Chelsey Michel, SPT, Christa Wolf, SPT, and Mary Okine, SPT
23 Comments on “Group-Based Training for Balance in Older Adults”
What would be ways you could incorporate these findings into everyday treatment with a geriatric patient with a high risk of falls? Did you have any specific exercises that were overly effective or clinically friendly that you could perform on a one-on-one basis, i.e. an individual therapy session?
Kristin,
In my short time in the clinic this fall, I have used the information gained in this study many times for patients with balance deficits. While I may not complete the full mini-BESTest with many patients, I do check the reactive balance capabilities of my patients. I have found that stepping activities in all planes, forward, lateral, etc, have helped to improve my patients reactive balance. With our individual care as opposed to group classes, it is much easier to customize your exercises in directions that may be more difficult for that patient, and up the safety factor with one on one attention. Thanks for your question!
We did not have a significant change in balance confidence following the intervention period. We did see an increase in scores and therefore if we had a larger population size we may have reached a significant change. We also found that the ABC assessment has also been shown to be at risk for subjective rater overconfidence, causing higher scores that don’t necessarily give a true reflection of the participants balance confidence. Let me know if you have any further questions! Thanks!
Did you notice a difference in results between the initial “high risk” and “low risk” groups of fallers? It would make sense to possibly see greater improvement in those that were considered high risk, but were improvements still seen in scores for those at low risk, especially those that were close to the cutoff score? Also, could you further explain what sway and stepping exercises you performed? I would love to use them with my balance patients!
We did notice differences between the two group of fallers with the high risk faller group showing noticeable improvements. We had eight individuals who were considered high risk based on our cutoff score and by the end of the 12 week period only three out of the eight participants could be considered to have an increased risk of fall.
As mentioned in the poster, the exercises were developed and instructed by the Good Samaritan society. With the sway exercises, participants started by exploring their limit of stability in the forward direction, side-to-side direction and entire limit of stability while they kept their heels and feet on the floor. The participants then did forward sway until their heels came off the floor only slightly without any wobbles (6x). They were then instructed to add calf raise (6x) and then calf raise with a hold (6x). Participants then dropped into a mini squat and moved upward using their calves (6x). They marched in place starting with a narrow base to a wide base of support (3x), and they stepped back to stretch their calf on each side (2-3x). Finally, they performed the lateral leg exploration (e.g circles),lateral leg lift left side focusing on a target (previously chosen) without leaning with the foot pointed forward (12x) and then lateral alternate lifting (12x) with a final rep hold.
The stepping exercise consisted of a series of exercises performed by the participants and the introduction part comprised of side natural step with slight foot activation and lift. The participants then performed angle back natural step with foot turned out into a bow, backward natural step while keeping their distant feet. They engaged this pattern rhythmically 3x. Introduction of daily 100 as goal and options for progression. The participants performed statue hold single leg support through alternate walking and then they returned to their seat gently. Hope this helps. Let us know if you have any more questions.
It was mentioned that the ABC assessment might have had some scoring quirks that affected the results, what do you think would be a better assessment for this intervention? Also, were their any sort of floor/ceiling affects with the other assessments that may have affected the outcomes?
As far as the ABC scale goes, it is a validated test for the population this study was focused on, but we did notice that a lot of our patients had a heightened perception of their balance than what it was measured objectively. For example, one question on the ABC is “How confident are you on your ability to stand on a chair and reach something off a high shelf?” We had participants that would come in using an assistive device, or with noticeable balance deficits during the testing, say that they were 100% confident in their ability to complete that task without falling. When in all reality, I, as a healthy 24-year-old, can’t tell you that I would be 100% confident in completing that task. However, with this test, we did notice a trend that patients may be more aware of their balance deficits and capabilities during their time in the class. I’m not sure about there being a better assessment, though it would be interesting to use something like the FABQ and see what behaviors they avoid due to their balance deficits.
We did notice some ceiling affects with the 4-Stage Balance Test and the SWAY. We did notice that many parts of the 4-Stage balance test were too easy for many of our higher level patients. The SWAY is designed for concussion research, so it makes sense that our patients did not see a significant change in their scores.
We did research prior to implementing our study and found prior balance research studies had participants attend anywhere from twice a week to five times a week. All the studies showed significant results compared to the control group and therefore we made the decision to do twice a week based on what would be feasible for our trainer and the participants. Our trainer was able to offer 4 classes a week (2 groups of participants attended twice a week) and it gave our participants an opportunity to attend another session (if there was room available) to make up for a missed day. We decided on 12 weeks because we found that some research studies that went for 6 weeks did not plateau and therefore more balance gains could be made but studies that went for longer than 12 weeks began to see a plateau around the 12 week mark. We did see significant results with twice-weekly class and therefore if you can only see a patient twice a week you may still make a significant improvement in balance. I can’t say you would get better or worse gains in balance with more or less training a week but other studies have shown significant improvements with twice, three times, and five times a week. I would recommend keeping you and your patient’s schedule in mind and do what works for the two of you. Thanks and let me know if I can answer anything further!
In retrospect, are there any objective/functional outcome measures you wish you would have done with the group that are different from the ones you did? Do you think other measures would have been more indicative of progress?
We looked at past research done in this area in addition to our objectives to narrow down the functional measures we used in our study. The ABC scale as mentioned earlier on by one of my research partners was one that participants seemed to rate themselves higher during the initial assessment and for that reason it seemed difficult to know what their true capabilities were. Other than that we thought the functional measures we chose was appropriate for our study.
Looking back on your study now is there anything you would have done differently regarding the data analysis, abstract writing, or oral presentations? Essentially, as someone in the group continuing this project do you have any advice for us after we have finished all of our data collection?
Have someone in your group get really comfortable with the data analysis program! Start as soon as you can with the analysis and you’ll save yourself a lot of headache later. It’s a pain, but don’t be afraid to write to just get it out on paper and then go back and reword as needed. Don’t dress out during the oral presentations. Set your presentation up so you talk about the sections you wrote. Feel free to contact any of us with more questions!
Emily,
I would also like to add to Christa’s comment and state that we got a lot of questions on the exercises used in the program and so including this in your presentation may prevent some of those questions. As PT students we are always looking to incorporate more exercise ideas into our treatments and so keep that in mind when making your presentation. Also as Dr. Jordre would say, the more pictures and less words the better! This makes your presentation more fun to look at and helps prevent reading off the slides during the presentation. As Christa stated we did get a few more in-depth questions about data analysis and so make sure you guys know why you ran the tests you did and what the data/results mean.
Good luck!
Megan,
Our limitations included a sample of convenience, small sample size, & a lack of research on the SWAY balance system. All of the participants were from one Good Samaritan facility here in South Dakota and therefore one should use caution when generalizing the results. Having all participants from one location makes it hard to generalize to this population in another state or even facility. Also we had a small sample size of 29 and I believe that we may have reached more significant data with a larger population size. We definitely saw trends towards significance with some of the data and I’d be interested to see if a larger sample size would cause us to reach a significant level especially with the lateral reactive stepping (in the MiniBEST). Another limitation may be the number of classes actually attended by the participants. We found that some did not make it to all the sessions due to cancelations, appointments, etc. and therefore think we may have had even more balance improvements over the 12 weeks.(Important to note that we did see significant improvements in balance over the 12 weeks even with classes being missed and therefore more compliance through the 12 weeks may show even better improvements.) Lastly we utilized the SWAY balance system and unfortunately there is a lack of research with this tool in the older population for balance. We did not get any significant results with the SWAY and I do think this tool needs more research on balance before it is accepted as a reliable tool.
After seeing these positive results in your small sample size, is there a way to expand this study to reach a larger population? How do you think the results would change? Do you think a more community-dwelling elderly population would benefit the same from this protective stepping intervention?
The group based protective stepping class has been implemented in other independent living facilities with positive results noted. This was the first time this group-based protective class was implemented at the Good Samaritan independent living facility where we did our research and again we saw positive results. With this in mind, we believe that if this study was expanded to a larger population significant results would be seen. We could have used a larger sample size but as I mentioned above this was a new training program and it would be much easier to start small by limiting the study to one facility and even with that we were amazed by the number of participants we had for the study. One way to expand this study would be to gradually recruit participants from more than one independent living facility to obtain a much larger sample population and then see how the results would be influenced by the sample size, which we believe would be positive. And based on the results obtained another study could be done to incorporate the community-dwelling adults. If the community-dwelling population are having balance issue just like our sample population did, then yes, we think they would benefit the same from the group-based protective stepping class. As one ages the risk of falls also increases and one way to prevent this from happening is to be able to show improvement in anticipatory and reactive balance control.
Did you find that protective stepping balance improved after just 6 weeks of training or did it require the full 12 weeks for a statistically significant result? In the clinic it may not be appropriate to see a patient for longer than 6 weeks (insurance coverage limitations, etc). What recommendations would you have for individuals who cannot complete a full 12 weeks of this particular balance training protocol? Have you found better/worse/similar results with other programs or does this particular program have the most positive results according to the literature?
Jerrica,
We did see a significant improvement in MiniBEST scores after just 6 weeks. You’re right, in many settings we cannot see patients for an entire 12 weeks. But, by beginning this program and setting the patient up with a solid home exercise program or referring them to a community balance class such as this one, patients would be able to continue to improve on their own. This class was not led by a physical therapist, and improvements were still seen throughout the group, so I do not believe skilled PT would be required for the entire 12 weeks. I would recommend for those with balance deficits at least begin with a course of physical therapy to ensure safety for participation in a class, as well as recommendations for what class may be the most beneficial for the specific deficits the patient may have. Throughout our research, we saw that almost any exercise or activity program will help seniors to improve their balance. Our major focus with this study was reactive stepping, which has previously been trained one-on-one with large perturbation equipment. Through this study, we were able to show that reactive stepping can be improved in a group-based setting, without the use of this large equipment, being more cost-effective and efficient for the participants and the facilities.
It was mentioned above that there is a lack of evidence showing the reliability of the SWAY balance system in assessing balance in the older population. Do you think that there is a better tool that you could have used to assess balance in this study? If so, what would you have chosen?
Natalie,
The SWAY balance tool uses the same four foot positions that the 4 stage balance test uses and the 4 stage balance test has more research backing it. I think it was good that we included the 4 stage balance test in our study (even though they use the same foot positions) because I think we got more reliable information for this test and as a community we understand the 4 stage balance test better. On top of the SWAY and 4 stage balance test, we also used the MiniBESTest which is a very comprehensive balance assessment. It looks at reactive balance, anticipatory balance, as well as gait. Therefore it is hard to find another test that would look at another area of balance on top of what we already included. If I were to pick another test to include, I would include the Fullerton Advanced Balance Scale (FAB scale). The FAB scale does include jumping as well as tandem walking. Unfortunately it does overlap a lot with the MiniBESTest and so it could get repetitive for the participants.
USD PT Research 
What would be ways you could incorporate these findings into everyday treatment with a geriatric patient with a high risk of falls? Did you have any specific exercises that were overly effective or clinically friendly that you could perform on a one-on-one basis, i.e. an individual therapy session?
LikeLike
Kristin,
In my short time in the clinic this fall, I have used the information gained in this study many times for patients with balance deficits. While I may not complete the full mini-BESTest with many patients, I do check the reactive balance capabilities of my patients. I have found that stepping activities in all planes, forward, lateral, etc, have helped to improve my patients reactive balance. With our individual care as opposed to group classes, it is much easier to customize your exercises in directions that may be more difficult for that patient, and up the safety factor with one on one attention. Thanks for your question!
LikeLike
Did you notice a decrease in fear of falling by the end of the intervention period and post-intervention testing?
LikeLike
We did not have a significant change in balance confidence following the intervention period. We did see an increase in scores and therefore if we had a larger population size we may have reached a significant change. We also found that the ABC assessment has also been shown to be at risk for subjective rater overconfidence, causing higher scores that don’t necessarily give a true reflection of the participants balance confidence. Let me know if you have any further questions! Thanks!
LikeLike
Did you notice a difference in results between the initial “high risk” and “low risk” groups of fallers? It would make sense to possibly see greater improvement in those that were considered high risk, but were improvements still seen in scores for those at low risk, especially those that were close to the cutoff score? Also, could you further explain what sway and stepping exercises you performed? I would love to use them with my balance patients!
LikeLike
We did notice differences between the two group of fallers with the high risk faller group showing noticeable improvements. We had eight individuals who were considered high risk based on our cutoff score and by the end of the 12 week period only three out of the eight participants could be considered to have an increased risk of fall.
As mentioned in the poster, the exercises were developed and instructed by the Good Samaritan society. With the sway exercises, participants started by exploring their limit of stability in the forward direction, side-to-side direction and entire limit of stability while they kept their heels and feet on the floor. The participants then did forward sway until their heels came off the floor only slightly without any wobbles (6x). They were then instructed to add calf raise (6x) and then calf raise with a hold (6x). Participants then dropped into a mini squat and moved upward using their calves (6x). They marched in place starting with a narrow base to a wide base of support (3x), and they stepped back to stretch their calf on each side (2-3x). Finally, they performed the lateral leg exploration (e.g circles),lateral leg lift left side focusing on a target (previously chosen) without leaning with the foot pointed forward (12x) and then lateral alternate lifting (12x) with a final rep hold.
The stepping exercise consisted of a series of exercises performed by the participants and the introduction part comprised of side natural step with slight foot activation and lift. The participants then performed angle back natural step with foot turned out into a bow, backward natural step while keeping their distant feet. They engaged this pattern rhythmically 3x. Introduction of daily 100 as goal and options for progression. The participants performed statue hold single leg support through alternate walking and then they returned to their seat gently. Hope this helps. Let us know if you have any more questions.
LikeLike
It was mentioned that the ABC assessment might have had some scoring quirks that affected the results, what do you think would be a better assessment for this intervention? Also, were their any sort of floor/ceiling affects with the other assessments that may have affected the outcomes?
LikeLike
As far as the ABC scale goes, it is a validated test for the population this study was focused on, but we did notice that a lot of our patients had a heightened perception of their balance than what it was measured objectively. For example, one question on the ABC is “How confident are you on your ability to stand on a chair and reach something off a high shelf?” We had participants that would come in using an assistive device, or with noticeable balance deficits during the testing, say that they were 100% confident in their ability to complete that task without falling. When in all reality, I, as a healthy 24-year-old, can’t tell you that I would be 100% confident in completing that task. However, with this test, we did notice a trend that patients may be more aware of their balance deficits and capabilities during their time in the class. I’m not sure about there being a better assessment, though it would be interesting to use something like the FABQ and see what behaviors they avoid due to their balance deficits.
We did notice some ceiling affects with the 4-Stage Balance Test and the SWAY. We did notice that many parts of the 4-Stage balance test were too easy for many of our higher level patients. The SWAY is designed for concussion research, so it makes sense that our patients did not see a significant change in their scores.
Thank you for your questions!
LikeLike
What was the reasoning for choosing twice a week? Is there any research that says more balance training is more effective?
LikeLike
We did research prior to implementing our study and found prior balance research studies had participants attend anywhere from twice a week to five times a week. All the studies showed significant results compared to the control group and therefore we made the decision to do twice a week based on what would be feasible for our trainer and the participants. Our trainer was able to offer 4 classes a week (2 groups of participants attended twice a week) and it gave our participants an opportunity to attend another session (if there was room available) to make up for a missed day. We decided on 12 weeks because we found that some research studies that went for 6 weeks did not plateau and therefore more balance gains could be made but studies that went for longer than 12 weeks began to see a plateau around the 12 week mark. We did see significant results with twice-weekly class and therefore if you can only see a patient twice a week you may still make a significant improvement in balance. I can’t say you would get better or worse gains in balance with more or less training a week but other studies have shown significant improvements with twice, three times, and five times a week. I would recommend keeping you and your patient’s schedule in mind and do what works for the two of you. Thanks and let me know if I can answer anything further!
LikeLike
In retrospect, are there any objective/functional outcome measures you wish you would have done with the group that are different from the ones you did? Do you think other measures would have been more indicative of progress?
LikeLike
We looked at past research done in this area in addition to our objectives to narrow down the functional measures we used in our study. The ABC scale as mentioned earlier on by one of my research partners was one that participants seemed to rate themselves higher during the initial assessment and for that reason it seemed difficult to know what their true capabilities were. Other than that we thought the functional measures we chose was appropriate for our study.
LikeLike
Looking back on your study now is there anything you would have done differently regarding the data analysis, abstract writing, or oral presentations? Essentially, as someone in the group continuing this project do you have any advice for us after we have finished all of our data collection?
LikeLike
Have someone in your group get really comfortable with the data analysis program! Start as soon as you can with the analysis and you’ll save yourself a lot of headache later. It’s a pain, but don’t be afraid to write to just get it out on paper and then go back and reword as needed. Don’t dress out during the oral presentations. Set your presentation up so you talk about the sections you wrote. Feel free to contact any of us with more questions!
LikeLiked by 1 person
Emily,
I would also like to add to Christa’s comment and state that we got a lot of questions on the exercises used in the program and so including this in your presentation may prevent some of those questions. As PT students we are always looking to incorporate more exercise ideas into our treatments and so keep that in mind when making your presentation. Also as Dr. Jordre would say, the more pictures and less words the better! This makes your presentation more fun to look at and helps prevent reading off the slides during the presentation. As Christa stated we did get a few more in-depth questions about data analysis and so make sure you guys know why you ran the tests you did and what the data/results mean.
Good luck!
LikeLiked by 1 person
What were were your limitations for the study and how do you think they affected your results?
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Megan,
Our limitations included a sample of convenience, small sample size, & a lack of research on the SWAY balance system. All of the participants were from one Good Samaritan facility here in South Dakota and therefore one should use caution when generalizing the results. Having all participants from one location makes it hard to generalize to this population in another state or even facility. Also we had a small sample size of 29 and I believe that we may have reached more significant data with a larger population size. We definitely saw trends towards significance with some of the data and I’d be interested to see if a larger sample size would cause us to reach a significant level especially with the lateral reactive stepping (in the MiniBEST). Another limitation may be the number of classes actually attended by the participants. We found that some did not make it to all the sessions due to cancelations, appointments, etc. and therefore think we may have had even more balance improvements over the 12 weeks.(Important to note that we did see significant improvements in balance over the 12 weeks even with classes being missed and therefore more compliance through the 12 weeks may show even better improvements.) Lastly we utilized the SWAY balance system and unfortunately there is a lack of research with this tool in the older population for balance. We did not get any significant results with the SWAY and I do think this tool needs more research on balance before it is accepted as a reliable tool.
LikeLike
After seeing these positive results in your small sample size, is there a way to expand this study to reach a larger population? How do you think the results would change? Do you think a more community-dwelling elderly population would benefit the same from this protective stepping intervention?
LikeLike
The group based protective stepping class has been implemented in other independent living facilities with positive results noted. This was the first time this group-based protective class was implemented at the Good Samaritan independent living facility where we did our research and again we saw positive results. With this in mind, we believe that if this study was expanded to a larger population significant results would be seen. We could have used a larger sample size but as I mentioned above this was a new training program and it would be much easier to start small by limiting the study to one facility and even with that we were amazed by the number of participants we had for the study. One way to expand this study would be to gradually recruit participants from more than one independent living facility to obtain a much larger sample population and then see how the results would be influenced by the sample size, which we believe would be positive. And based on the results obtained another study could be done to incorporate the community-dwelling adults. If the community-dwelling population are having balance issue just like our sample population did, then yes, we think they would benefit the same from the group-based protective stepping class. As one ages the risk of falls also increases and one way to prevent this from happening is to be able to show improvement in anticipatory and reactive balance control.
LikeLike
Did you find that protective stepping balance improved after just 6 weeks of training or did it require the full 12 weeks for a statistically significant result? In the clinic it may not be appropriate to see a patient for longer than 6 weeks (insurance coverage limitations, etc). What recommendations would you have for individuals who cannot complete a full 12 weeks of this particular balance training protocol? Have you found better/worse/similar results with other programs or does this particular program have the most positive results according to the literature?
LikeLike
Jerrica,
We did see a significant improvement in MiniBEST scores after just 6 weeks. You’re right, in many settings we cannot see patients for an entire 12 weeks. But, by beginning this program and setting the patient up with a solid home exercise program or referring them to a community balance class such as this one, patients would be able to continue to improve on their own. This class was not led by a physical therapist, and improvements were still seen throughout the group, so I do not believe skilled PT would be required for the entire 12 weeks. I would recommend for those with balance deficits at least begin with a course of physical therapy to ensure safety for participation in a class, as well as recommendations for what class may be the most beneficial for the specific deficits the patient may have. Throughout our research, we saw that almost any exercise or activity program will help seniors to improve their balance. Our major focus with this study was reactive stepping, which has previously been trained one-on-one with large perturbation equipment. Through this study, we were able to show that reactive stepping can be improved in a group-based setting, without the use of this large equipment, being more cost-effective and efficient for the participants and the facilities.
LikeLike
It was mentioned above that there is a lack of evidence showing the reliability of the SWAY balance system in assessing balance in the older population. Do you think that there is a better tool that you could have used to assess balance in this study? If so, what would you have chosen?
LikeLike
Natalie,
The SWAY balance tool uses the same four foot positions that the 4 stage balance test uses and the 4 stage balance test has more research backing it. I think it was good that we included the 4 stage balance test in our study (even though they use the same foot positions) because I think we got more reliable information for this test and as a community we understand the 4 stage balance test better. On top of the SWAY and 4 stage balance test, we also used the MiniBESTest which is a very comprehensive balance assessment. It looks at reactive balance, anticipatory balance, as well as gait. Therefore it is hard to find another test that would look at another area of balance on top of what we already included. If I were to pick another test to include, I would include the Fullerton Advanced Balance Scale (FAB scale). The FAB scale does include jumping as well as tandem walking. Unfortunately it does overlap a lot with the MiniBESTest and so it could get repetitive for the participants.
LikeLike