General versus walking exercises on the static and ...

167

Artigo Original

General versus walking exercises on the static and dynamic balance of healthy elderly persons. Efeitos dos exercícios gerais físicos e exercícios de caminhada no equilibrio dinâmico e estático em idosas saudavéis. Felipe Augusto dos Santos Mendes(1), Fátima Aparecida Caromano(2), Maiza Ritomy Ide(3), Débora Stripari Schujmann(4), Maria Helena Morgani de Almeida(5), Eduardo Vital de Carvalho(6).

Abstract Introduction: Aging is a set of progressive structural and functional changes in the human body. Objective: This study aimed to assess the effects of 2 physical activity programs (general physical exercises and walking training) on dynamic and static balance of healthful elderly subjects. Method: Thirty elderly persons were randomly assigned to general physical exercises program (GA), walking training (GB) and control group(GC). Static and dynamic balance improved signiÞcantly in the GA and GB in static and dynamic balance, after intervention. Results: The GC did not showed changes. There was no signiÞcant difference between GA and GB. Conclusion: We concluded that general exercises and walking training improve dynamic and static balance of healthful elderly person. The effect is similar in the two studied modalities.

Resumo Introdução: O envelhecimento é um conjunto de progressivas alterações estruturais e funcionais do corpo humano. Objetivo: Este estudo teve por objetivo avaliar os efeitos de dois programas de atividade física (exercícios físicos gerais e caminhada) no equilíbrio estático e dinâmico de pessoas idosas saudáveis. Método: Trinta pessoas idosas foram randomicamente encaminhadas para os grupos exercícios físicos gerais (GA), caminhada (GB) ou controle (GC). Resultados: O equilíbrio estático e dinâmico aumentaram signiÞcante para GA e GB após a intervenção. O GC não apresentou mudanças. Não encontrou-se diferenças signiÞcativas entre GA e GB. Conclusão: Nós concluímos que ambas as formas de intervenção produzem melhora no equilíbrio estático e dinâmico de idosos saudáveis e que, o efeito foi similar nas duas modalidades de intervenção.

Artigo recebido em 19 de agosto e aceito em 1 outubro de 2011. 1. Ms, Paulista University, Jundiaí, São Paulo. 2. Prof. Dr. Departament of Physical Therapy, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo. 3. Ms, Departament of Physical Therapy, Universidade do Oeste do Paraná, Cascavel, Paraná. 4. Fisioterapeuta, Departament of Physical Therapy, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo. 5. Prof. Dr. Departament of Physical Occupation Therapy, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo. 6. Fisioterapeuta especialista em neurologia. Adress for correspondence: Fátima Caromano. Rua Cipotânea, 51, Cidade Universitária USP Butantã – São Paulo – Brazil. CEP – 05360-160. E-mail: [email protected].

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General versus walking exercises on balance of elderly.

ing should be a progressive program (both in intensi-

INTRODUCTION Aging is a set of progressive structural and functional changes in the human body

(1)

. The aging process

varies from person to person and depends on the genetic aspect, environment, hygiene and health care. It also depends on social, economical and cultural level(2).

ty and frequency) that would contemplate harmonically physiological and psychological aspects involved with balance reactions. Regular physical activity develops or maintains the efÞciency of the reßexes involved in postural control, es-

Aging leads to neurologic changes, such as de-

pecially through adequate neurosensorial information,

crease in the size of the brain, nervous conduction speed

which allows the central integrative structures to gen-

and magnitude and amplitude of the reßex reply. This

erate a more appropriate motor response.10 Many re-

change leads to slowness in the achievement of the

searches relate the general exercises(25-30), the walking

motor tasks and can affect gait and balance(3,4). (5)

training(31-34) and the balance training(35, 36) with the bal-

deÞnes balance as an organic func-

ance of elderly persons. Many of these researches also

tion that requires constant muscular readjustments and

analyze the relation between the exercise and the risk of

adaptations in the joint positioning, stabilizing the body

falls. However, it was not found clinical trials that com-

inside its base of support. These readjustments occur to

pare the effects of general exercises with walking train-

compensate the internal perturbation voluntary move-

ing in the balance of elderly persons.

Lane et al.

ment causes to the body and they depend on the vi-

This study aims to compare the effects of two phys-

sual, vestibular, hearing, sensitive and motion systems,

ical exercise programs on dynamic and static balance of

that are controlled by the central nervous system(6,7).7

sedentary healthful elderly persons.

(8)

, these readjustments also depend on

The conclusion of this study is important to the clin-

muscle strength (mainly ßexors and extensors muscles

ical decision process during consideration of possibilities

of the knees and hips) and the range of motion of the

and needs of older patients.

To Wolfson et al

lower limbs, which decrease with age. Motor and sensitive damages are a common cause of falls. The improve-

METHOD

ment in muscle strength is related to better balance(9). Ageing is associated with a decrease in the quality

Participants

of balance regulation, in particular through dysfunctions

Thirty volunteers, 18 women and 12 men, mean

of gaze control and postural stabilization, which results

age of 68.7 ± 3.5 years, were recruited. Subjects are

in an increased risk of falling(10). The aging inßuences

described in Table 5. To be included, subjects could not

on the ability to balance under conditions of reduced or

have been smokers, haven’t been practicing any physi-

conßicting sensory information(11).

cal exercise or walking more than 1 kilometer per week

There is a consensus about the age-related balance

in the last 5 years, must be socially active in the com-

damages. However, the differences from one person to

munity, do not present muscle-skeletal, neuromotor or

another are much more important than the age of the

cardiovascular illness that could prevent them from per-

subject.6 The changes in the readjustment mechanisms

forming the physical activities. Time availability, access

of the balance also contribute to gait and posture im-

to transport, acceptance of the training routine (absence

pairments, mainly in elderly persons(12-15).

with justiÞcation and replacement of the session), inten-

Older patients have more problems with chronic

tion to complete the training and the signing of the in-

balance impairment and falls, which are an important

formed consent form were also considered. It was still

risk-factor of impairment and high mortality for this pop-

necessary that subjects who were randomly assigned

ulation, commonly leading to traumas and resulting in

into the control group should not do physical exercis-

large expenses(16-17).

es per 4 months. All the participants were assessed by

(19)

performed a one-year follow-up

clinic and physical therapy examination. The Ethics and

of 94 elders, fallers and non-fallers and identiÞed a 15%

Research Committee of the Hospital of Clinics of Facul-

fall rate, with no relation between poor balance test re-

ty of Medicine of University approved this study (proto-

sults and incidence of falls. On the other hand, Melzer

col 1092/04).

Laessoe et al.

et al.(20) found signiÞcant relation between poor postural stability test results and risk of falling among commu-

PROCEDURES

nity-dwelling elders. From the decade of 1980, walking with fast step

Assessment of the Static balance

is recommended to improve parameters related to

To the assessment of the static balance, it was re-

the cardiovascular, neuromuscular and muscle-skele-

quested to the subject to supported the body in 8 pre-

tal systems(21-23). Shimada et al.

recommends walk-

determined positions, described in Table 1, as suggested

ing training to institutionalized elderly persons to re-

by Ikeda et al.(37) and Nuzik et al.(38) The tests were per-

(7)

(24)

duce falls. To Oddson et al. , balance exercise train-

Ter Man. 2011; 9(46):

formed at this exact disposition and Þlmed (Panasonic)

169

Felipe Augusto dos Santos Mendes, Fátima Aparecida Caromano, Maiza Ritomy Ide, et al.

using VHS tapes (Sony T-120EDC) and tripod, for poste-

(Panasonic), using VHS tapes (Sony T-120EDC) and tri-

rior analysis. The results considered the best of 3 tries.

pod, in frontal and lateral view, on their way front and

Criteria were elaborated to quantify the balance perfor-

backwards. After that, the performance was analyzed

mance observed during the tasks proposed. These crite-

and classiÞed according to criteria described in Table 3.

ria are presented in Table 2.

The results considered the best of 3 tries.

Using these criteria, the addition of the scores of

After that, it was performed the sit down and stand

the task proposed generated the Index of Static Balance

up test. It was requested the subjects to sit down and

(ISB) that varied from 11 to 55. The Þrst value is relat-

stand up of a steady chair, with lean and without arms

ed to the best possible balance.

support, 3 times. The test was also Þlmed. The best scores were considered for the study. The analysis of

Assessment of the Dynamic Balance The dynamic balance was analyzed through 2 tests: to hurdle an obstacle and to sit down and stand up of a chair. In the Þrst test, the subject must hurdle a hypothetical obstacle 3 times. The hypothetical obstacle was

the performance in this task was done according to criteria described in Table 4. Using these criteria, the addition of the scores of the task proposed generated the Index of Dynamic Balance (ISB), which varied from 3 to 14. The Þrst value is related to the best possible balance.

1 m far from the volunteer, and was delimited in the

After the baseline test, the participants were strat-

dark-gray ground for 2 white adhesive ribbons of 30 cm

iÞed by sex and randomly assigned to general exercis-

of length and 3 cm of width. The subjects were Þlmed

es (GA), walking exercises (GB) and control group (GC), with 4 men and 6 women each group. GA was prescribed a program of physical exercises. The GB attended a walking exercise program. GC did

Table 1. Positions analyzed in the assessment of static balance. To remain over the calcaneal To remain over the toes To remain over the right leg, with arms along the body

not receive nutritional orientation. GA and GB were prescribed exercises per 4 months, 2 per week, 1 hour each session, with intensities set at low to moderate, obtaining 40-70 % of maximum heart hate. The aim of the general exercises was to improve

To remain over the left leg, with arms along the body

the general range of motion, muscle strength and bal-

To remain over the right leg, with shoulders abducted at 90 degrees

ance, besides to reeducate the movements of the upper

To remain over the left leg, with shoulders abducted at 90 degrees To remain over the right leg with the left arm in movement To remain over the left leg with the right arm in movement

and lower limbs. The program of general exercises included breathing, stretching, postural, motor skill and muscle strength exercises. The order of the exercises training respected its level of difÞculty, from the easier to the most complex one.

Table 2. Criteria for classiÞcation of static balance. Criteria

ClassiÞcation

Adopt and keep the position of the test for 30 seconds, with few tonus readjustments to keep the posture.

1

Adopt and keep the position of the test for 30 seconds, with few tonus readjustments during the whole test.

2

Adopt and keep the position of the test for 30 seconds, with many tonus readjustments to keep the posture.

3

Adopt and keep the position of the test for 30 seconds, with many tonus readjustments to keep the posture. Subject falls with both legs (it is allowed the maximum of 3 falls).

4

Table 3. Criteria for classiÞcation of the hurdling obstacle test Criteria

ClassiÞcation

Jumps obstacles removing both feet of the ground (gives impulse with one leg, projects the 2 legs out of the ground and the body ahead, decelerates with the contralateral leg and stabilizes the 2 legs in the ground), hurdling the obstacle.

1

Take wide steps and uses the aid of the upper limbs to impel himself or rotates the trunk to hurdles the obstacle.

2

Jumps the obstacle removing both feet of the ground (impels himself with one leg, projects the 2 legs out of the ground and the body ahead, decelerates with the contralateral leg and stabilizes the 2 legs in the ground), but does not hurdles the obstacle.

3

Take wide steps and uses the aid of the upper limbs to impels himself or rotates the trunk, but does not hurdles the obstacle

4

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RESULTS

The walking exercises were performed in a plain and covered place. The 1st month of the training was

Baseline characteristics

developed in 3 stages: the Þrst 15 minutes in normal speed (not to slow, nor to fast), associated with respi-

The initial homogeneity between the groups was

ratory exercises. The next 30 minutes, it was interca-

conÞrmed through Kruskal-Wallis test. The baseline

lated 5 minutes of fast speed with 5 minutes of normal

scores of age, height and weight were similar in the

speed, until completion of time. In the last 15 minutes,

groups (p = .91, .76 and .82, respectively). After inter-

the walking exercise was performed with normal speed.

ventions, no signiÞcant differences in weight scores were

In the last 3 months of the walking training, the difÞcul-

found (p = .318). Results are presented in Table 5.

ty level was increased. In the last weeks of the program, Static and dynamic balance

the subjects walked normally the 1st and the last 5 minutes and walked fast the other 50 minutes. If necessary,

The dynamic and static balance scores (baseline

subjects could intercalate short periods of deceleration

and post-test) are described in Table 6. Dynamic and

in these 50 minutes of fast walking.

static balance presented signiÞcant improvement in GA and GB.

The post-test assessment was performed at the end of the intervention.

Comparing the groups, a signiÞcant difference was observed between the interventions groups (GA and GB)

Statistical Analysis Statistical analysis was performed using the Stata,

and the control group (GC), to dynamic and static bal-

version 9.0. An “intent-to-treat” analysis was also con-

ance. It was not observed differences between the GA

sidered. Statistical signiÞcance for all analyses was set

and GB. The comparison can be observed in the Graph

at p < .05. Because most of the data followed non-nor-

1 and Table 7.

mal distribution, non-parametric tests were used in all DISCUSSION

statistical analysis. To conÞrm the initial homogeneity between the

We believe that many factors lead to the improve-

groups, the 3 groups had their age, height and weight

ment of balance of the subjects who performed general

compared through Kruskal-Wallis test. Baseline and

exercises (GA), since that exercises inßuence many fac-

post-test results in the groups were analyzed through

tors related to the static and dynamic balance, such as

Wilcoxon Signed-Ranks Test. Kruskal-Wallis test was

muscle strength, range of motion and also balance. The improvement in static and dynamic balance

also used to compare the groups.

Table 4. Criteria for classiÞcation of the performance of the elderly person in the sit down and stand up test. Criteria

ClassiÞcation

Stand up and sit down from the initial position, without aid

1

Stand up and sit down from the initial position, with the aid of 1 hand

2

Stand up and sit down after modifying the initial position, with the aid of both hands

3

Stand up and sit down after modifying the initial position, with the aid of both hands, in the 2nd or 3rd try

4

Stand up and sit down after modifying the initial position, with the aid of some other person

5

Table 5. Baseline comparison among the groups. Baseline comparisons among the groups † Men

Baseline mean GA

GB

GC

4

4

4

Subjects 6

6

6

Age (years)

Women 0.91*

68.4

68.8

68.8

Height (cm)

0.76*

171.4

169.2

169.7

Weight (Kg)

0.82*

69.7

65.8

68.0

Static Balance Index

0.87*

33.0

34.0

33.0

Dynamic Balance Index

0.92*

7.5

7.7

7.5

† Kruskal Wallis Test * Not signiÞcant differences GA= general exercises, GB= walking exercises, GC= control group

Ter Man. 2011; 9(46):

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Table 6. Baseline and post-test static balance and dynamic, in the groups. Static balance

Dynamic Balance

Mean ± SD

p**

Baseline

Post-test

Ga

33,0 ± 4,3

29,4 ± 3,7

0,023*

Gb

34,0 ± 4,7

30,1 ± 3,8

0,001*

Gc

33,0 ± 4,3

33,0 ± 4,1

0,193

Mean ± SD

p**

Baseline

Post-test

7,5 ±1,8

6,0 ± 1,1

0,007*

7,7 ±1,3

6,2 ± 1,4

0,001*

7,5 ±1,8

7,6 ± 1,8

1,0

† Kruskal-Wallis Test * SigniÞcant difference (p < 0,05)

Table 7. Comparison of the balance in the groups

given by the general exercises found in this research agrees with other authors, although most of them an-

Static Balance

Dynamic Balance

Ga x Gb x Gc

0,001*

0,001*

Ga x Gb

0,970

1,0

Ga x Gc

0,017*

0,004*

Two works showed improvement in balance of el-

Gb x Gc

0,001*

0,004*

derly persons submitted to exercises. Nelson et al.(28)

† Kruskal-Wallis Test * SigniÞcant difference (p < 0,05) GA= general exercises, GB= walking exercises, GC= control group

alyzed only static balance. The studies used different methods and exercise programs. Some of them related balance with falls and injuries.

studied 70 subjects older than 70 years and found improvement in balance in those who performed general domiciliary exercises, besides improvement in functional capacity. Helbostad et al.(27) studied 77 elderly subjects older than 75 years, not institutionalized. Subjects were randomly assigned into 2 groups. Both of them performed domiciliary exercises and one of them also performed group exercises (balance and strengthening training), for 12 weeks. Authors concluded that home supervised exercises improved balance of the subjects, with no additional effects given by group training, and no maintenance of effects after 6 months. Several studies with programs of mixed exercises found decrease in the number of falls in elderly persons. Means et al.(30) studied the effects of an exercise program over balance, mobility, falls and injuries and found improvement in functional performance and protection against falls and injuries in the subjects. Suzuki et al.(29) performed a randomized clinical trial to assess the effect of moderate exercises in the prevention of falls in elderly persons. Authors concluded that domiciliary exercises reduce signiÞcantly the number of falls at short and long term, contributing to improve health and quality of life of elderly persons. Graafmans et al.(26) studied the relation between the physical activity and the risk of falls in elderly persons. Researchers concluded that a higher level of physical activity protects against falls. DiBrezzo, Shadden, Raybon and Powers(39) showed that a 10week exercise program including stretching, strengthening, and balance-training exercises can improve health and factors that affect risk of falling among older adults.

Graph 1. Baseline and post-test comparison to the static balance and dynamic, respectively. GA= general exercises, GB= walking exercises, GC= control group

Barnett, Smith, Lord, Williams & Baumand(40) demonstrated that a 12-month weekly group exercise program can improve balance and reduce risk factor for falls in

Ter Man. 2011; 9(46):

172


at-risk elders. Rubenstein et al.(25) showed the beneÞ-

ercises improve posture control during the static bal-

cial effects of low to moderate exercises in strength, re-

ance. Schoenfelder(32) investigated the effects of an ex-

sistance, mobility and number of falls in elderly women

ercise program (walking and ankle strengthening train-

with chronic illness.

ing) on balance, ankle muscle strength, speed of gait

Carter, Khan, McKay, Petit, Waterman, Heinonen et

and decrease of number and fear of falling. The authors

al.(41) studied the effects of a twice-weekly community-

found maintenance of almost every analyzed variable,

based exercise program designed for elder women with

suggesting that the regular exercise hinders the deteri-

osteoporosis, and found signiÞcant increase in dynamic

oration and improves fall-related aspects in elderly per-

balance and strength of the intervention group compared

sons. A similar study (same aims and procedures) was

with controls. However, Papaioannou, Adachi, Winegard,

performed by Schoenfelder and Rubenstein(34) in institu-

Ferko, Parkinson, Cook et al.(42) investigated the effects of

tionalized elderly persons. The subjects in the interven-

6-month domiciliary exercises in post-menopause women

tion group (ages between 64 and 100 years) showed im-

with osteoporosis and fractures history. Participants exer-

provement or maintenance of balance and fear of fall-

cised 60 minutes per day, 3-times per week. The exercis-

ing in the results.

es included stretching, aerobic and strengthening train-

Means et al.(31) studied the effects of a 6-week exer-

ing. It was not found relation between exercises and de-

cise program (muscle strengthening, balance and motor

crease in number of falls or injuries.

skill and walking training) in sixty-Þve > 60 year-old fall-

Balance-speciÞc exercises were also studied in el-

ers. Results showed a slight improvement in the per-

derly persons. Nitz and Choy(36) found improvement in

formance of subjects during a test with obstacles. The

the balance and decrease of falls. Similar result was

number of falls and injuries was not modiÞed.

found by Steadman et al.(35) in a study with 199 elder-

This study demonstrates that general exercises and

ly persons. The authors also found better quality of life

walking training have similar effects on balance of elder-

in the treat subjects. Seidler and Martin(43) found beneÞ-

ly persons. Hence, they can be recommended to reduce

cial effects of a 5-week balance-speciÞc exercise proto-

the number of falls in elderly persons. It also proves that

col on postural stability during activities of daily living of

both programs can be independently recommended with

faller elderly persons.

the same objectives.

The walking training group also had improvement in dynamic and static balance. This result agrees with

CONCLUSIONS

some researches. Some of them studied exclusively the

General exercises program of physical exercises

effects of walking training, while others associated other

and walking training are beneÞcial to dynamic and stat-

modalities of exercises. Melzer et al.(33) investigated 121

ic balance of elderly healthful sedentary persons. Effects

elderly persons and concluded that regular walking ex-

are similar in both proposed exercise programs.

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