Effect of Attention Based Exercises in Balance Control and Fall Risk in Elderly Females - An Interventional Study

Introduction

Aging is a complex, intra-individual process defined as the time independent, progressive decline in an individual’s physiological integrity, which eventually leads to deteriorated physical and mental function.¹ A person spends 75 percent of his/her entire lifespan undergoing the process of decline.² With global population aging trends, many countries are implementing healthy aging policies to minimize disability and increase quality in the extended years of life.³ A significant aspect in the promotion of health among aging is the prevention of falls and fall related injuries which can cause substantial disability and have great impact on functional independence and quality of life of older people. Falls place a significant strain on families and are an independent predictor of admission to nursing homes. This causes massive stress and burden for individuals, while also leading to enormous societal costs and indirect expenses for families.

Balance is a fundamental skill important for the safe performance of many activities that acquiesce older people to remain independent in their community.⁴ As the individual ages, there is deterioration in balance control system, exerting negative impact on the multitasking abilities in both indoor and outdoor environments. This is further accentuated in elderly population when they are needed to perform any task requiring divided attention, making them prone to falls. An inability to restore balance due to competition for attentional resources between postural system and a second task, is one of the major reasons for falls in older adults with balance impairments.

Several studies have indicated that aspects of cognition, particularly the declining executive function are predictive of fall risks in older adults without dementia or overt cognitive impairments.⁵ Since deficits in executive functions increase with age, this may impair the ability of the older individuals to compensate for age related changes in balance. However, very few studies assessed the role of cognitive impairments in balance control among the aging population.

The functional benefits of components of cognition, specifically attention in the balance control and fall risk of aging population plays a major role. Research suggests that cognitive and motor systems are interconnected, and engaging both simultaneously can lead to significant improvements in balance and gait. Attention-based exercises require participants to focus on a task while maintaining balance, which can help strengthen the neural pathways involved in these dual processes. This is particularly important for elderly females, who may experience both cognitive decline and decreased physical stability. Hence the study aimed to determine the effect of attention based exercises in balance control and fall risk in elderly population.

Materials and Methods

Source of data

Subjects with early and moderate stage balance impairments, with or without a recent history of fall in the past six months at St Anne’s old age home, Capitanio Dakshin Kannada district, were selected for the study.

Method of data collection

The data for this study were collected from normal older adults in the age group of 60-70 years. The method of data collection was based on the following steps:

Study design: Experimental interventional study.

Sampling method: Purposive sampling method.

Sampling size: 54 subjects fulfilling the inclusion and exclusion criteria.

Sampling technique: Purposive sampling with set inclusion and exclusion criteria.

Sample size estimation: Zα=1.96 zβ=0.842 S=2.88 d=2.22. Thus, the sample size (n) = (1.96+0.842)2 * (2.88)2 (2.2)2 =7.85*2*8.29 (2.2)2 = 26.90 ≈ 27.

Inclusion criteria

• Elderly female population aged 60-70 years.

• Subjects who could walk 15 ft without any assistive device.

• Physically and mentally stable subjects (even met with a fall, once or more in the last six months).

Exclusion criteria

• Neurological and psychosomatic disorders affecting the physical function of the patient.

• Subjects with neurological, musculoskeletal and cardiovascular impairments.

The standard statistical analysis were applied to the collected data and the study outcome measures were compared between two groups for statistical significance using independent sample t-test.

Duration of study: Approximately 12 weeks.

Follow up: Subjects were assessed for study outcome measures i.e. Berg Balance Scale and FRAT (fall Risk Assessment Tool).

Materials: Demographic data sheet, stopwatch, two standard chairs (with reasonable height), one with armrest and one without, aerobic stepper or a stool (with average step height), air filled ball, chalk 32, 15 ft walk-way with markers, and an informed consent form.

Methods

Phase 1 - Ethical clearance: The synopsis was submitted to the Institutional research committee (IRC) and permission was obtained. Following this, 54 subjects were selected following the set inclusion and exclusion criteria from an old age home in Dakshin Kannada district.

With purposive sampling method, subjects for the study were selected and allocated into two arms (Group A and Group B). In the initial phase of the study, all subjects were assessed using the Berg Balance Scale and John Hopkins Fall risk assessment tool for their baseline scores and then detailed information about the procedure was explained. Written and signed consent was taken from all the participants recruited for the study. Subjects were explained about the warm up and cool down sessions, and the practice before and after each session.

Group A (Experimental group)

The warm up session included three exercises:

1. Marching in place (2 minutes)

2. Active static stretching of major muscles: 30 sec hold (3 rep)

3. Active range of motion exercises for each joint (5 rep)

Subjects allotted to Group 1 were made to perform a set of 11 exercises targeting the static and dynamic aspects of balance. These involved exercises that strengthen the core and back to keep the subject upright with major focus on cognitive input.

1. One leg stance with and without support

2. Marching in place

3. Ball exercise (Bouncing the ball off a wall)

4. Dribbling a football

5. Wall push-ups

6. Clock reach

7. Back leg rises with and without support

8. Walking on heels

9. Walking on toes

10. Walking heel to toe

11. Forward stepping

The exercise prescription was formulated following the ACSM (American College of Sports Medicine) guidelines, adhering to the FITT (Frequency, Intensity, Time, and Type) protocol. The program included a frequency of five days per week, an intensity level of 5–6 on a 0–10 scale, and a duration of 30 to 60 minutes per session. The prescribed type of exercise comprised aerobic activities designed to minimize excessive cardiological or orthopedic stress. Each session concluded with a 10-minute cool-down period.

Group B (Control group)

Twenty seven subjects included in Group B were provided with flexible goal oriented therapy, conforming to existing practices of treatment for elderly with mobility problems.

Treatment consisted of assisted walking within parallel bars, stair practices, and transfers. Treatment schedule concentrated on augmenting balance with emphasis on a safe gait pattern.

The intervention was structured to ensure that participants in this group performed aerobic exercises twice a week. The exercises were set at an intensity level of 3–4 on a scale of 0–10, with each session lasting 20 minutes. The selected aerobic activities were carefully chosen to minimize stress on the cardiovascular system.

After 12 weeks of intervention, all subjects were assessed using Berg Balance Scale (BBS) and John Hopkins Fall Risk Assessment Tool (JHFRAT) for post-test values.

Study outcome measures

1. Balance by Berg Balance Scale

2. Fall risk by Modified Johns Hopkins FRAT (Fall Risk Assessment Tool)

Results

In the present study, 54 subjects were recruited, with 27 in each group by simple randomization. Participants of Group A were examined for the effectiveness of attention based balance training in elderly and subjects in Group B were observed as controls, performing mobility exercises to reduce the inactivity in this population.

Before the intervention, the recruited participants were subjected to the balance and mobility evaluation with intended standardized outcome measures, Berg Balance Scale and Modified John Hopkins fall risk assessment tool (JHFRAT).

The data collected before and after intervention were subjected to various statistical tests in terms of analysis of age and study parameters. Data were also analyzed to test the hypothesis of the study.

This study involved a convenience sample of older women residing in an old age home in Dakshin Kannada district. Both Group A and Group B included 27 subjects each, in the age group of 60-70 years. The mean age of the study participants was 64 years. The mean age of female subjects recruited in this study was 64 years.

Group A had 27 female subjects. With the randomness in sample allocation, majority of the subjects (18) included were in the age range of 60-61 years.11 subjects (i.e., 20%) included in this group were found to be have major fall risk due to aging.

The mean value of mobility scores assessed by JHFRAT in Group A participants was 3.78±1.601, while the mean value of scores in Group B participants was 1.48±1.312. The comparison of above using student “t” test showed a P value of 0.868 which is non-significant, implying that participants of both the groups had a homogeneous range of mobility or risk of fall before intervention.

Analysis of Parameters Within Group A after Intervention

Analysis of pre and post balance scores (BBS)

The mean value of balance scores with BBS in Group A subjects before intervention was 36.37±1.471, and this increased to a value of 47.26±1.196 after the intervention. By using paired “t” test, comparison of above parameters resulted in a t value of 23.661 and a P value of 0.000 representing a very high significance in analysis. This indicated that Group A subjects highly benefitted from the attention focussed intervention provided to them for a 12 week duration.

Analysis of pre and post fall risk scores (JHFRAT)

Group A (Paired sample statistics)

Mean value of mobility score (fall risk) for subjects in Group A before the intervention was 3.78±1.601, and this dropped to 1.48±1.312 after the intervention. Comparison of this parameter with above values using paired t test resulted in a t value of 16.480 and a P value of 0.000, which represented a very high significance in analysis. This indicated that subjects in Group A trained with the attention based intervention showed a positive reduction in the fall risk and improvement in their mobility skills from the 12 weeks intervention.

Analysis of Parameters Within Group B after Intervention

Analysis of pre and post balance scores (BBS)

Group B (Paired sample statistics)

Mean value of balance scores prior to intervention for subjects in Group B was 36.59±1.279, which increased to 38.89±1.396 following intervention. Comparison of values with paired t test resulted in a t value of -16.480 and a P value of 0.000 representing high significance according to analysis, even though with fewer subjects compared to Group A, indicating a positive effect of the intervention.

Analysis of Balance Scores and Fall Risk Scores

Analysis of pre and post fall risk scores (JHFRAT)

Mean value of fall risk scores prior to intervention in subjects of Group B was 3.85±1.657 which dropped to a mean of 2.96±2.103 following intervention. Comparison of values with paired t test yielded a t value of 4.567 and a P value of 0.000 representing high significance according to analysis, even though with fewer subjects compared to Group A, indicating a positive effect of intervention

Discussion

With the proportion of older adults increasing in many industrialized nations, much research is being dedicated to understanding the changes that occur with aging. Although it is well established that sensory feedback plays a critical role in postural control, the less appreciated fact is that the delay in the transmission and processing of sensory feedback can disrupt standing balance.^6,7 The accumulated behavioural, neuropsychological and neuroimaging evidence shows that slow gait, postural instability and fall risk in elderly are associated with cognitive capacities.^8,9

It has been hypothesized that an inability to produce an appropriate postural response due to competition for attentional resources between the demands of postural system and the cognitive task contributes to falls in older adults with poor balance.¹⁰ One factor that has consistently been shown to enhance the performance and learning of motor skills, including balance skills, is the performer’s focus of attention.^11,12 This finding directed the master idea to determine the effect of including an attention component to a selected set of balance exercises in the elderly population.

Age and Gender Distribution

The study's demographic analysis showed a mean age of 64 years among the participants. The age distribution was relatively balanced between the two groups, ensuring that age-related variability did not confound the results. The majority of participants (33.3%) were in the 60-61 age range, followed by a significant portion (22.2%) aged 68 years and above. This age distribution is crucial as it reflects a population likely to experience significant age-related decline in balance and mobility, thus providing a relevant sample for the study's objectives.

Baseline Measures of Balance and Fall Risk

Initial assessments revealed that the two groups were homogeneous in terms of baseline balance and fall risk. The mean BBS score was 36.37 in Group A and 36.59 in Group B, with no statistically significant difference (P=0.556). Similarly, JHFRAT scores indicated comparable fall risk levels, with Group A having a mean score of 3.78 and Group B a score of 3.85 (P=0.868). These findings underscore the importance of randomization in creating equivalent groups, thereby ensuring that any observed post-intervention differences can be attributed to the interventions themselves rather than pre-existing disparities.

Post-Intervention Outcomes in Group A

The intervention's impact on Group A was marked by significant improvements in both balance and fall risk. Post-intervention, the mean BBS score in Group A rose to 47.26, indicating a substantial improvement in balance (P=0.000). This result suggests that attention-based balance training can effectively enhance postural stability among elderly females. The improvement is likely due to the dual-task nature of the training, engaging both cognitive and motor systems. Previous research supports the notion that such dual-task exercises can strengthen neural pathways involved in balance control and coordination, leading to better functional outcomes.

Additionally, the JHFRAT scores for Group A decreased from 3.78 to 1.48, reflecting a significant reduction in fall risk (P=0.000). This finding aligns with the literature suggesting that targeted balance training can mitigate fall risk factors, including poor postural control and muscle weakness. The substantial reduction in JHFRAT scores indicates that attention-based exercises not only improve balance, but also contribute to overall safety and functional independence in this population.

Comparative Analysis Between Groups

The comparison of post-intervention outcomes between the two groups revealed a statistically significant difference in both BBS and JHFRAT scores. The mean difference in BBS scores between Group A and Group B was 8.37 (P=0.000), indicating a significantly greater improvement in balance in the intervention group. This result strongly suggests that attention-based balance training is more effective than general mobility exercises in enhancing postural control.

Similarly, the difference in post-intervention JHFRAT scores between the groups was also significant, with Group A showing a more substantial reduction in fall risk compared to Group B (mean difference = -1.481, P =0.003). The greater improvement in fall risk in Group A can be attributed to the specific focus on balance and attention in the intervention, which is critical in addressing the multifactorial nature of falls in the elderly population.

The differential outcomes between the two groups can be attributed to the nature of the interventions. Attention-based balance exercises require participants to simultaneously engage in cognitive and motor tasks, potentially enhancing neuroplasticity and improving the coordination between cognitive and motor systems.

This dual engagement may be particularly beneficial for elderly females, who often experience both cognitive and physical declines with aging. The study results are consistent with the existing literature underscoring the interconnectedness of cognitive and motor systems and suggests that dual-task training can lead to superior improvements in functional abilities.

Furthermore, the statistically significant differences observed between the groups in post-intervention BBS and JHFRAT scores underscore the efficacy of attention-based training. The study's use of standardized outcome measures and rigorous statistical analysis, including the Student’s t-test, bolsters the reliability of these findings. The significant P values (0.000) for both balance and fall risk outcomes in Group A confirm the effectiveness of the intervention.

Overall, these findings advocate the inclusion of attention-based balance training in fall prevention and rehabilitation programs for the elderly, particularly for women who are at a higher risk of falls. The study also highlights the need for further research to explore the underlying mechanisms contributing to the observed improvements and to optimize the design of dual-task training protocols for maximum benefit.

The findings from this study highlight the significant benefits of attention-based balance training in improving balance and reducing fall risk among elderly females. The intervention group (Group A), which received specific attention-focused exercises, showed remarkable improvements in balance, as indicated by the increase in Berg Balance Scale (BBS) scores from 36.37 to 47.26 post-intervention. Similarly, the Modified John Hopkins Fall Risk Assessment Tool (JHFRAT) scores demonstrated a substantial reduction in fall risk, with scores decreasing from 3.78 to 1.48. These results suggest that attention-based balance training effectively enhances postural stability and reduces fall risk, supporting the hypothesis that integrating cognitive tasks with physical exercises can optimize functional outcomes.

In contrast, the control group (Group B), which engaged in general mobility exercises, also exhibited improvements but to a lesser extent. The BBS scores in Group B increased from 36.59 to 38.89, and the JHFRAT scores decreased from 3.85 to 2.96. While these changes are statistically significant, they are not as pronounced as those observed in Group A, indicating that while mobility exercises contribute to improved physical function, they may not be as effective as attention-based training in enhancing balance and reducing fall risk.

Conclusion

Poor health, pain, fear of falling and the risk of injury are the most frequently mentioned factors by elderly individuals as limiting their physical activity. In women, this pattern generally reflects the time pressures associated with their multiple roles at this stage of life and earlier. Lack of self-compassion associated with age also attributes to the cause. This study concludes that simple attention-based balance training, in early and moderate stage balance impairments, is fruitful and feasible among the comparatively inactive, 60-70 year old female population. Further, this intervention was found to alleviate their fear of fall to a great extent, contributing to self-confidence, enabling them to adopt a physically active lifestyle during the final years of their life.

Conflict of Interests

The author do not have any conflict of interest to declare.

Acknowledgements

I express my heartfelt indebtness and owe a deep sense of gratitude to my teacher and my faculty guide Prof. L. Gladson Jose Principal, Dr M.V. Shetty College of Physiotherapy and for the regular advice, magnitude of dynamic and untiresome guidance, suggestion and encouragement throughout the course of present research.

I would like to express my sincere thanks to all the respectable staff members of Dr M.V. Shetty College of Physiotherapy, without their co-operation this study wouldn’t have been successful. I acknowledge my sincere gratitude towards the Narayana Hrudayalaya Institute of Physiotherapy for providing me the time and opportunity for publishing this study.