The loss of strength, balance, and mobility are no longer considered inevitable consequence of aging. Physiological impairments related to functional dependency are potentially reversible with appropriate exercise intervention (Morgan, 2005; Nelson et al., 2004). Furthermore strength training research programs have been especially helpful in improving balance, physical performance and reducing falls (Hoglund, Sadovsky, & Classie, 2009; Kruger, Buchner, & Prohaska, 2009; Nelson et al., 2004).
Several interventional researchers have been conducted to prevent falls among elderly people (Judge, 2003; Kim, Yoshida, & Suzuki, 2010; McMurdo, Millar, & Daly, 2000). In this study we will examine a home-based training intervention to improve strength of muscles which can directly improve balance and reduce the risk of falls among community dweller elderly or through increased self-efficacy.
Risk of falls due to balance impairment among elderly people is reversely associated with muscular strength (Clemson, Cumming, 2004). Effectiveness of muscle exercise interventions to improve balance and reduce the risk of falls in aged people with high risk for falling have been a matter of controversial in different studies (Salminen et al., 2001). While some found exercise training programs successful in reducing the risk of falls (Cheung, Au, Lam, & Jones, 2008; Clemson et al., 2010; Gobbi et al., 2009a; Nelson et al., 2004), others have found contrary results (Au-Yeung et al., 2002; Clemson et al., 2010; Rubenstein et al., 2000).
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The need for a home-based training exercise program is felt by some researchers (Kamide, Shiba, & Shibata, 2009). Muscle strengthening exercise intervention by home facilities has its own advantages and disadvantages. Home-based exercise program, in comparison to clinic-based interventions which are very luxurious and seem to be very tempting and promising (Takano et al., 2010), sounds to be more feasible. As a matter of fact, the lack of public availability of high-tech facility in developing courtiers, transportation barriers for elderly, the problem of cost-benefit and cost effectiveness of any high-tech program are major barriers to use clinical-based exercise programming for elderly people (Nelson et al., 2004). Moreover, it is estimated that about one half of seniors aged 85 years or above rarely leave their homes and interventional trials targeting on those “housebound” aged are scarce(Ashworth, Chad, Harrison, Reeder, & Marshall, 2005).
Nelson et al 2004 summarized that a home-based exercise program in community-dwelling elders with functional impairment is feasible and effective in improving functional performance, despite limited supervision. They also added that home-based exercise programs that focus on strength and balance training improve functional performance in elderly people and should be promoted by the allied health community (Nelson et al 2004). Low price and organizational flexibility make it an alternative or a supplement to other forms of physical exercise and active lifestyle (Hinrichs et al, 2009)
On the other hands, compliance, which is a major problem in centered-based exercise among elderly people, can be achieved by home-based programs. Previous researches emphasis that adherence to any exercise program is low among elderly people especially in long run (Campbell et al., 1997; Dishman, 1991; Gobbi et al., 2009b; Sturnieks, St George, & Lord, 2008e; Sun et al., 2005). Blanchard 2008 stated that less than 15 percent of elderly people participate in center-based exercise program. He added that to achieve a larger number of participants, there has been a shift toward implementing home-based rehabilitation programs. Home-based muscular strength training can be considered as an alternative to expensive and low compliance clinical-based muscle training (Blanchard, 2008).
There have been some problems in previous home-based programs. They still rely on most expert personnel who closely supervise their patients and provide them with high standard care at their home (Gardner, Robertson, McGee, & Campbell, 2002; Nelson et al., 2004; Luukinen et al., 2007a). The others emphasize on individualized tailored programs (Clemson et al., 2010) which raises the cost of intervention program. Moreover, these programs, although were reported to be effective, lack in large scale randomization was the main limitation of the studies (Nelson et al., 2004). Moreover, because of low health literacy among Iranian elderly population, any home-based training intervention without proper supervision and adherence will not be able to achieve its objectives (Carpenter, 2010a). A well cited study suggested that elderly people need supervision to improve strength in a home-based setting (Baker et al., 2001). To overcome the problem of health illiteracy among elderly people we planned to involve participants’ adult children who have the most interaction with the client in training program to supervise him/her during training and fill up the log books.
Fear of falling, a risk factor for falls, is being understood as an emerging public health problem (Denkinger et al., 2010; Hill, Schwarz, Kalogeropoulos, & Gibson, 1996; Li, Fisher, Harmer, & McAuley, 2005). Evidence suggests that both fallers and non fallers experience psychological problems associated with falls (Honaker, 2001). Previous researches have termed psychological factors as fear, diminished self – efficacy and loss of confidence(Topping, 1994; Gai, Gomes, & Jansen, 2009; Legters, Verbus, Kitchen, Tomecsko, & Urban, 2006; Pednekar, 2007).
In community dwelling elderly, a complex interaction has been found among fear of falling, falls self- efficacy, increased physical impairments and diminished functional ability and activity participation (Legters et al., 2006; Maxwell, 2006; Mihalko, 1997; Tinetti, Richman, & Powell, 1990b; Pednekar, 2007).
This interactive cycle encompasses fear of falling which leads to activity restriction and further decreasing physical capabilities such as functional mobility, balance and strength which leads to decreased confidence and fear of falling (Pednekar, 2007).
A home-based training exercise should be directed toward strengthening weak muscles and balance. The consequence of muscular weakness and co-contraction is lack of confidence (Tinetti, Richman, & Powell, 1990a) which makes elderly people loss their self-confidence and fear of falls (Hill et al., 1996). Fear of falling deteriorates the balance reactions and leads to increased risk of falls and increased risk of injury (Okada, Hirakawa, Takada, & Kinoshita, 2001). Loss of confidence among elderly people results in functional limitations and may cause restriction in activity due to fear of falling, which is very common problem among community-dwelling older adults with or without experience of falls (Hansma, Emmelot-Vonk, & Verhaar, 2010). Under a public health perspective, the access to home-exercise programs seems to be easier. Once implemented, a home-exercise program should be capable to reach a broad audience (Ashworth et al 2005). So, it is logical that improved muscular strength can result in self-confidence, reduce fear of falls, increase balance and decrease risk of falls.
A great number of studies have proposed that only additional research with frail elderly individuals will help answer if home-based training would improve balance in older ages (Nelson et al., 2004; Baker et al., 2001). We, therefore, decided to test the hypothesis that an individual home-based muscle strength training in high risk individuals (60 years old and above elderly people with previous history of falls in last 12 months) would be feasible with minimal expert supervision and would result in clinically important improvements in balance and functional performance. The role of care givers in this study is to fill the log books, because most of the elderly subjects have health illiteracy.
Significant of the study
This dissertation contributes to the scientific literature in different interrelated ways. Firstly, the finding of this study can contribute to the body of knowledge in regard to falls among elderly. Falls have been explored by several researchers from different aspects; however it needs more scientific and empirical investigations to find out the ways to prevent the fall or alleviate the incidence of falls among frail elderly community-dwellers. To achieve a better understanding of falls, its consequences and prevention of falls, this area of research needs a richer body of knowledge to illuminate the way for other researchers to explore the ways to reduce risk of falls.
Secondly, the findings of this study, practically, can contribute to alleviate the problem of falls among frail elderly people in community. This study looks the problem of falls from both biological (muscular strength) and psychological (self-efficacy) point of view. So, any falls prevention program has to consider the results of this dissertation as evidence to plan a comprehensive program on falls. In addition, finding of this dissertation can be used by falls prevention planners. All programs designed to prevent falls can benefit from this study, because it is planned to reduce morbidity and reduces burden of falls for person, family and healthcare services. American Geriatrics Society recommends some activities including exercise and/or physical to prevent falls among elderly people. Health professionals after orienting to the program can deliver and supervise the exercise training program for older people. The program has been tested as a single intervention but could be delivered in a multifactorial falls prevention program, too.
Thirdly, the findings of this study can be used by other health practitioners in different disciplines to utilize exercise training to reduce the risk of falls among their elderly clients. So many other researchers have investigated the benefits of the exercise for other high risk groups such as patients with chronic diseases e.g. Parkinson Disease (PD), Multiple Sclerosis (MS), Stroke, Arthritis and other neuromuscular or articular diseases, depression, anxiety, etc. This study highlights the importance of exercise training among elderly people. Moreover, the current study is one of the first studies on the problem of falls in Iranian elderly community. In developing countries where sources are limited, the exercise program can be offered first to those with high risk e.g. history of falls, aged 70 and older. However, other aged people can benefit the advantages of this program.
This study is planned to investigate the relationship between muscular strength to risk of fall among community dweller elderly people. To achieve this objective, the following specific goals are followed:
To describe the subjects’ muscular strength, self-efficacy, fear of falls and balance before and after intervention
To examine the relationship between subjects’ background variables, muscular strength, self-efficacy and fear of falls before and after intervention
To examine the relationship between subjects’ muscular strength and risk of falls before and after intervention
The home-based training exercise can improve muscular strengths among elderly people. Strong muscles can directly increase physical balance which is considered as proxy for decreased risk of falls among elderly people. Moreover stronger muscled can increase self-efficacy and reduce fear of falling and decreased risk of falls among elderly people.
Definition of key words
History of falls
Conceptual: History of falls is previous experience of the event of falls. In this study, fall is an unexpected, involuntary loss of balance by which a person comes to rest at a lower or ground level (Kelly & Dowling, ). Other researchers have defined falls as “An unintentional descent that may or may not result in an injury, and in which any motion of descent may not necessarily result in a ‘landing.’ (Berry et al., 2010).
Operational: In this research, history of falls is defined as any report of falls incidence by which a person comes to rest at a lower or ground level, in subjects of the study. Any incidence of falls in last 12 months is considered as history of falls. Moreover, the number of falls during intervention is questioned. Data are collected by a questionnaire. In the questionnaire history of falls during last 12 months and causes of falls are questioned. No history of falls, one incidence of falls and two or more falls are categorized as non-faller, accidental faller and recurrent faller, consecutively.
Fear of Falls
Conceptual: fear of falling, first described as “ptophobia,” by Bhala, O’Donnell, & Thoppil, 1982, which means a phobic reaction to standing or walking and was subsequently classified by Murphy & Isaacs in 1982 as “Post fall syndrome” (Jung, 2008).
Operational: In this study Falls Efficacy Scale (FES) is used to assess clients’ fear of falling. It is a rating scale with 10 items to assess clients’ confidence in performing daily activities. Each item is rated from 1, meaning extreme confidence to 10, meaning no confidence at all. Participants with lower self-efficacy report avoiding most of activities because of fear of falling and get higher FES scores. On the other hands, participants with higher self-efficacy report less avoiding most of activities because of fear of falling and represent lower FES scores.
Conceptual: Benjuya, Melzer, & Kaplanski defined balance as the ability to maintain an upright posture during both static and dynamic tasks (Bird, Hill, Ball, & Williams, 2009).
Operational: In this study balance is the subjects score in “Berg Balance Scale”. Total Score is varies between 0 and 56. In interpretation of Berg Balance Scale low, medium and high risk of falls are corresponded to 41-56, 21-40 and 0-20, respectively.
Conceptual: Muscular strength is defined as the maximal ability of a muscle to contract and generate force (Hanney, Kolber, Schack-Dugre, Negrete, & Pabian, 2010).
Operational: operationally muscular strength in lower extremity and hand grip are assessed. For lower extremity muscular strength the chair stand test commonly used. The chair stand test is a physical performance test used to assess lower-extremity function. A 5 repetition test is a measure of strength (Ward et al., 2010). Subjects’ hand grip force score in their left and right hands will be recorded. Individual patients whose grip strength is less than the lower limit of the confidence intervals can be considered to be impaired grip (Bohannon, Peolsson, Massy-Westropp, Desrosiers, & Bear-Lehman, 2006).
Conceptual: A subset of physical activity. It is planned and repetitive body movement, which improves or maintains one or more components of physical fitness (e.g., cardiovascular endurance, muscular strength, balance, flexibility)(Pate, 1995).
Operational: operationally exercise is a set of muscular strengthening action used to increase balance in terms of Berg Balance Score (BBS) and reduce the risk of falls among participants of the study.
Conceptual: Bandura (1986) defined self-efficacy as, “People’s judgments of their capabilities to organize and execute courses of action required attaining designated types of performances” (p. 391). Self efficacy means one’s self confidence towards learning. People usually engage in certain behaviors when they believe they are capable of implementing those behaviors successfully, this means that they have high self-efficacy (Bandura, 2007).
Operational: In this study subjects’ scores in the Activities-specific Balance Confidence (ABC) Scale are considered as their self-efficacy. The Activities-specific Balance Confidence Scale is a scale with 16 items; each item is rated from 0% (no confidence) to 100% (complete confidence). Clients are asked to rate the level of confidence that they will lose their balance in daily activities.
This study will be conducted based on a modern biologic theory called “wear and tear” theory and Orem’s self-care theory. In this study the wear and tear theory is used to explain why muscular strength and balance deteriorates during old ages. Orem’s self-care theory is utilized to explain how self-care through exercise can maintain and improve an old person’s ability for balance and reduce the risk of falls. Moreover, Bandura’s self-efficacy explains the moderating role of self-efficacy between muscular strength, fear of falls and balance to risk of falls among elderly people.
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Proposed conceptual framework
Fear of Falls
There has been a lack of investigation on effectiveness of home-based exercise, since there have been few randomized control trials (RCTs) evaluating home-based exercise (Kamide et al 2009). Home-based exercise programs are thought to be effective in improving functional performance and balance in functionally impaired elders (Nelson et al 2004). It is demonstrated that participation in a supervised home-based exercise program was associated with significant improvements in exercise beliefs, including exercise self-efficacy and outcomes expectation (Matsuda, Shumway-Cook, & Ciol, 2010). This study is trying to investigate effectiveness of home-based exercise on reducing the risk of falls among elderly people based on theoretical framework and review of related literature.
This chapter is devoted to disclose two main sections of the dissertation. First, the theoretical framework of the study will be discussed and then the main related literature to this study will be reviewed.
In this section, theories of “wear and tear” and “self-care” are introduced. The wear and tear theory explains the process of biologic changes during old ages which makes human’s cells and tissues degenerated. Moreover, self-care theory explains how anyone (self-care agent) can exert some measurements and actions to maintain health and well being.
Wear and Tear Theory
Wear and tear theory of ageing was first introduced by Dr. August Weismann in 1982 (Salvi, Akhtar, & Currie, 2006). The wear and tear theory of aging believes that the effects of aging are caused by damage done to cells and body systems over time. Essentially, these systems “wear out” due to use. Once they wear out, they can no longer function correctly (Giampapa & Williamson, 2004). According to the theory, aging occurs through wear and tear that leads to the progressive accumulation of damage(Murphy & Partrige, 2008) The theory postulates that the daily grind of life, in particular disuse or overuse, literally wears the body out, leading to disease states (tears). The degeneration of muscles, cartilage and eventual grinding of bone on bone is examples of the aging process on body joints, as wear and tear exceed the body’s ability to repair (MacWilliam, 2002).
The wear and tear profile over the course of time determines such degradations as loss of information (genetic and epigenetic mutations during the life course), loss of structural integrity (increases in entropy), and breakdowns in the emergent property of complexity (Juckett, et al. 2009).
Based on wear and tear theory, senile muscular muscles atrophy starts after middle ages, especially when muscles are disused or overused (Giampapa et al., 2004). The process of degeneration is associated with senile changes in body and progressively reduces muscular bulk. There are good evidences to support that type 2 muscles are more prone to degenerated than type 1 muscles (Mannion et al., 2000).
Deterioration in muscular size and number in old ages causes muscular atrophy and in combination of other senile changes in other organs (neurons) (Klitgaard et al., 2008) eventually ends up a loss of muscular strength and balance disorder which may predisposes old people to risk of falls (Sturnieks, 2008). Lack of muscular strength and balance affects patients’ self-efficacy and make them more susceptible to falls (Campbell et al., 1997), because of fear of falls(Denkinger et al., 2010).
‘Self care’ theory was given by Dorothea Orem between 1959 and 2001 with a unique philosophy that patients have different level of independently. Orem’s self-care framework is based on the three components of self-care deficit theory, self-care theory and the nursing system theory (Denyes, Orem, & Bekel, 2001).
Self-care is defined by WHO as activities individuals, families, and communities perform in order to enhance their health, prevent diseases, limit illnesses, and restore health (Klainin & Ounnapiruk, 2010). These activities are undertaken by lay people on their own behalf, either independently or in participative collaboration with healthcare professionals. There are several examples for self-care behavior including seeking health-related information, exercising and consuming healthy diets (Klainin et al., 2010).
Self-care agency, as defined by Orem (2001), refers to the power of individuals to engage in self-care and their capability for self-care. The person who uses this power or self-care ability is the self-care agent. Self-care agency is acquired and affected by family members and care giver. They specifically may affect the client’s adherence to behavioral changes and treatment regimens and overall outcomes (Rutledge et al., 1999). There is a power component to self-care agency, which addresses the importance of knowledge, attitudes, and skills that enable the individual to engage in self-care (Kumar, 2007)
Nursing system are interventions needed when individual is unable to perform the necessary self-care activities and categorized in three distinct levels as follow:
Wholly compensatory in which care givers provides entire self-care for the client. An example of this category is an elderly person hospitalized in critical care unit who need a care giver for his basic needs to survive.
Partial compensatory in which a care giver and client perform care; client can perform selected self-care activities, but also accepts care done by the care giver for needs the client cannot meet independently. An example of this category is an elderly person who needs help for some activities such as ambulating, but is able to perform most activities by his own.
Supportive-educative in which training is planned to help the client develop/learn their own self-care abilities through knowledge, education, support and encouragement. A good example of this category is educating the elderly client to perform exercise to strengthen the muscles or to teach how to do insulin self-injection.
In this research, the third category of nursing system will be applied among elderly people to strengthen their upper and lower extremities muscle to improve their balance and reduce the risk of falls
Review of literature
A recent study, by Matsuda et al 2010, proposed that effectiveness of any exercise to improve physical function varies with level of frailty, format and intensity of exercise program, and kind of supervision. A systemic review summarized the best evidence for effectiveness of interventions designed to reduce the incidence of falls in older people living in the community, concluded that home-based exercises and Tai Chi were specific exercise programs that showed benefit (Carpenter, 2010b).
Home-based exercise program among relatively healthy older adult are proven to be effective in functional performance than group-based programs. In an Iranian study researchers conducted a 12 weeks home-base exercise training in 40 -65 years old Iranian women to prevent osteoporosis and increase muscular strength and balance (Shirazi et al., 2007). In another study researchers conducted a home base training exercise on Parkinson disease patient. They concluded that individuals with Parkinson’s disease can significantly improve functional performance measures utilizing a convenient, cost effective, home-based exercise intervention (Nocera, Gainesville, Horvat, & Athens, 2008). Other recent studies on standing exercise and balance training program on balance confidence, balance performance, and gait in debilitated, ambulatory community-dwelling older adults supported that exercise can improve balance, However, definitive conclusions need to await validation from more rigorously designed studies before the present training program can be confidently recommended to physical therapists engaged in home care practice(Miller, Magel, & Hayes, 2010).
In New Zealand, the Otago Exercise Program is designed as a home-based training exercise with combination of strength, balance exercises and walking program to prevent falls. The program is individually designed program three times a week and progressed over time. Four randomized controlled trials in different setting disclosed the effects of training program among elderly people. In another supervised 6-week, multidimensional home-based exercise program, researchers found that the program was safe and associated with improvements in physical and exercise-related belief outcome measures(Matsuda et al., 2010).
Some researchers have used some technical instrument to improve balance and reduce the risk of falls among elderly people (Runge, Rehfeld, & Resnicek, 2000). However, any community home-based program should integrate the training into peoples’ everyday life. It would be feasible, economic and more acceptable for elderly people rather than high technical procedures.
A randomized controlled pilot study with 12-week physical and/or nutritional intervention program was followed by six months of home-based exercises for the training groups, followed up with training diaries aiming to describe the effects of a physical training and nutritional intervention program on the physical activity level and activities of daily living (ADL) in frail elderly people found moderate correlations between increases in physical activity level and ADL as well as between the amounts of home-based exercises and ADL for the two training groups (Rydwik, Frandin, & Akner, 2009). Another study found that a 6-month, home-based exercise program consisting of progressive strength training, balance exercises and general physical activity improves functional performance and balance in functionally impaired elders (Nelson et al., 2004). Finding of another study concluded that an exercise class even once every 2 weeks is very effective in enhancing physical function in ambulatory individuals aged over 73 years, provided that it is supplemented by a home-based exercise program (Suzuki, Kim, Yoshida, & Ishizaki, 2004). However they suggested a large scale study to confirm their results and to evaluate the most effective exercises for the prevention of falls. Researchers concluded that incorporation of exercises in daily life is important in maintaining an appropriate level of physical function in the elderly.
Prevention of falls and injuries is not easy, however, because they are complex events caused by a combination of intrinsic impairments and disabilities (Kannus, Niemi, Parkkari, Palvanen, & Sievznen, 2007) fall prevention in elderly people consists of regular strength and balance training, vitamin D and calcium supplementation, reduction of the number and doses of psychotropic medication, cataract surgery, and professional home-hazard assessment and management in people with a history of falling (Kannus, Sievenen, Palvanen, Jervinen, & Parkkari, 2005). On the other hand, a single-factor intervention such as exercise could also reduce many impairments and disabilities and more distant risk factors for falling simultaneously.
Muscle mass diminishes considerably between the ages of 20 and 80 years (Sturnieks, St George, & Lord, 2008d). Sarcopenia is a common problem among elderly people and is associated with loss of muscle mass and strength (Iannuzzi-Sucich, 2002). Understanding age-related changes in the physiological systems imperative to balance is of importance to prevent falls in older people and reduce the injury-related burden on individuals and society (Sturnieks, St George, & Lord, 2008c). It has been estimated that the human beings in their 4th to 8th decade of life lose approximately half of muscle mass and muscle strength (Spirduso, 2005).
Senile muscular atrophy predominantly occurs in type 2 muscle fibers which ends up a degenerated muscular bulk in which remaining muscle mass is not only smaller and weaker but slower as well (Kostka, 2010; Faulkner, 1995).
The most primary atrophy occurs in quadriceps, hamstrings and back muscles with the highest concentration of type II fibers (Kostka, 2010). It has also been consistently proven that power-generating capabilities of type II fibers is approximately four times more than of type I fibers (Faulkner, 1995; Metter, 1997). Muscular strength is typically maintained at peak levels until the fifth or sixth decade, after which accelerated losses occur, with strength decreasing approximately 50% by the age of 80 year (Sturnieks, St George, & Lord, 2008b).
Deficits in skeletal muscle strength, balance, and gait, being major causes of frailty and risk factors for falls, are equivalently and potentially reversible by exercise training (Suzuki et al., 2004). One proposed intervention for preventing falls and fall-related injuries in the elderly is exercise. If falls occur at least in part because of physical deficits in balance, strength, reaction time, and flexibility, then it is plausible to believe that exercise targeted to improve these deficits might result in fewer fall and/or injury events.
The role of strength exercise in falls prevention is under investigation. In a recent study, researchers evaluated the balance and weight training to alter gait characteristics of elderly to reduce the likelihood of slip-induced falls. The results indicated decreases in heel contact velocities and the friction demand characteristics after 8 weeks of training, although fundamental gait characteristics, such as walking velocity and step length, were not changed (Kim & Lockhart, 2010). Latham, et al 2003 in a randomized control trial found that among older people recently discharged from hospital quadriceps strengthening exercises failed to reduce falls rates and was associated with a significant risk of musculoskeletal injury (Sturnieks, St George, & Lord, 2008a).
A recent study investigating the effects of a multifactorial fall prevention trial on the specified risk factors of falling, incidence of falls and injurious falls did not find significant difference between control and intervention groups (Sjosten et al., 2007). However there are some evidences to support effectiveness of training program among elderly people (Kruger et al., 2009; Madureira, Bonfb, Takayama, & Pereira, 2010)
Review of literature reveals that self-confidence deteriorates because of muscular weakness and make old people to fear of falls (Davis, 1999; Evitt, 2003; Gai et al., 2009).
Bandura in his book 1997 wrote that:
People make causal contributions to their own psychosocial functioning through mechanisms of personal agency. Among the mechanisms of agency
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