in older adults recently discharged from the hospital [36]. Many of these previous interventional methods have adapted programs performed in the standing position to focus on dynamic balancing and walking ability [37,38]. This study provides the first demonstration of the effectiveness of exercise in a seated position for the prevention of falls.
suggesting that their effects could be maintained for at least that length of time. In contrast, dynamic balancing and ability to stand up were decreased six months after the intervention was completed, indicating that the effects on movements related to body weight shifting did not last for long compared to the abovementioned three functions. Since few studies have evaluated the continuation of internal factors after the completion of an intervention program, the duration of the effects’ continuation has not been sufficiently clarified [15,39,40]. The present findings provide a new criterion regarding the length of effectiveness associated with the SSEs. Adherence to SSE Adherence to practicing the SSEs was sufficiently high (87.8%), and most participants were able to continue the twice-a-week exercise program without any adverse events. Adherence to the SSE program was higher than that of the cluster randomized, controlled trial reported in the previous study [40]. One of the advantages of the SSE program may be its simplicity and convenience, i.e. older adults can practice it anytime and anywhere without special equipment. Study limitations
Timing of improvement in physical function and duration of effects From the initiation of the SSEs, agility was improved within one month, and the ability to stand up, static balancing and flexibility were improved within three months. It is notable that the SSEs have immediate effects on certain physical functions. These improvements may be obtained by quick body shifts and movements, which are different from the slow body weight shifts experienced with tai chi [13,16]. Improved agility, static balancing and flexibility were observed to continue for six months after the SSE period was completed,
The current study had several limitations. First, relatively healthy participants were selected, so that the effect the SSE program had on the prevention of falls may not be generalizable. Whether similar results can be obtained in frail older adults remains to be studied. The BMI at baseline differed between the intervention and control groups, and a low BMI may increase the risk of falls [4]. Since the BMI of the intervention group was significantly lower than that of the control group, members of the intervention group were considered more likely to fall. Nevertheless, the number of fallers was few in the intervention group, indicating the effectiveness of SSEs. Second, since the
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program was developed to prevent the first fall among relatively healthy older adults, time to first fall and number of fallers were used in this analysis, rather than all falls, to avoid overweighting of total falls by some subjects who fell frequently. The number of falls should be taken into account in future studies of fall prevention among older adults who are likely to fall. Third, the ordinary care in the control group was not standardized across sites, but no other exercise program was conducted. Some of the intervention effect may be motivational from the group environment. Finally, although research assistants were not informed of the results of the randomization, they could have been unblinded by staff or participants. However, as mentioned above, staff and participants were asked not to tell the research assistants the results of randomization. The staff in the intervention arm may also have been biased in not reporting falls, but research assistants checked the medical records each month and confirmed their findings with both the participants and the staff.
Conclusion The SSE program proved to be effective for fall prevention and the improvement of physical function, but the participants were relatively healthy. The next step is to make the transition from trials of efficacy to general implementation. The SSEs have certain advantages: no special equipment is needed, the exercise program is extremely inexpensive because the stick is composed of rolled-up newspaper, and the exercises can be safely practiced in the seated position. The SSEs should be replicated in a different setting and culture, since they are quite simple, using sticks made of newspaper. Because the number of clusters was limited to five facilities in this study, further investigations including larger institutional and in-home populations may be needed.
Acknowledgements The authors would like to thank the residents and staff of Kaikounosato, Hakuroen, Takasagosou, Yumesakiwarakuen and Fukujuen for their gracious participation.
Declaration of interest The authors report no conflicts of interest.
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10. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146. 11. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2012;12:CD005465. 12. Province MA, Hadley EC, Hornbrook MC, et al. The effects of exercise on falls in elderly patients. a preplanned meta-analysis of the FICSIT Trials. Frailty and injuries: cooperative studies of intervention techniques. JAMA 1995;273:1341–7. 13. Tousignant M, Corriveau H, Roy PM, et al. Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial. Disabil Rehabil 2013;35:1429–35. 14. Campbell AJ, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997;315:1065–9. 15. Clemson L, Fiatarone Singh MA, Bundy A, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ 2012;345:e4547. 16. Liu H, Frank A. Tai chi as a balance improvement exercise for older adults: a systematic review. J Geriatr Phys Ther 2010;33:103–9. 17. Maki BE, McIlroy WE. Control of rapid limb movements for balance recovery: age-related changes and implications for fall prevention. Age Ageing 2006;35:ii12–18. 18. Yokoi K, Naito Y, Takabatake S. The effects of the ‘‘short stick exercise’’ on fall prevention among community-dwelling elderly. Sagyouryouhou 2012;31:189–202 [in Japanese]. 19. Wang CY, Chen LY. Grip strength in older adults: test-retest reliability and cutoff for subjective weakness of using the hands in heavy tasks. Arch Phys Med Rehabil 2010;91:1747–51. 20. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res Q Exerc Sport 1999;70:113–19. 21. Podsiadlo D, Richardson S. The timed ‘‘Up & Go’’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142–8. 22. Salbach NM, Mayo NE, Higgins J, et al. Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil 2001;82:1204–12. 23. Baltaci G, Un N, Tunay V, et al. Comparison of three different sit and reach tests for measurement of hamstring flexibility in female university students. Br J Sports Med 2003;37:59–61. 24. Kita K, Hujino K, Nasu T, et al; Japanese Clinical Orthopaedic Association, Committee on Musculoskeletal Rehabilitation. A simple protocol for preventing falls and fractures in elderly individuals with musculoskeletal disease. Osteoporos Int 2007;18: 611–19. 25. Duncan PW, Weiner DK, Chandler J, et al. Functional reach: a new clinical measure of balance. J Gerontol 1990;45:192–7. 26. Falstein ME, Folstein SE, McHugh PR. ‘‘Mini-mental state’’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98. 27. Fukuhara S, Suzukamo Y. Manual of the SF-8 Japanese version. Kyoto: Institute for Health Outcomes & Process Evaluation Research; 2004. 28. Rapp K, Lamb SE, Bu¨chele G, et al. Prevention of falls in nursing homes: subgroup analyses of a randomized fall prevention trial. J Am Geriatr Soc 2008;56:1092–7. 29. Nickens H. Intrinsic factors in falling among the elderly. Arch Intern Med 1985;145:1089–93. 30. Horak FB, Nashner LM. Central programming of postural movements: adaptation to altered support-surface configurations. J Neurophysiol 1986;5:1369–81. 31. Maki BE, McIlroy WE, Perry SD. Influence of lateral destabilization on compensatory stepping responses. J Biomech 1996;29: 343–53. 32. Newton RA. Validity of the multi-directional reach test: a practical measure for limits of stability in older adults. J Gerontol A Biol Sci Med Sci 2001;56:M248–52. 33. Hilliard MJ, Martinez KM, Janssen I, et al. Lateral balance factors predict future falls in community-living older adults. Arch Phys Med Rehabil 2008;89:1708–13. 34. Shimada H, Obuchi S, Furuna T, et al. New intervention program for preventing falls among frail elderly people: the effects of perturbed
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walking exercise using a bilateral separated treadmill. Am J Phys Med Rehabil 2004;83:493–9. 35. Fitzpatrick R, Rogers DK, McCloskey DI. Stable human standing with lower-limb muscle afferents providing the only sensory input. J Physiol 1994;480:395–403. 36. Vogler CM, Sherrington C, Ogle SJ, Lord SR. Reducing risk of falling in older people discharged from hospital: a randomized controlled trial comparing seated exercises, weight-bearing exercises, and social visits. Arch Phys Med Rehabil 2009;90:1317–24. 37. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148–57.
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Appendix Table A1. Content, times and duration of 6 sessions of SSE for elderly people. Step no. 1
Warming up exercise
2
Throwing and catching stick One-hand version
3
Throwing and catching stick Both-hands version
Lifting arms raising stick Tapping shoulders Stepping over stick Twisting Passing stick behind back Rolling stick
Times
Duration (min)
5 times each
5
3 times each
5
3 times each
5
Throwing and catching stick Step 1: Hold center of stick with palm down. Throw stick up and catch with same hand. Step 2: Throw stick up and catch it with other hand. Step 3: Next, hold end of stick instead of center. Catching stick with palm down Step 1: Before throwing stick, decide which part you want to catch. Then, throw stick and catch. Step 2: Again, before throwing stick decide which part you want to catch. Hold end of stick. Then, throw and catch. Step 3: Hold stick with palm down. Toss it a little and catch it rhythmically right end first, then center and finally the left end. Catching stick vertically Step 1: Hold stick vertically. Then, throw and catch. Step 2: Throw stick with one hand. Catch it with the other hand. Step 3: Hold top or bottom end of stick. Throw and catch. Step 4: Before throwing stick decide which part you want to catch. Throw and catch point you decided on. Step 5: Hold stick vertically and toss it. Try to catch stick at top. Then, catch it at center and bottom rhythmically. Clapping hands before catching Step 1: Throw stick, clap your hands and catch stick. Step 2: Clap your hands twice (before catching stick) Step 3: Decide which part of stick you want to catch. Then, clap your hands and catch the point you picked. Step 4: Hold top of stick. Then, throw, clap your hands, and catch it. Step 5: Hold bottom of stick and do the same. Step 6: Hold stick horizontally. Follow steps 1 through 5. Trying to throw and catch Hold stick with both hands, palms down. Throw stick with both hands and catch it with both hands. Catching stick with palms down Hold stick horizontally with both hands. Throw and catch stick with rhythm. Change the part of the stick you catch every time. Catching stick vertically Hold stick vertically with both hands. Throw and catch it with rhythm. Change the part of the stick you catch every time. (continued )
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Table A1. Continued
Step no.
Times
Duration (min)
3 times each
3
3 times each
3
3 times each
3
Catching stick with one palm up, the other palm down Hold stick with both hands, left palm down, and right palm up. Throw stick. When catching, switch your hands. Left palm up, right palm down.
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4
Keeping stick balanced Keeping stick balanced on palm Put stick on palm in upright position and hold a few seconds. Next, hold for five seconds. Then, try to hold it as long as you can. Keeping balance of stick on floor Put stick on floor. Put one end of stick on floor and hold the other end with palm. Then, take palm off stick for a second and support stick again with palm so that it does not fall. Keeping balance of stick on floor and clapping hands Put stick on floor. Support it with palm. Take hand off stick and clap hands. Catch stick just before it falls on floor. Putting stick on back of your hand Hold stick with palm down. Toss it up and catch it on the back of your hand like you are playing ‘‘otedama’’, a Japanese traditional game using a small bean bag.
5
Flipping stick over Flipping stick toward you and catching Hold end of stick pointing the other end away from you. Flip stick toward you. Catch the other end. Flipping stick forward and catching Flip stick over forward. (Reverse process.)
6
Dropping the stick Dropping and catching stick Hold bottom of stick upright. Loosen grip and drop stick a little. Catch center of stick before it drops. Do the same and catch top end of stick. Dropping stick and catching stick between knees Hold stick upright at face level. Drop stick and catch it between your knees.
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20
Short stick exercises for fall prevention among older adults: a cluster randomized trial Katsushi Yokoi, Kouichi Yoshimasu, Shigeki Takemura, Jin Fukumoto, Shigeki Kurasawa & Kazuhisa Miyashita To cite this article: Katsushi Yokoi, Kouichi Yoshimasu, Shigeki Takemura, Jin Fukumoto, Shigeki Kurasawa & Kazuhisa Miyashita (2015) Short stick exercises for fall prevention among older adults: a cluster randomized trial, Disability and Rehabilitation, 37:14, 1268-1276, DOI: 10.3109/09638288.2014.961660 To link to this article: http://dx.doi.org/10.3109/09638288.2014.961660
Published online: 22 Sep 2014.
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Date: 05 November 2015, At: 16:32
http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(14): 1268–1276 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.961660
RESEARCH PAPER
Short stick exercises for fall prevention among older adults: a cluster randomized trial
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Katsushi Yokoi1,2, Kouichi Yoshimasu2, Shigeki Takemura2, Jin Fukumoto2, Shigeki Kurasawa1, and Kazuhisa Miyashita2 1
Department of Rehabilitation Sciences, Kansai University of Welfare Sciences, Osaka, Japan and 2Department of Hygiene, School of Medicine, Wakayama Medical University, Wakayama, Japan Abstract
Keywords
Purpose: To investigate the effects of short stick exercise (SSEs) on fall prevention and improvement of physical function in older adults. Methods: A cluster randomized trial was conducted in five residential care facilities. The intervention group (n ¼ 51) practiced SSEs for six months, followed by routine care for six more months. The control group (n ¼ 54) received ordinary care for 12 months. The primary outcome measure was the number of fallers, taking into account the time to first fall using the Kaplan–Meier method. The secondary outcome measures were physical and mental functions. Results: The number of fallers was significantly lower in the intervention group (n ¼ 6) than in the control group (n ¼ 16) during the 12 months. The adjusted hazard ratio for a first fall in the intervention group compared with the control group was 0.15 (CI, 0.03 to 0.74, p ¼ 0.02). The fall-free period was significantly longer in the intervention group than in controls (mean ± SD, 10.1 ± 3.0 versus 9.0 ± 4.1 months, p ¼ 0.027). The functional reach and sit and reach tests were significantly improved at three and six months. Conclusion: The SSEs appeared effective for fall prevention and improvement of physical function in older adults.
Exercise, falls, older adults, residential care History Received 22 December 2013 Revised 21 August 2014 Accepted 1 September 2014 Published online 22 September 2014
ä Implications for Rehabilitation
The newly developed short stick exercises appear an effective means of reducing falls among older adults in residential care facilities. The short stick exercises seem to have an immediate effect on improving physical functions. Effects gained by performing the short stick exercises, such as static balance, flexibility and agility may last for six months. The short stick exercises were found to be easy for older adults to practice continuously in residential care facilities.
Introduction Falling may shorten the duration of healthy life and decrease the quality of life (QOL) [1]. The annual cumulative incidence of falling has been reported to be approximately 30% among older adults in the community and as high as 50% among residents living in institutions [1]. Therefore, there has been a need to collect and examine evidence for the effectiveness of fall prevention programs in institutional settings [2]. The most commonly identified risk factors for falls in older adults are loss of muscle strength and flexibility and impaired balance and reaction time [3,4]. Balancing ability is affected by the visual system, vestibular system, somatesthetic system,
Address for correspondence: Katsushi Yokoi, MS, Department of Rehabilitation Sciences, Kansai University of Welfare Sciences, 3-11-1 Asahigaoka, Kashiwara, Osaka 582-0026, Japan. Tel: +81-72-978-0088. Fax: +81-72-978-0377. E-mail: [email protected]
muscular strength and reaction time [5–7]. Not only impaired dynamic balance but also impaired static balance increases the risk for falls [8]. It should be noted that these functions deteriorate with age. A study that analyzed rapid steps to regain balance during a forward fall showed that older adults have longer reaction times for taking steps than younger adults [9]. An effective method to prevent older adults from falling needs to be established. Certain multifactorial approaches, including individual risk assessment of falls and exercise interventions, have been shown to be effective [10,11]. Regarding other exercise interventions, balance training and tai chi were also found to be effective [2,12,13]. In particular, the Otago Exercise program [14] and the LIFE study [15] showed concrete exercise methods. However, few studies have thoroughly described the frequency, types and details of exercises in care facilities. In addition, a majority of interventions require special equipment, space and complex protocols. Effective activity programs must be safe for older adults to practice.
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DOI: 10.3109/09638288.2014.961660
Therefore, we developed short stick exercises (SSEs) that involve the throwing and catching of a short stick while sitting in a chair to accustom older adults to postural imbalance, thus preventing their falling and stumbling. The SSEs could be a fall prevention exercise focused on the modifiable risk factors of physical functions for falls. The SSEs consisted of six steps. Step one was for warming up, and steps two through six included throwing, catching, keeping, flipping and dropping a short stick. Movements that combine two or more physical functions were found to be effective for fall prevention in a previous study [10]. The SSEs combine movements with balance, flexibility and agility during the throwing and catching of a stick. Furthermore, the SSEs involve the shifting of body weight and rotation of the trunk required in tai chi [16]. The balancing action in combination with rapid reaching movements is critical for fall prevention [17]. The SSEs include the frequent reaching for the short stick task, which may enable older adults to achieve a quick response to their environment even from a seated position. In our pilot study in a local community, performance of the SSEs decreased the number of older adults experiencing falls [18]. We randomly assigned 62 older adults from four municipalities to the intervention group (SSEs twice per week for six months) or the control group (a routine daily schedule for six months). The number of fallers was significantly decreased in the intervention group (n ¼ 2) compared with the control group (n ¼ 9) during the six months. Furthermore, the performances of the functional reach and sit and reach tests in the intervention group were significantly improved. We hope that the benefits gained from exercising in a relatively safe position will lead to improving independent, free-standing, locomotor control and thus prevent future falls. In the current study, the effects of the SSEs on fall prevention were investigated among older adults in residential care facilities. We hypothesized that performing the SSEs for six months would reduce the number of fallers and improve physical function, particularly balance, in institutionalized older adults. This hypothesis was based on our pilot study involving community-dwelling older adults.
Methods Subjects and study protocol As clusters for the study, the residential care facilities with 50 beds in the Kinki area in Japan, where no intervention for fall prevention was conducted, were recruited. Five residential care facilities (n ¼ 240; 10 beds were unoccupied at the time of recruitment) met the criteria and were enrolled in the study. Clustering was conducted to protect the control group from contamination. A sequence was not generated, because the number of recruited residential care facilities was limited. Randomization was performed by lottery using envelopes by a researcher not involved in the study. The subjects were not notified of group assignment at the time of recruitment. Subjects who met the criteria were able to walk without assistive devices and take care of themselves without assistance, had sufficient cognition to follow directions, had never performed an SSE before, and were allowed by their chief physician to exercise. Furthermore, individuals with dementia or severe cardiac, pulmonary or musculoskeletal disorders that are associated with a higher fall risk were excluded. Thus, 106 subjects were regarded as eligible participants and were enrolled in the study. One person did not provide written consent to participate in the study, so that a total of 105 subjects remained. At the time of recruitment, there were no significant differences among residential care facilities or in the sex, age and underlying diseases of the residents (data not shown). A total of 51 individuals in two residential care facilities (18 males and 33 females) were assigned to the intervention group.
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These individuals practiced the SSEs twice per week for six months and were then followed-up for an additional six months after the intervention was completed. In contrast, 54 persons in the three other residential care facilities (24 males and 30 females) were assigned to the control group and followed their usual routines for 12 months. None of the excluded residents within the intervention facilities performed the SSEs. Basic attributes, physical functions, cognitive functions and health-related QOL were investigated at baseline. Physical functions were re-evaluated 1, 3, 6 and 12 months after the initiation of the study, and the other items were re-evaluated at 6 and 12 months. This study was approved by the Ethics Committee of Wakayama Medical University. Oral and written consent of the study participants was obtained after they were given thorough explanation of this study. Outcome measures Primary outcome measures The primary outcome measures were the number of fallers and the time to first fall. Fall incidents were confirmed by research assistants through interviews with the staff and by reviewing medical records. The staff and nurses in the facilities were asked to report the state of falls when they found the participants had fallen. During the 12 months, research assistants checked the participants’ medical records every month and confirmed falls with both the participants and the staff. A fall was defined as an unintentional coming to rest on the ground, floor or other lower level, excluding coming to rest against furniture, walls or other structures [12]. Prior to the study, staff members at the residential care facilities were assessed to ensure that they could report falls based on this definition. Six typical types of falling were videotaped and shown to the staff. It was ensured that the staff regarded the falls defined above as ‘‘outcomes’’. Research assistants were not informed of the results of the randomization. The staff was asked not to tell the research assistants about which group was undergoing the intervention. Secondary outcome measures The secondary outcome measures were physical functions that are generally considered to be ‘‘internal’’ factors for falling. Grip strength was measured twice, and the higher of the two measurements was used, based on a previous study [19]. The 30-second chair-stand test (CS-30) [20], timed up and go (TUG) [21], and five-meter walk [22] were each measured once. The sit and reach test [23], the one leg balance with eyes open (OLB) [24], and the bar-gripped reaction test were performed twice and the average values computed. In the bar-gripped reaction test, subjects were asked to catch a 700-mm-long plastic bar as soon as possible after it was dropped. The functional reach (FR) was measured three times to calculate the mean [25]. Additionally, MMSE [26] and SF-8 were measured in a private room. SF-8 is a comprehensive scale that assesses the physical and mental components of health-related QOL through eight questions. These components were computed using the standard formula in the SF-8 manual [27]. A higher value is indicative of superior health-related QOL. The evaluation was conducted by the research assistants in the same place under the direction of one occupational therapist. Intervention program Subjects in the intervention group practiced the SSEs twice per week for six months with strictly recorded attendance, under the instruction of the same staff member at each site. To ensure the
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uniformity of instruction, staff members were provided with a poster and an explanatory leaflet to show them the SSE procedure before the initiation of this study. The stick used in the exercise was a Japanese newspaper rolled in a stick shape with red adhesive tape around the center and at both of the ends (21.5 inches in length, 1.0 inch in diameter, 200 g in weight). The exercises consisted of the following six steps: (1) warming up, (2) throwing the stick with one hand, (3) throwing the stick with both hands, (4) balancing the stick, (5) spinning the stick and (6) dropping the stick (Figure 1). The exercises were conducted in the sitting position and took approximately 25 min in total. The exercise sessions were conducted on a group basis. Details of the exercises are shown in the Appendix. The staff was asked to check the vital signs of participants before and after the SSEs and to carefully observe them to prevent them from falling from the chair during the SSEs. No other intervention was conducted for fall prevention, such as other exercises and environmental modification in the facilities, in both groups during this 12-month study period. Usual care Daily housekeeping, hobbies and work were continued as usual in both the control and intervention groups throughout the study period. In the control group, 10-minute group stretching exercises had always been conducted as usual care every morning. No other alternative exercises were conducted in the study. Analysis methods Sample size As mentioned above, the annual cumulative incidence of falls by residents in residential care facilities was reported to be more than 30% [1]. Because the annual cumulative incidence of falls with an
Figure 1. Performing the short stick exercises.
Disabil Rehabil, 2015; 37(14): 1268–1276
intervention was estimated to be approximately 5% in our previous study [18], an effective goal of a 25% reduction in falls was set, and the sample size was calculated as 43 in each group (a ¼ 0.05 [two sides], b ¼ 0.20). To calculate the clusterbased sample size, the intra-cluster correlation coefficient was set to 0.02, the design effect was set to 1.38, and the necessary sample size was calculated to be 55 in each group. Statistical analysis First, to investigate the fall prevention effects of the SSEs, the time to the first fall was compared between the intervention and control groups using the Kaplan–Maier log-rank test and the Cox regression method, adjusting for baseline characteristics. Second, changes in the physical function measurements at baseline and at one, three and six months were compared using repeated two-way analysis of variance with a linear mixed model. Third, changes in cognitive functions and health-related QOL were compared at baseline and at six months. In addition, the physical function measurements at one, three and six months were compared with the baseline values in the intervention group, using Bonferroni’s multiple comparison test to clarify the timing of physical function improvement. Moreover, to estimate the duration of effects after the SSE intervention was completed, variables at the completion of the SSE period were compared with those measured six months after the completion of the intervention using paired t-tests. An intention-to-treat analysis was adopted based on the initial intervention assignment to analyze the number of fallers and the time to first fall. The analysis of physical and mental functions included only the subjects with complete data. The adherence rate in the intervention group was defined as the number of subjects who attended all of the twice-a-week SSE sessions for six months divided by the number of subjects who completed the SSEs for six months. SPSS version 19 (SPSS, Inc., Chicago, IL) was used for
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DOI: 10.3109/09638288.2014.961660
all statistical analyses, and a significance level of less than 0.05 was adopted.
Results
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During the study period (from January 2010 to January 2011), 10 individuals in the intervention group and 12 individuals in the control group were lost to follow-up. Consequently, 41 (15 males and 26 females) and 42 individuals (18 males and 24 females) formed the intervention group and the control group, respectively, at the end of the study (Figure 2). There were no significant differences between the intervention and control groups at baseline, except that body mass index (BMI) was higher in the control group (Table 1). No significant differences were found in physical functions, cognitive functions and health-related QOL between the intervention and control groups. Number of fallers and time to first fall During the first six months, three members (5.9%) in the intervention group and 11 (20.0%) in the control group fell. The adjusted hazard ratio for a first fall in the intervention group compared with the control group was 0.21 (95% CI 0.04–0.98). In addition, there were fewer fallers in the intervention group than in the control group throughout the follow-up period (6 versus 16).
Figure 2. Flow chart of study participants.
Recruitment
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The fall-free period was significantly longer in the intervention group than in the control group (mean ± SD, 10.1 ± 3.0 months versus 9.0 ± 4.1 months, p ¼ 0.027). The adjusted hazard ratio for a first fall in the intervention group was calculated to be 0.15 (95% CI 0.03–0.74). These findings were supported by the Kaplan–Meier method with the log-rank test, which showed that the number of accumulated non-fallers was significantly greater in the intervention group (p ¼ 0.026 at 6 months; p ¼ 0.019 at 12 months; Figure 3). The number needed to treat was calculated to be 5.62. Physical function, cognitive function and health-related QOL Interaction of physical function measures between the groups and time was observed in the CS-30 (p50.01), FR (p50.01), bargripped reaction test (p50.01), TUG (p50.01), OLB (p50.01), and the sit and reach test (p50.01). In these measurements, improvements were observed in the intervention group that were not observed in the control group. Given that BMI differed between the two groups at baseline, BMI was adjusted in the relevant statistical analyses (Table 2). Significant time-and-group interactions were observed in the MMSE (p50.01) and the Mental Component Summary of the SF-8 (p50.01), but the effect size was small (Table 2).
Recruited from 5 residential care facilities (n = 240) Excluded (n =134) No eligibility
Registration 106 applicants for participation Baseline Assessment
Excluded (n=1) No interest
105 persons included in the study
Randomization Intervention for 6 months
Intervention group
Control group
(2 residential care facilities, n=51)
(3 residential care facilities, n=54) Lost to follow-up (n = 1) Low back pain
Lost to follow-up (n = 1) Refusal
Assessment at 1 month
(n = 50)
(n = 53)
( = 46) (n
( = 48) (n
Lost to follow-up (n = 4) 1: Health problem 2: Hospitalization 1: Death
Assessment at 3 months
Lost to follow-up (n = 2) 1:Hospitalization 1: Low back pain
Lost to follow-up (n = 1) Low back pain
Assessment at 6 month and follow-up for 6 months
(n = 45)
(n = 46)
Lost to follow-up (n = 4) 1: Transfer to another nursing home 2: Hospitalization 1: Death
Completion of 12-month follow-up
Lost to follow-up (n = 5) 1: Refusal 1: Low back pain 2: Hospitalization 1: Death
Lost to follow-up (n = 4) 1: Refusal 1: Hospitalization 2: Death
Intervention group Total follow-up (n = 41)
Control group Total follow-up (n = 42)
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Table 1. Baseline characteristics of participants.
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Characteristics Age (yrs) Male Body mass index (kg/m2) Past fall Multiple fall Previous fracture Alcohol intake Disease Hypertension Ischemic heart disease Diabetes Bone and joint disease Cerebrovascular disease Cataract No. of medications used Tranquilizer Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Pulse rate (counts/min) Use of slippers for indoor movement Living room structure First floor Second floor Room type Single room Double room
Intervention group (Short stick exercise) n ¼ 51 80.2 18 21.0 19 9 6 1
(7.9) (35) (3.4) (37) (18) (12) (1.9)
19 12 8 19 1 17 7.0 21 133.0
(37) (24) (16) (37) (2.0) (33) (3.4) (41) (18.0)
Control group (Usual care) n ¼ 54 78.5(5.2) 24 (44) 23.8 (4.1) 20 (37.0) 14 (26) 4 (7.4) 1 (1.8) 27 15 9 21 0 13 7.8 18 138.1
(50.0) (28) (17) (39) (0.0) (24) (4.7) (33) (16)
p value 0.22 0.34 50.01 0.98 0.31 0.46 0.74 0.22 0.62 0.89 0.86 0.49 0.29 0.30 0.41 0.13
70.8 (12)
74.3 (9.1)
0.09
69.9 (12) 46 (90.0)
70.5 (9.5) 49 (91.0)
0.78 0.61
35 (69.0) 16 (32.0)
35 (65.0) 19 (35.0)
0.68
25 (49.0) 26 (51.0)
23 (43.0) 32 (57.0)
0.51
Age, body mass index, medication, systolic blood pressure, diastolic blood pressure and pulse rate values are mean (SD), and other values are n (%).
Timing of improvement in physical function Multiple comparisons of each measurement with the baseline values in the intervention group showed significant improvements at one, three and six months in the bar-gripped reaction test, at three and six months in the FR and sit and reach test, and at three months in the CS-30. The other measurements did not show any significant improvements (Table 2).
Figure 3. Survival curves for time until first fall among residents in the intervention and control groups. Survival curves were determined by the Kaplan–Maier log-rank test. Using multiple Cox proportional hazard analysis adjusting for age, sex, body mass index, past history of falls, alcohol intake, chronic disease, medication, blood pressure, pulse rate, use of slippers, room structure, and room type, the hazard ratio at six months was calculated to be 0.21 [95% CI, 0.04 to 0.98, p ¼ 0.048], and that at 12 months was 0.15 [95% CI, 0.03 to 0.74, p ¼ 0.02]). The solid line denotes the intervention group; the dotted line denotes the control group.
was conducted. The intervention program significantly reduced the number of residents who fell and prolonged the time to first fall. The SSE program was found to improve physical functions, which are the internal factors associated with falling. Improvements in static balancing and flexibility were found to continue for at least six months after the intervention was completed. This study showed that exercising in a seated position improved independent free-standing locomotor control and, thus, prevented future falls. In addition, although the SSE program is a single-exercise intervention, it proved nearly as effective as multifactorial interventions among older adults with intact cognitive function in nursing homes with respect to the hazard ratio for falls [28].
Duration of effects Compared to six months after initiation of the study (when the SSE period was completed), the intervention group at 12 months showed a significant decrease in the CS-30 (p ¼ 0.04) and the TUG (p50.01), whereas no significant differences were observed in the FR, bar-gripped reaction test, OLB, and sit and reach test. Adherence Thirty-six of the 41 subjects who completed the six-month intervention program attended all of the twice-a-week SSE sessions, resulting in an adherence rate of 87.8%. Five subjects missed at least one SSE session due to poor health conditions or private business. Low back pain was reported by one participant during the intervention, though its relationship with the SSEs was unclear. No participant reported shoulder pain.
Discussion An interventional study in which elderly residents in residential care facilities performed SSEs twice per week for six months
Fall-prevention effects Traditionally, the causes of falling have been attributed to internal factors, such as motor or cognitive disturbances, and external factors, such as slippery floors and dim lighting in the living environment [29]. The beneficial effects on fall prevention might be attributed to changes in internal factors related to falling, which are balancing ability, reaction time, muscle strength and flexibility, because no change was observed in external factors, such as the living environment. SSEs can help simulate three strategies by which balancing while standing is maintained: ankle, stepping, and especially hip strategies [30,31]. The SSE in the seated position includes many elements of movement, such as the slow and rapid movements of the pelvis and trunk to maintain balance of the stick, the reach of the hand while picking up the stick from the floor, and the agility to catch a falling stick. Furthermore, the limits of stability [32] in the standing position may be accomplished in the sitting position during SSEs, and it was found that the range of reaching was improved.
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Table 2. Changes in physical and mental function during 6 months. Intervention group (short stick exercise) n ¼ 41
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Variables Physical function Grip strength (kg) Right Left CS-30 (times) FR (cm) Bar-gripped reaction test (cm) TUG (s) Five-meter walk (s) Comfortable speed Maximum speed OLB (s) Sit and reach (cm) SF-8 PCS (points) Mental function MMSE (points) SF-8 MCS (points)
Baseline
18.9 19.7 10.8 24.1 40.9
(7.5) (8.6) (4.4) (7.9) (12.6)
1 month
19.8 19.9 12.5 27.8 32.6
(8.1) (8.5) (4.2) (7.2) (9.7)**
3 months
19.6 20.0 13.4 31.2 28.6
(8.0) (8.4) (4.5)* (6.7)** (7.6)**
Control Group (Usual care) n ¼ 42
6 months
19.0 18.6 13.0 30.7 30.0
(8.0) (8.2) (4.8) (7.9)** (10.4)**
Baseline
19.1 19.3 10.1 24.6 38.9
(6.8) (6.2) (3.5) (7.1) (9.7)
1 month
19.7 18.9 10.8 23.7 36.2
(7.0) (7.1) (3.7) (6.5) (10.9)
3 months
18.5 18.1 9.6 22.5 37.4
(6.8) (6.8) (4.7) (6.5) (2.5)
p value 2-way ANOVA*** with Effect 6 months mixed model Size
18.9 17.6 10.1 22.9 34.9
(7.2) (6.9) (3.5) (6.3) (11.3)
0.06 0.28 50.01 50.01 50.01
0.00 0.01 0.04 0.21 0.10
12.6 (4.4)
12.7 (3.8)
11.8 (3.9)
11.6 (4.0)
12.2 (4.2) 12.3 (5.5)
12.3 (5.8) 12.8 (5.0)
50.01
0.01
7.3 5.2 4.5 22.2 48.5
7.4 5.3 5.7 24.9
6.7 4.9 8.1 26.5
7.1 5.0 6.4 28.8 49.4
7.3 5.4 5.2 21.2 48.2
7.5 5.5 3.2 19.8
(2.6) (1.9) (2.6) (7.6) (6.1)
0.06 0.07 50.01 50.01 0.36
0.00 0.00 0.04 0.32 0.00
24.6 (2.5) 46.6 (5.8)
50.01 50.01
0.00 0.01
(2.5) (1.8) (4.5) (6.4) (5.8)
25.2 (2.0) 49.2 (2.0)
(2.1) (1.8) (5.4) (6.6)
(1.8) (1.8) (11.7) (7.5)*
(2.0) (1.7) (6.8) (7.5)** (5.3)
25.7 (2.3) 49.7 (4.7)
(2.4) 7.4 (2.0) 5.4 (7.5) 3.2 (6.2) 19.1 (5.5)
(3.0) (1.9) (4.5) (7.1)
25.4 (2.6) 49.8 (5.0)
(2.5) 7.7 (2.0) 5.6 (8.1) 2.1 (7.0) 19.8 47.9
Values are mean (SD). CS-30 ¼ 30-Second chair-stand test; FR ¼ functional reach; TUG ¼ timed up and go; OLB ¼ one leg balance with eyes open; PCS ¼ Physical Component Summary; MMSE ¼ Mini-Mental State Examination; MCS ¼ Mental Component Summary. *p50.05, **p50.01. ***Analysis of covariance for physical function measurements adjusted for baseline characteristics.
Fall-prevention effects could be due to the unbalanced physical conditions experienced during SSEs. The actions to throw or catch the stick in the SSEs could improve the reaction time for reaching of the upper limbs and step reaction. In addition, this exercise program could prevent multiple steps following motordriven waist-pull perturbations, which could cause falls [33]. One intervention study reported methods to induce a disturbance with a bilateral separated treadmill [34]. The treadmill exercise significantly improved static balance and reaction time compared with usual exercise. The SSE program has been shown to improve sit to stand abilities, even though it is a seated exercise. Antigravity muscles are constantly contracting to control the posture in the standing position [35]. The SSEs enable the participants to experience resistance training without weights. The ability to shift body weight may also be improved. In a previous study, seated exercise through resistance training reduced the fall risk score in older adults recently discharged from the hospital [36]. Many of these previous interventional methods have adapted programs performed in the standing position to focus on dynamic balancing and walking ability [37,38]. This study provides the first demonstration of the effectiveness of exercise in a seated position for the prevention of falls.
suggesting that their effects could be maintained for at least that length of time. In contrast, dynamic balancing and ability to stand up were decreased six months after the intervention was completed, indicating that the effects on movements related to body weight shifting did not last for long compared to the abovementioned three functions. Since few studies have evaluated the continuation of internal factors after the completion of an intervention program, the duration of the effects’ continuation has not been sufficiently clarified [15,39,40]. The present findings provide a new criterion regarding the length of effectiveness associated with the SSEs. Adherence to SSE Adherence to practicing the SSEs was sufficiently high (87.8%), and most participants were able to continue the twice-a-week exercise program without any adverse events. Adherence to the SSE program was higher than that of the cluster randomized, controlled trial reported in the previous study [40]. One of the advantages of the SSE program may be its simplicity and convenience, i.e. older adults can practice it anytime and anywhere without special equipment. Study limitations
Timing of improvement in physical function and duration of effects From the initiation of the SSEs, agility was improved within one month, and the ability to stand up, static balancing and flexibility were improved within three months. It is notable that the SSEs have immediate effects on certain physical functions. These improvements may be obtained by quick body shifts and movements, which are different from the slow body weight shifts experienced with tai chi [13,16]. Improved agility, static balancing and flexibility were observed to continue for six months after the SSE period was completed,
The current study had several limitations. First, relatively healthy participants were selected, so that the effect the SSE program had on the prevention of falls may not be generalizable. Whether similar results can be obtained in frail older adults remains to be studied. The BMI at baseline differed between the intervention and control groups, and a low BMI may increase the risk of falls [4]. Since the BMI of the intervention group was significantly lower than that of the control group, members of the intervention group were considered more likely to fall. Nevertheless, the number of fallers was few in the intervention group, indicating the effectiveness of SSEs. Second, since the
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program was developed to prevent the first fall among relatively healthy older adults, time to first fall and number of fallers were used in this analysis, rather than all falls, to avoid overweighting of total falls by some subjects who fell frequently. The number of falls should be taken into account in future studies of fall prevention among older adults who are likely to fall. Third, the ordinary care in the control group was not standardized across sites, but no other exercise program was conducted. Some of the intervention effect may be motivational from the group environment. Finally, although research assistants were not informed of the results of the randomization, they could have been unblinded by staff or participants. However, as mentioned above, staff and participants were asked not to tell the research assistants the results of randomization. The staff in the intervention arm may also have been biased in not reporting falls, but research assistants checked the medical records each month and confirmed their findings with both the participants and the staff.
Conclusion The SSE program proved to be effective for fall prevention and the improvement of physical function, but the participants were relatively healthy. The next step is to make the transition from trials of efficacy to general implementation. The SSEs have certain advantages: no special equipment is needed, the exercise program is extremely inexpensive because the stick is composed of rolled-up newspaper, and the exercises can be safely practiced in the seated position. The SSEs should be replicated in a different setting and culture, since they are quite simple, using sticks made of newspaper. Because the number of clusters was limited to five facilities in this study, further investigations including larger institutional and in-home populations may be needed.
Acknowledgements The authors would like to thank the residents and staff of Kaikounosato, Hakuroen, Takasagosou, Yumesakiwarakuen and Fukujuen for their gracious participation.
Declaration of interest The authors report no conflicts of interest.
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Appendix Table A1. Content, times and duration of 6 sessions of SSE for elderly people. Step no. 1
Warming up exercise
2
Throwing and catching stick One-hand version
3
Throwing and catching stick Both-hands version
Lifting arms raising stick Tapping shoulders Stepping over stick Twisting Passing stick behind back Rolling stick
Times
Duration (min)
5 times each
5
3 times each
5
3 times each
5
Throwing and catching stick Step 1: Hold center of stick with palm down. Throw stick up and catch with same hand. Step 2: Throw stick up and catch it with other hand. Step 3: Next, hold end of stick instead of center. Catching stick with palm down Step 1: Before throwing stick, decide which part you want to catch. Then, throw stick and catch. Step 2: Again, before throwing stick decide which part you want to catch. Hold end of stick. Then, throw and catch. Step 3: Hold stick with palm down. Toss it a little and catch it rhythmically right end first, then center and finally the left end. Catching stick vertically Step 1: Hold stick vertically. Then, throw and catch. Step 2: Throw stick with one hand. Catch it with the other hand. Step 3: Hold top or bottom end of stick. Throw and catch. Step 4: Before throwing stick decide which part you want to catch. Throw and catch point you decided on. Step 5: Hold stick vertically and toss it. Try to catch stick at top. Then, catch it at center and bottom rhythmically. Clapping hands before catching Step 1: Throw stick, clap your hands and catch stick. Step 2: Clap your hands twice (before catching stick) Step 3: Decide which part of stick you want to catch. Then, clap your hands and catch the point you picked. Step 4: Hold top of stick. Then, throw, clap your hands, and catch it. Step 5: Hold bottom of stick and do the same. Step 6: Hold stick horizontally. Follow steps 1 through 5. Trying to throw and catch Hold stick with both hands, palms down. Throw stick with both hands and catch it with both hands. Catching stick with palms down Hold stick horizontally with both hands. Throw and catch stick with rhythm. Change the part of the stick you catch every time. Catching stick vertically Hold stick vertically with both hands. Throw and catch it with rhythm. Change the part of the stick you catch every time. (continued )
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Table A1. Continued
Step no.
Times
Duration (min)
3 times each
3
3 times each
3
3 times each
3
Catching stick with one palm up, the other palm down Hold stick with both hands, left palm down, and right palm up. Throw stick. When catching, switch your hands. Left palm up, right palm down.
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4
Keeping stick balanced Keeping stick balanced on palm Put stick on palm in upright position and hold a few seconds. Next, hold for five seconds. Then, try to hold it as long as you can. Keeping balance of stick on floor Put stick on floor. Put one end of stick on floor and hold the other end with palm. Then, take palm off stick for a second and support stick again with palm so that it does not fall. Keeping balance of stick on floor and clapping hands Put stick on floor. Support it with palm. Take hand off stick and clap hands. Catch stick just before it falls on floor. Putting stick on back of your hand Hold stick with palm down. Toss it up and catch it on the back of your hand like you are playing ‘‘otedama’’, a Japanese traditional game using a small bean bag.
5
Flipping stick over Flipping stick toward you and catching Hold end of stick pointing the other end away from you. Flip stick toward you. Catch the other end. Flipping stick forward and catching Flip stick over forward. (Reverse process.)
6
Dropping the stick Dropping and catching stick Hold bottom of stick upright. Loosen grip and drop stick a little. Catch center of stick before it drops. Do the same and catch top end of stick. Dropping stick and catching stick between knees Hold stick upright at face level. Drop stick and catch it between your knees.
