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Deborah Perry Schoenfelder and Linda M. Rubenstein
This study tested a 3-month ankle-strengthening and walking program designed to improve or maintain the fall-related outcomes of balance, ankle strength, walking speed, risk of falling, fear of falling, and conﬁdence to perform daily activities without falling (falls efﬁcacy) in elderly nursing home residents. Nursing home residents (N ϭ 81) between the ages of 64 and 100 years participated in the study. Two of the fall-related outcomes, balance and fear of falling, were maintained or improved for the exercise group in comparison to the control group. © 2004 Elsevier Inc. All rights reserved.
LDER ADULTS WHO RESIDE in nursing homes often have multiple health risks, including the risk of falling with the resultant potential for injury. Frail elders who fall are likely to fall repeatedly, further increasing their risk for serious injury. Fractures, soft-tissue injury and immobility may lead to long-term disability or death. The fear of falling again may inhibit physical activities necessary for good health and can compromise quality of life when older people restrict their activities beyond what is necessary for safety (Lachman, et al., 1998; Mustard & Mayer, 1997). There is promise that exercise can improve fallrelated outcomes. Results of a pilot study suggested that a walking and ankle-strengthening program could improve fall-related outcomes and prevent or slow physical deterioration in elderly nursing home residents (Schoenfelder, 2000). This follow-up study investigated the effectiveness of an ankle-strengthening and walking program for elderly nursing home residents in improving balance, ankle strength, and walking speed; decreasing risk of falling and fear of falling; and improving conﬁdence in performing daily activities without falling (falls efﬁcacy).
annually, with a mean incidence rate of 1.5 falls per bed per year (Nygaard, 1998). Risk Factors Risk factors for falling are classiﬁed as intrinsic or extrinsic. Intrinsic factors are internal to the individual. Increased age, a history of falls, impaired balance, poor muscle strength including ankle strength, and slow walking speed are examples of intrinsic risk factors (Davis, Ross, Nevitt, & Wasnich, 1999; Mustard & Mayer, 1997). Other intrinsic risk factors include age-related physiologic changes and chronic conditions of various body systems, particularly cardiovascular, neurologic, musculoskeletal, and urologic conditions (Edwards & Lee, 1998; Tinetti & Williams, 1998). Gait and balance impairments are strong predictors for falling, and walking velocity has been found to be slower for older adults who fall than for older nonfallers (Cho & Kamen, 1998; Davis, Ross, Nevitt, Wasnich, 1999; Edwards & Lee, 1998). Acute health status changes also put older adults at
Deborah Perry Schoenfelder, PhD, RN, Clinical Associate Professor, College of Nursing, The University of Iowa, Iowa City, IA, USA; Linda M. Rubenstein, PhD, Assistant Research Scientist, Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA. Supported by grant # 1 R15 NR04220-01A1 through the National Institutes of Health. Address reprint requests to Deborah Perry Schoenfelder, PhD, RN, College of Nursing, The University of Iowa, 378 Nursing Building, University of Iowa, Iowa City, IA 52242. E-mail: email@example.com © 2004 Elsevier Inc. All rights reserved. 0897-1897/04/1701-0004$30.00/0 doi:10.1016/j.apnr.2003.10.008
Incidence Falls are the most frequently reported adverse incident in long-term care facilities (Gurwitz, Sanchez-Cross, Eckler, & Matulis, 1994). A fall can be deﬁned as any event in which a person inadvertently or intentionally comes to rest on the ground or another low level (Tideiksaar, 1998). At least 40% of older nursing home residents fall
Applied Nursing Research, Vol. 17, No. 1 ( February), 2004: pp 21-31
Although elderly nursing home residents are at a great risk for falling and deterioration of physical and functional abilities. 1999. in a study that used strength and balance exercises for older women living in the community. fear of falling has been identiﬁed as a risk factor for falling (Baloh. The way older persons function in and interact with their environments also affects their safety. In addition to being a consequence of falling. & Powell. Robertson. is an important factor to consider in fall prevention efforts (Tinetti. low lighting. this population has not been studied extensively to test the effects of exercise on fallrelated outcomes. 1990). Older nursing home residents who participated in a walking program showed improvement in their ambulatory status (measured on a seven point scale ranging from “independence” to “complete dependence”) and a decrease in falls after participating in the program (Koroknay. The proportion of participants who were injured from a fall was lower in the exercise group (26. Enrietto. . Cohen-Mansﬁeld. and slippery ﬂoors (North American Nursing Diagnosis Association. 1997). Walking is a common form of exercise and can be highly beneﬁcial for older adults. Jacobson. Cumming. 1998). Corona. 1998). as does adverse reactions to medications (Leipzig. endurance training.1%) (Campbell et al. One study suggested that those who are distracted by doing a familiar. Mustard & Mayer. & Tinetti. 1995). There is evidence that exercise can also reduce falling and risk of falling in older people. Richman.22 SCHOENFELDER AND RUBENSTEIN risk for falling (Kuehn & Sendelweck. 2000). Extrinsic risk factors for falling are those environmental hazards that increase the chances of falling such as the presence of throw rugs. so that equipment needs and time commitment for subjects and research staff were at a minimum. manual task along with functional maneuvers are more apt to fall (Lundin-Olsson. this population has not been studied extensively to test the effects of exercise on fall-related outcomes. 1997). including muscle strengthening exercises. & Campbell. A simple program was chosen that included an ankle strengthening exercise followed by up to 10 minutes of supervised walking. In addition. 1995). & Honrubia. the combination of an ankle-strengthening exercise and walking program has not been reported in the literature. Werner. ﬂexibility training. & Gustafson. For example. Nyberg. Although elderly nursing home residents are at a great risk for falling and deterioration of physical and functional abilities. Schoenfelder.2%) than in the control group (39. 2001. A review of controlled clinical trials reported that studies successfully reduced falls or risk of falls when strength and balance retraining. and walking to offset declining strength or to increase muscle strength and to improve balance and gait velocity (Chandler & Hadley. Exercise Studies Older adults beneﬁt from exercise of various types. aerobic exercises. 1996). There is evidence that falls efﬁcacy. Walking is a common form of exercise and can be highly beneﬁcial for older adults. Buchner and colleagues (1997) tested the effect of strength and endurance training for older community-dwelling adults and found there was a signiﬁcant beneﬁcial effect of exercise on time to ﬁrst fall and on the overall fall rate for exercisers that was not present for those in the control group. the conﬁdence that an individual has to do daily activities without falling. The bulk of the research that tests the effects of exercise on fall-related outcomes for older adults has been done with community-dwelling elders.. 2000). participants in the exercise group had improved balance and had a lower fall rate than the control group. and Tai Chi were used (Gardner. & Braun. Keeping an exercise program uncomplicated and yet effective is key for beginning or sustaining a program so that nursing home staff will include a regularly scheduled program into their busy work days and elders will be more apt to exercise consistently.
The group did. fall risk data. mobility/activity information. METHODS Setting and Participants The study was conducted in 10 private. and conﬁdence to perform daily activities without falling (falls efﬁcacy). (4) did not have an unstable physical condition. ranging in size from 68 beds to 178 beds. The predicted relationship of the exercise program and the fall-related outcomes is depicted in Figure 1. walking speed. Subjects assigned to the intervention group participated in a 3-month ankle-strengthening and walking program and had data collected on demographics. The researchers hypothesized that the proportion of elders with consistent or improved fall-related outcomes would be signiﬁcantly higher for those individuals participating in the ankle strengthening and walking program than for those elders who did not participate. fear of falling. Equipment necessary for the exercise program in- Figure 1.FALL-RELATED OUTCOMES 23 Procedure Participants were matched in pairs by Risk Assessment for Falls Scale II scores (RAFS II) and randomly assigned within each pair to the intervention or control group. The fall-related outcomes for this study were balance. Intervention The 3-month supervised exercising was done three times weekly for about 15 to 20 minutes each time. The procedures to protect human subjects in this study were reviewed and approved by The University of Iowa Institutional Review Board. When subjects were roommates or spouses. examiners doing the assessments had no contact with the participants other than the assessments once group assignments were made. Physicians were contacted and asked to indicate potential participants who might have physical conditions that would contraindicate taking part in the exercise program. (2) were able to ambulate independently or with an assistive device so that they could take part in the ankle-strengthening and walking program. The program was advanced as strength and endurance increased and the exercises were mastered. walking speed. Relationship of independent variables and outcome variables. falls risk. balance. and falls efﬁcacy before the intervention and at 3 months (completion of the intervention) and 6 months after initiation of the intervention. Nursing home residents were recruited who (1) were at least 65 years old. receive an attention placebo to control for the effects of attention and motivational strategies. chart reviews were conducted by research team members to ascertain any chronic conditions. The training program was tailored to individual’s ability to do the ankle exercise at the beginning of the program and the distance and time the subject was able to walk for the timed 6-meter walk at pretest. Subjects in the control group were assessed for the same baseline data as the intervention group subjects. The ankle-strengthening exercise was done ﬁrst followed by the supervised walking.” For all assessments conducted at 3 and 6 months. and (5) had a score of 20 or above on the Mini-Mental State Examination to be able to answer the interview questions and to understand and follow directions for the ankle strengthening and walking program. Data were gathered again at 3 and 6 months with no exercise intervention by the research team. ankle strength. evidence of an endstage terminal illness. those individuals were assigned to the same group to lessen the possibility of contamination between the intervention and control groups. The examiners were graduate and undergraduate students who were trained by the principal investigator to accurately collect the data and correctly and safely perform the exercise intervention. . fear of falling. After obtaining signed informed consent. however. or a history of acting-out or abusive behavior. ankle strength. (3) were able to speak English. Subjects in the control group were visited weekly by the same research team member that conducted the exercise program. urban nursing homes in eastern Iowa. About 30 minutes was devoted each time to an activity such as book reading or “friendly visiting.
subjects were encouraged to walk at a faster (yet safe and functional) pace for 10 uninterrupted minutes.89 in a psychiatric and neurologic population and interrater reliability was at least . increasing the weight when the subject is able to complete three sets of 10 to 15 repetitions. a spring gauge was moved. and then when able progressing to (2) bilateral heel raises (as described earlier) with ankle weights attached. with heel of one foot touching and in a straight line with the toe of the other). Ankle strength. . and other activities/exercises in which they participated.66) and lower for the second question (Kappa ϭ 0. race. fairly. slowly raise both heels until weight is on balls of the feet doing up to three sets of 10 to 15 repetitions. The ankle strengthening exercise consisted of (1) standing upright with knees straight. 1975) is an 11-item screening test of cognitive function. Ankle plantar ﬂexion strength was measured by having subjects place their dominant foot on a mechanical force transducer. if tolerated. the follow-up question “Do you think this concern has made you cut down on the activities that you used to do?” was asked to which the subject could respond with a “yes” or “no. Testretest reliability over a 24-hour period was at least 0. 1990).” “fairly concerned. Subjects walked for 10 minutes. In addition to strengthening the ankles. Scores range from 0 (severe dementia) to 30 (normal). subjects were asked how often they walked. and (3) tandem stance (“Sharpen Romberg” stance. Cognition. or very concerned. and length of residence at the nursing home were collected.82. Variables/Instruments Demographic information. and the greatest movement was recorded in newtons. education. Balance. Subjects were asked “How concerned are you about falling?” to which they could respond “not at all concerned. Richman. If and when that goal was reached. side by side). & Ward. Age. giving a measure of maximal ankle plantar ﬂexion strength. Although the intent of the exercise program was not to walk at an exceedingly fast or unsafe pace. while holding onto the back of a straight chair. The mechanical force transducer was calibrated for accuracy by a technical expert from The University of Iowa Medical Instrument Shop who built the transducer and stabilizer. using 20 as the cutoff score.” Test-retest reliability for the ﬁrst question was acceptable (Kappa ϭ 0.36) (Tinetti. Team members were graduate and undergraduate students who were trained by the principal investigator to safely supervise correct performance of the exercise intervention. The scale was used as one factor to determine inclusion in the study. A research team member closely supervised subjects as they exercised. this exercise served as a warmup for the walking program. Then when seated. marital status. No assistive devices were allowed. eyes were open during the stances. attended group exercise classes. & Powell. Level of mobility was ascertained by asking participants whether they ambulate unassisted. The time to walk six meters was measured in seconds with a stopwatch. & McHugh. or with an assistive device and another person. and arms could be in any position. Caplan. The Mini-Mental State Examination (Folstein. Ankle-strengthening exercise. A score of 23 or below has been established as indicative of cognitive impairment (Cockrell & Folstein.” or “very concerned.” If subjects responded somewhat. subjects attempted to plantar ﬂex their foot against the mechanical force transducer.” “somewhat concerned. Time was increased until 10 minutes of sustained walking was reached. 1993). with an assistive device. (2) semitandem stance (toe of one foot beside heel of other foot). 1988). Fear of falling. walking at a moderate or moderately fast pace was a reasonable goal for functional purposes. Walking speed. In addition. sex. Balance was measured by a stopwatch for up to 10 seconds in three stances: (1) parallel stance (“Classic Romberg” with feet together. Mobility/activity information.24 SCHOENFELDER AND RUBENSTEIN cluded any assistive device the subject used and a straight chair. Subjects were also observed for their mobility level when walking speed was measured. Walking program. Folstein. The foot and upper leg were contained in an apparatus to stabilize the foot and leg and keep the knee ﬂexed at a 90° angle and to keep the plantar surface of the foot at a 90° angle with the lower leg.57 to 0.96. Pearson correlation coefﬁcients reported by Graybiel and Fregly (1966) for the parallel and tandem stances ranged from 0. Three trials were conducted. Strength was corrected for body size by dividing the measure by the height of the subject (Lord.
Items assessed are length of time since admission.” The item “reach into cabinets or closets” was modiﬁed to “reach into closets” and the item “walk around the house” was changed to “walk around the nursing home” to better ﬁt typical activities for nursing home residents. & Powell. Internal consistency was maintained in the modiﬁed version (Cronbach’s alpha ϭ 0. Bennett. There were no signiﬁcant baseline differences between the intervention and control groups for all outcome measures. walking speed. Study Results Mobility status at baseline was signiﬁcantly associated with balance. clean up your nightstand or dresser) and “get up at night to go to the bathroom. the tool was modiﬁed so that the list of activities were appropriate for elderly nursing home residents and still measured the concept of falls efﬁcacy (Schoenfelder. Falls efﬁcacy was measured by using a modiﬁed Falls Efﬁcacy Scale (FES). and 6 months. Gyldenvand. 1994). fear of falling. walking time. depression. Baseline mean scores for selected sample characteristics and fall-related variables are reported in Table 2. Exact nonparametric tests were used to assess variables with small cell sizes and for repeated measured analyses. The items “prepare meals not requiring carrying heavy or hot objects” and “answer the door or telephone” were deleted because these items did not make sense for most residents within their nursing home settings. The RAFS II (Ross. The two deleted items were replaced with the items “do “light” housekeeping in your room” (eg. medications. chronic diseases. and urinary function. Total scores range from 1 to 39 with a score of 14 or greater indicating a high risk for potential of trauma by falling. Internal consistency was shown with a Cronbach’s alpha coefﬁcient of 0. & Reinboth. mobility. The Falls Efﬁcacy Scale (Tinetti. falls efﬁcacy. Tests for group differences used the Pearson’s chi square test or Fisher’s Exact test for categorical data and either a t test (normal distributions) or Kruskal-Wallace (nonnormal distribution) test for continuous data. 1990).99). 3 months. Data Analysis The main study outcomes were balance. and falls efﬁcacy. Baird. 2000). communication. The RAFS II was used in an acute care hospital and three extended care facilities and found to be 90% accurate for predicting falls (Gyldenvand. and risk of falling (chi-square p values Յ .FALL-RELATED OUTCOMES 25 Fall Risk Assessment. ankle strength. 1990) is a 10-item tool designed to assess the degree of perceived self-conﬁdence for avoiding a fall during each of 10 relatively nonhazardous activities of daily living routinely performed by community dwelling elders. The scale was used for assigning subjects in matched pairs to the intervention or control groups and to assess the outcome variable of risk for falls. Descriptive statistics were generated for the intervention and control groups at baseline. The demographic. Richman. nurses. age. Richman. vision.89 for a sample of community-dwelling older adults (Dayhoff. mental status. 1991) is a 13item tool that provides an indication of the risk of falling. Watson. & Powell.05). Comparisons were made between the intervention and control groups based on the proportion of elders who remained the same or improved versus those who declined by 3 and 6 months. Expert validation was accomplished by reaching consensus among therapists. history of falling. balance. and physicians concerning the activities to include in the FES. Test-retest reliability revealed a Pearson’s correlation of 0. Data were collected for all variables at baseline. agitation. RESULTS Sample Characteristics The initial sample (N ϭ 81) consisted of 62 women and 19 men between the ages of 64 and 100 years (mean ϭ 84. also shown in Table 2. and activity characteristics for the entire sample at pretest are summarized in Table 1. all group and repeated measures analyses controlled for baseline mobility . Fiftythree percent of the participants had fallen in the past year. anxiety. Mobility status was signiﬁcantly associated with age but not gender. In consultation with a nursing home director of nursing and two gerontological nursing experts. Because of this association. Falls efﬁcacy. 1984).71 for a sample of community elders and residents of an intermediate care facility (Tinetti. & Backer. risk of falling.1).
9 10.7 47.8 13.4 8.4 23.1 16. Demographic.1 10.3 21.1 12.2 23. Lack of signif- .4 28.0 4.6 66.8 59. Most elders were able to complete the parallel stance for 10 seconds at baseline. Mini-Mental State Examination.6 0 14.1 17.6 25.3 66.9 5.5 16.5 63.4 19.8 7. The mean age for independent walkers was 5 to 7 years younger than the mean ages for the assistance groups.3 30.5 27. This ﬁnding also remained signiﬁcant at 6 months.5 7.5 Abbreviation: MMSE.7 10.8 81.7 32 7 2 10 17 10 26 4 4 5 13 26 (N ϭ 38) 9 18 11 (N ϭ 38) 4 26 8 82.0 42.5 17.5 23. Mobility status was signiﬁcantly associated with age but not gender.3 35.and 6-month follow-ups are shown in Table 3.8 2.4 24.3 28.5 68.8 5.8 48.1 7. and there was no signiﬁcant change within or between groups over time.7 23.7 83.3 52.8 30 12 4 6 22 10 34 2 3 3 7 35 15 16 11 10 25 7 (N ϭ 41) 35 6 0 6 9 27 71.1 26. status.0 85. Among those who used assistive devices and for all mobility levels combined. Most other outcome variables exhibited nonsigniﬁcant changes over time in the predicted direction (indicated in bold in Table 3).5 12.2 61. In the time period from 3 to 6 months.7 38.1 25. even though the intervention group had not done the supervised exercise program for 3 months.26 SCHOENFELDER AND RUBENSTEIN Table 1.4 64.9 24.5 14.8 33.7 74. and the results for change at the two follow-ups are listed in Table 4.4 14.6 9. Means for selected sample characteristics at the 3.1 7.1 24.1 83.4 28.4 21.6 9. a signiﬁcantly larger proportion of the intervention group showed maintenance or improvement over time with the semitandem stance compared with the control group at the completion of the exercise program at 3 months. among those who used an assistive device.3 32 5 2 4 11 24 82.7 63.3 10.3 12.8 18. a signiﬁcantly larger proportion of the intervention group exhibited the same or improvement in fear of falling compared with the control group.7 75. and Activity Characteristics at Baseline Total Sample (N ϭ 81) Frequency Percent Intervention Group (N ϭ 42) Frequency Percent Control Group (N ϭ 39) Frequency Percent Demographic Variables Gender Female Male Age 64-69 70-79 80-89 90 and older Marital Status Widowed Married Divorced/separated Never married Mental status (MMSE) 20-23 24-30 Education Less than high school High school graduate/trade school Beyond high school and other than trade school Mobility Walks independently Uses assistive device Assistive device ϩ person Activity Walking 3 or more times/week 1 or 2 times/week Does not walk weekly Exercise Class 3 or more times/week 1 or 2 times/week Does not attend exercise classes 62 19 6 16 39 20 60 6 7 8 20 61 (N ϭ 79) 24 34 21 (N ϭ 80) 14 51 15 (N ϭ 80) 67 11 2 10 20 51 76.6 43. Mobility.
6 (17.3 (24.7) 25. icance was most likely related to the small numbers of respondents in each mobility group.3 (3.29 0.1 (7.8 (4.7 (14.7) 8.5 (3.8) 79.5) 1.7 (18.49 0. Baseline Mean Scores for Selected Sample Characteristics Total Sample Variable N Mean Score (SD) Intervention Group N Mean Score (SD) N Control Group Mean Score (SD) Difference in Intervention and Control Group mean scores (p Level.1) 30 30 30 30 30 30 30 30 9.94 0.1) 36.4) 39 39 39 39 39 39 36 84.2 (1.5 (17.3) 42 2.9 (15.0 (4. The exercise program emphasized balance and did indeed improve balance as measured by the semitandem stance.4) 2.6 (3.2 (3. range 1-39)* Falls efﬁcacy scale (range 1-100) Fear of falling (range 1-4) 66 23.2 (2.0 (3.3) 33 33 33 33 33 33 33 33 9.9 (2.6) 6.2) 2.8) 76.4 (2.5 (3.8 (14.3) 8.5 (3.9 (2.3 (1.0) 20.8) 8.6) 2.4 (3.9) 25.9) 29.8) 9.5 (15.4) 30 24.8) 79.5) 18.9) 20.9 (12.2) 8.7 (3.3 (16.3) 2.6) 58 58 58 58 58 58 58 58 9.1) 15.8 (23. .8) 67 67 67 67 67 67 66 66 9.8 (21.0 (2. range 0-30) Balance (up to 10 seconds) Parallel Semi-tandem Tandem Ankle strength (n/m) Walking speed (in seconds) Falls Risk (RAFS II score.9 (7. CochranMantel-Haenszel methods) Abbreviation: MMSE.3) 8.4 (1.6 (16. range 1-39.7 (3.7) 42 42 42 42 42 42 40 83.33 0.3 (3.6 (3.5 (1. Mini-Mental State Examination.3) 77.9 (2.1) 2.3 (3.3 (3.3) 58 22. 14 & above indicates high risk) Falls Efﬁcacy Scale (range 0-100) 81 81 81 81 81 81 76 84.2 (19.0 (4.6) 7.2) 28 21.3) 2. the effect remained signiﬁcant 3 months after completion of the program.9) 20.9) 3.5 (19.2 (2.7 (2.4) 15.0 (2.4) Fear of Falling (range 1-4) 81 2.3 (7.7) 4.12 (p level.6) 15.2) 3.6 (4.1) 2.7 (20.7) 8.0 (3.0) 28.4) 20.3) 16.8) 25.2 (17.3 (3. Wilcoxon Rank-Sum Test) Age (in years) Mental status (MMSE score.6 (2.7) 25.4 (16.6) 30.5) 25.3) 0. *Fourteen and above indicates high risk.2) 33 24.9) 2.50 0.5) 27.2 (2.9) 33.8 (3.1 (21.3 (3.5 (22.5 (1.4 (3.6 (19.7) 15.50 0.9) 28 28 28 28 28 28 28 28 9.3) 77.4 (3.7 (16.7) 78.9) 80.7) 2.0 (24. Fear of falling was signiﬁcantly affected.3 (4.3) 78. Reestablishing the exercise program after an illness or injury or hospitalization would therefore be warranted for elderly nursing home residents.33 81 81 15. Means (SD) for 3 Months and 6 Months Follow-up for Selected Sample characteristics Total Sample 3 months Mean (SD) 6 months Mean (SD) Intervention Group 3 months Mean (SD) 6 months Mean (SD) Control Group 3 months Mean (SD) 6 months Mean (SD) Variable N N N N N N MMSE Score (range 0-30) Balance Parallel Semitandem Tandem Ankle strength (Newton/meters) Walking speed in seconds Fall risk (RAFSII. The tandem stance was too difﬁcult for most subjects to do and therefore did not show signiﬁcant maintenance or improvement.5 (3.91 0.9) 18.2) 42 42 15.6 (26.6 (4. This ﬁnding suggests that interruption in an exercise program does not mean the positive effects are immediately lost.0) 23.5) 9. Mini-Mental State Examination.6 (1.7) 15.3) 39 39 15.0) 20.2 (3.2) Abbreviation: MMSE.6 (1.5 (1.3 (3.9) 3.5) 8.83 0.2) 39 2.5 (1.7 (3. specifically from 3 to 6 months for intervention subjects who required an assistive device to ambulate. DISCUSSION There were signiﬁcant changes as hypothesized for semitandem stance.1 (20.3 (2.4 (1.9) 9. It is likely that concern for falling was raised during the Table 3.9 (4.8) 74.8 (21.3) 33 22.FALL-RELATED OUTCOMES 27 Table 2.9) 19.5) 3.6 (22.8) 0. Not only was balance maintained or improved at the completion of the supervised exercise program.8 (4.2) 19.2) 34 34 34 34 34 34 33 33 8.
580 0.028* NA 0.7 (6) 75.795 0.2 (7) 20.487 0.0 (8) 75.0 (10) 100.5 (15) 75.8 (7) None 30. the results for all mobility levels were in the predicted direction (p ϭ .318 0.345 0.7 (6) None 41.0 (1) 68.0 (8) 22. Lower .0 (1) 66.6 (5) 50.0 (6) 59.0 (2) 53.733 0.0 (3) 58.0 (5) 38. It is difﬁcult to know why fear of falling did not signiﬁcantly improve for the independent group and the device and person group.7 (6) 53. The results may be partially explained by the small numbers in each group (independent.127 0.08).3 (10) 87.738 0.436 0.7 (2) 77.3 (1) 44.3 (2) 52.845 0NA 0.182 0.3 (13) 33.121 0.740 0.0 (3) 73.054.0 (3) 50.6 (12) 50.4 (8) 33.0 (14) 66.0 (2) 100.4 (19) 100.3 (26) 50.2 (20) 100.571 0.0 (5) 93.7 (11) 55.4 (24) (Chi-square or Fisher’s Exact tests) 0.099 0.277 0.7 (6) 60.3 (1) 36.0 (3) 64.571 0.7 (9) 69.306 % (frequency) 20. and likelihood ratio tests.8 (10) 66.1 (25) 50.744 0.8 (6) 89.0 (2) 55.0 (2) 58.3 (14) 78.6 (5) 59.7 (11) 37.126 0.7 (4) 76.179 NA 0.5 (25) % (frequency) 60.28 SCHOENFELDER AND RUBENSTEIN Table 4. However.5 (3) 31.0 (4) 100. Although the results were not signiﬁcant.4 (9) 33.4 (19) 100.249 0.053* 0.0 (4) 100 (15) 88.2 (2) 43.0 (3) 64.785 0.8 (11) 66.7 (22) 62.0 (1) 86. exercise program for subjects who were increasing their level of exercise.6 (12) 50 (2) 55.0 (2) 47.592 0.5 (5) 54.808 NA 0.3 (2) 38. Larger sample sizes would most likely show a signiﬁcant effect for this important fall-related outcome.5 (10) 50.0 (8) 100.0 (6) 100.0 (18) 66.964 NA NA NA NA NOTE.308 0.1 (8) 33.417 0.9 (22) 25.1 (13) 75.057* NA 0. Results for Change Over Time Stay the Same or Improve versus Decline From Pretest to 3-Month Posttest Variable.789 0. having been more accustomed to a less active lifestyle.523 0. device and person) as compared with the device-only group.0 (20) (Chi-square or Fisher’s Exact tests) 0.0 (3) 46.0 (2) 55.9 (6) 93.9 (9) 55.0 (6) 54.461 0. *bold print: p Յ .2 (7) 66.0 (10) 100.502 0. Group.7 (14) 75 (6) 36.0 (24) 50.0 (3) 88.171 0.529 0.5 (13) 100 (9) 81.4 (10) 50. Fisher’s Exact tests.198 0.3 (1) 45.6 (5) 50 (16) 66.7 (4) 41.008* 0.1 (17) 50. It was expected that ankle strength would be signiﬁcantly affected by the exercise program because there was an exercise speciﬁcally targeted at strengthening ankles.853 0.2 (15) 66.520 NA 0. not applicable. Abbreviation: NA. bold print only: change in predicted direction.1 (8) 100. as time progressed.4 (12) 0 (3) 30 (3) None 21.806 0. and Mobility Class Intervention Control p Value Stay the Same or Improve versus Decline From 3Month to 6-Month Posttest Intervention Control p Value Semitandem Device and Person Device Only Independent All Levels Tandem Device and Person Device Only Independent All Levels Walking Speed Device and Person Device Only Independent All Levels Ankle Strength Device and Person Device Only Independent All Levels Fear of Falling Device and Person Device Only Independent All Levels FES Total Device and Person Device Only Independent All Levels RAFS Device and Person Device Only Independent All Levels % (frequency) 80.4 (3) 33.5 (7) 44.0 (9) 60.076 NA 0.0 (6) 100 (1) 71.1 (20) 100 (3) 60.9 (14) 100 (3) 74.9 (19) 75.0 (20) % (frequency) 40.080 0.030* 0.7 (13) 89. it may have been that exercise subjects became less fearful of falling after they saw that they could exercise and move about safely. p Values are generated from chi-square tests.9 (19) 100 (8) 70.
Smith. and not time consuming. Walking speed. to the bathroom and to the dining area) rather than propel themselves in a wheelchair if they were able to walk at a more “functional” speed. Nevertheless. No doubt adherence was at a high level because the exercises were supervised. Nevertheless. falls risk. Attrition was also a limitation in this study that reduced the sample size to 67 at the 3-month follow-up and to 58 at the 6-month follow-up. two of the fall-related outcomes in this study. walking requires balance and the act of walking regularly probably improves balance as it did in this study. Again. 2000). the ankle exercise would probably increase dorsiﬂexion and plantar ﬂexion ROM. This difﬁculty might be caused by having response labels only at the two ends of the scale. and falls efﬁcacy are important outcomes for evaluating the effectiveness of programs to prevent falls or stop the cycle of falling. conducted on a one-on-one basis. for the most part. Roberts. 100 point) to conceptualize and translate into a conﬁdence level.FALL-RELATED OUTCOMES 29 strength gain (knees and ankles) was signiﬁcantly associated with increase in gait speed and improved falls efﬁcacy (Chandler. excellent adherence to the exercise program and no reported adverse effects to the exercise program. The exception. because a large majority of older Iowans are white. and having conﬁdence in being able to perform activities without falling would likely lead to more active participation in those daily activities. and falls efﬁcacy also showed change over time in the predicted direction for some of the mobility levels. The results show promise that a simple exercise plan can have positive effects on fall-related outcomes. The tests and instruments used in this research were. Recommendations can be made for nursing practice based on this research. especially balance and fear of falling as indicated by this study. & O’Sullivan. the authors recommend using a tool to measure falls efﬁcacy that has few numbered points and has descriptors for each of those points. Duncan. Finally. it would seem that frail elders might be more apt to walk on a routine basis (eg. Walking speed. . it was expected that the study sample would not vary in ethnic or racial composition and that was the case. having small numbers in each cell made it difﬁcult to obtain signiﬁcant ﬁndings. as noted earlier. Recruitment was somewhat difﬁcult in that some potential subjects were hesitant to start an exercise program. Another possible limitation that was anticipated was that subjects might tend to respond to certain questions according to how they believed the examiner would want them to respond (eg. & Studenski. This needs to be considered when discussing generalizability of the results. Most of the attrition was due to extended illness or death. There were limitations with this research. this study can be replicated in settings with more diverse populations in the future. Also. falls risk. Several of the risk factors in the RAFS II are modiﬁable by health care intervention. Regarding walking speed. simple to do. the authors believe that walking speed. Although ankle range of motion (ROM) was not measured in this study. Kochersberger. In addition. Major strengths of this study were the use of a control group. The ﬁndings in this study have implications for nursing research. conﬁdence levels on the FES). or the difﬁculty might be caused by having too large of a scale (ie. Recent ﬁndings suggest that interventions for increasing ankle ROM may increase balance and reduce falls in older adults (Mecagni. no falls or injuries occurred while exercising in this study and no physical complaints were expressed by the intervention subjects. In general. Based on the difﬁculty that subjects had responding to this instrument. 1998). falls risk. easy to administer and score. Subjects were instructed to respond according to how they truly felt rather than how they thought the examiner would want them to respond so as to minimize this potential limitation. A major challenge is encountered any time researchers are attempting to obtain large sample sizes with very old adults who are frail. Reducing the risk for falling and increasing falls efﬁcacy are also important outcomes to measure. Nursing home staff can easily be trained to use the exercise program. and falls efﬁcacy also showed change over time in the predicted direction for some of the mobility levels. was the FES. subjects voiced difﬁculty responding to the FES 100-point scale.
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