INTRODUCTION:

Individual above the age of 60 years belong to the rapidly raising proportion in Indian population. An independent, healthy life with increased life span is of paramount importance with the public health. With respect to this the decline in the performance of daily activities that rely on the mobility and balance represent a solemn drip in the functional status leading to the risk of institutionalization in elderly.

Aging results in decline in physical functions and adopting a regular physical activity and targeting the muscle weakness would produce greater benefits in this population¹. The older adults are prone to falls and the underlying cause would be mostly impaired balance and lack of muscle fitness due to aging²^,³. The data from centre of disease control and prevention showed that one among elderly aged 65 years and more reported falls every year with a 3% annual increase⁴.

Exercise intervention improves functional performance and prevents the risk of mobility impairment in older adults⁵. Elderly people can improve their health benefits with strength training exercises rather than the myth that resistance training is for increasing muscle mass. Strength training has shown positive impact on health related psychosocial factors such as stress, anxiety, depression⁶ and improvement in balance abilities. Health related quality of life (HRQOL) measure is used to study the effect or relationship of an exercise on the impact of fall prevention intervention on the various health aspects of the older adults like physical, emotional and social wellbeing.¹ Low quality of life in physical, psycho-social context related with falls⁷ results in concerns of falling.

Evidence indicates the role of cognition⁸^,⁹ associated with self belief¹⁰ and contentment on the physical status, which are relevant in the health related outcome measures like self reported musculoskeletal declines, functional limitations and quality of life¹¹. Researchers studied the influence of exercises on balance confidence, fear of fall, self satisfaction and perception on the functional status¹². With the practice of the important exercises like strength training¹³ targeting the age related declines, the individual with the changes in life style develop self belief and elevated content of their activity levels.

The fear of fall can result in self directed activity limitation than the real functional deficiencies. Hence the concerns of fall can be considered as an independent factor for the controlled physical activity levels and detriment of functional independence¹⁴. Fear of fall has been related to declining effects in balance, postural sway, gait variables, level of activity independence, psychological health and quality of life. Moreover the loss of self confidence on balance related activities culminating in fear of fall is an important predictor for the occurrence of fall in elderly adults¹⁵. Activities-specific balance confidence (ABC) scale, have been developed for screening the risks of fall and tested in the elderly population. Ultimately the concern of falling decreases the self confidence in the individuals and gradually limits the mobility and functional abilities leading to social dependence and even institutionalization¹⁶. The rate of fear of fall was reported to be up to 65 % in community dwelling individuals and upto 95% in elderly with a history of falls¹⁷.

With literature specifying/evidence on the impact of quality of life and confidence levels in elderly people, the effect of a robust exercise on balance related confidence and quality of life is yet to be explored. Despite the available research evidence about the impact of exercise intervention on the quality of life status and self reported confidence, there is a dearth of literature to relate the changes these outcomes with such essential exercise like strengthening exercise in elderly individuals. A recent systematic review showed positive outcomes on the effects of strength training on QOL, however only studies which showed improvements were only analyzed. Further the review claimed that many studies dint show improvements with strengthening exercise¹³. Its noteworthy the paucity of study on the effects of strength training on balance related confidence, however a prospective study declared that resistance training on older women showed falsely improved balance related confidence as the changes in this parameter dint not correlated with physical abilities and falls risk¹⁸. Based on this gaps identified on the literature reviewed, this study intended to analyze the effects of progressive strength training on balance related confidence and health related quality of life in older adults.

MATERIALS AND METHODS:

This study was conducted in elderly subjects from residential care homes. Ethical clearance was obtained from institutional human research and ethical committee. Written informed consent was obtained from all the participants, who volunteered and willing to take part in the study. The sample size for the study was calculated from the mean and standard deviation of HRQOL measure from previous studies with α = 0.05 and power = 95%. Nearly 23 participants were recruited in the study group. Elderly aged between 60 to 75 years of both genders, who were able to ambulate at least 5m with/without aide and able to stand independently for 1 min without support, ABC score of less than 70% were included. ABC scores of less than 70% indicates risk of falls in elderly¹⁹. The cognitive status of the participants was stable and mentally competent to perform the exercises safely, understand and respond appropriately to the tests and questionnaires used as outcome measures. Participants with unstable medical conditions and with significant visual or auditory impairments, vestibular disorders, severe pain on weight bearing during activity with musculoskeletal disorders of the lower extremity, who underwent regular exercises in the past 3 months and conditions like stroke, Parkinson’s disease, cancer were excluded.

The baseline data on age, sex and no of falls were recorded for data analysis. The pre test data on balance related confidence using ABC scale- short version and HRQOL using EQL-5D-5L were collected before beginning the intervention and post treatment (at the end of 8 weeks of intervention) from all the participants recruited in the study. EQL-5D-5L was chosen to measure the HRQOL in the elderly population due to the relevancy of its parameters like mobility, self care activities, daily activities, pain and discomfort, depression and pain on the exercise intervention. EQ-5D-5L self complete paper version received with request from Euro-QOL Research Foundation has questionnaire in 2 sections, first one is a detailed assessment of 5 domains on mobility, self care, usual activities, pain or discomfort and anxiety or depression. The 5 level domains have options as 1-no problems, 2-slight problems, 3-moderate problems, 4-severe problems, and 5-extreme problems. The participants have to check one of the most appropriate boxes next to the 5 level options under each domain. The second section is EQ VAS in which the participants has to rate their best health on a 20cm vertical VAS (visual analogue scale) marked between 0-100. The minimum and maximum endpoint in the VAS indicates worst and best health the individual can imagine. The scores of the scale provide self rated health measure of the respondents. The scale was explained by the investigator to the participants to enable them mark the relevant responses.

The Participants underwent 8 weeks of supervised strength training. The intervention was given 3 days (sessions) per week for a total of 24 sessions were done. Each session consisted of warm up exercises for 10 mins (Stretching of major lower limb muscles), followed by main exercises (progressive resisted exercises) for 40 mins and cool down exercises for 10 mins (same like warm up session). The participants received resisted exercise for the targeted muscles like Hip flexors, extensors, abductors, knee flexors and extensors, ankle dorsi -flexors and plantar flexors²⁰. External load was given through weight cuffs tied above the ankle joint, except for the ankle plantar and dorsi flexors it was secured around the foot. The program was based on the participant's 1RM (Repetition Maximum) and 1RM was reassessed every 2 weeks. In the first week of training, participants were trained at 30% of their 1RM and gradually increased to reach 80% of the 1RM, as tolerated by the participant. The protocol consisted of 1 set of 8-10 repetitions for each muscle group for 3 sessions per week for total of 8 weeks²¹. Each repetition lasted for 6 seconds. A rest period of 1min was allowed between each set of training. The participants were instructed to not hold the breath while performing exercises. The lifting and lowering of the weight during every repetition facilitated concentric and eccentric muscle action. The participants had slight muscle soreness during the initial sessions and they were treated symptomatically.

Statistical analysis:

The statistical analysis was done using SPSS statistics version 26. The samples were normally distributed at p < 0.05. The ABC scale was analyzed with parametric test. Paired t test was used to compare the pre and post test differences with 95% confidence level at significance level of p<0.05.The EQ-5D-5L values for all the 5 domains were tabulated in the EQ-5D-5L Crosswalk Index Value Calculator available in the Euro-QOL website. The comparative analysis of EQ-5D-5L scores for 5 dimensions individually was analyzed by chi square test, with weighted data and cross tab method. Pre and post test scores of EQ-5D-5L and EQ VAS scores was analyzed using wilcoxon rank test and paired t test respectively. Subsequent analysis was performed to find the association between ABC and EQOL scores using chi square test. ABC and EQOL variables presented as mean and standard deviation and additionally the individual EQOL measures are presented as percentages as per the data presentation recommendation from Euro-QOL research foundation -2019.

RESULTS:

Among the 23 participants, there were 10 males and 13 females. Baseline characters shown in the (Table 1). The pre and post test analysis showed significant improvements in the ABC, EQL-5D-5L, EQOL VAS scores (Table 2). The distribution of responses in EQ-5D-5L individual dimensions showed statistical significance. (Table 3)

Table1: Elderly participant’s baseline characters

Variable	Baseline measures
Age	67.61±4.49*
Male N (%)	10 (43%) ^#
Female N (%)	13 (57%) ^#
No. falls	0.57 ±0.84*

* Mean ± SD, ^# frequencies, SD- standard deviation, N=23.

Table 2: Effect of 8weeks strength training program on ABC, EQOL-5D-5L and EQOL VAS score.

Variables	^#Baseline	^#Post strength training	*p-value
ABC scores	61.08 ± 10.23	67.13 ± 10.02	0.000
EQOL -5D-5L	0.55 ± 0.11	0.64± 0.15	0.014
EQOL VAS	61.22±12.58	70.78±11.56	0.001

n=23, *p<0.001, ^#Mean ± S.D, VAS – visual analog scale.

Table -3. Distribution of Euro quality of life reporting from 1 to5 level dimensions in elderly subjects with impaired balance.

EQOL 5D-5L Dimension	Baseline n (%)	Post strength training n (%)	*p value
Mobility
No problems	3 (13)	7 (30)	0.001
Slight problems	11(48)	12(52)
Moderate problems	7(30)	4 (17)
Severe problems	2(9)	0 (0)
Unable to walk about	0(0)	0(0)
Self care
No problems	1(4)	6 (26)	0.001
Slight problems	14(61)	11(48)
Moderate problems	7(30)	6 (26)
Severe problems	1(4)	0 (0)
Unable to wash or dress	0(0)	0 (0)
Usual activities
No problems	1 (4)	5 (22)	< 0.001
Slight problems	8(35)	12 (52)
Moderate problems	12(52)	5 (22)
Severe problems	2(9)	1 (4)
Unable to do usual activities	0(0)	0 (0)
Pain/discomfort
No pain/discomfort	1(4)	6 (26)	< 0.001
Slight pain/discomfort	11(48)	14 (61)
Moderate pain/discomfort	10(44)	3 (13)
Severe pain/discomfort	1(4)	0 (0)
Extreme pain/discomfort	0 (0)	0 (0)
Anxiety/ depression
Not anxious/depressed	3 (13)	5 (22)	0.001
Slightly anxious/depressed	14 (61)	12 (52)
Moderately anxious/depressed	5 (22)	4 (17)
Severely anxious/depressed	1 (4)	2 (9)
Extremely anxious/depressed	0 (0)	0 (0)

n=23, *p<0.001

The correlation between the ABC and EQOL post test scores was performed using Chi square test with person co relation co efficient. The ABC scores were not correlated with Euro health related quality of life. (r=0.509).

DISCUSSION:

Studies investigated the discriminative and assessment qualities of the ABC scale and reported that the scale is able to distinguish older adults at various levels of functional mobility, with strong internal consistency, reliability in elderly²²^,²³^,²⁴. This data evidenced from literature that ABC scale is a good indicator of the 'fear of falling" promotes to screen the adults with a substantial risk of falling, thereby enrolling them into appropriate fall prevention program. The present study found that intervention with progressive strength training significantly improved balance related confidence in elderly with impaired balance with ABC post test mean scores as 67.13, with a change score of 6.05.

The ABC scores were significantly and independently related with future falls in the Indian older adults. The sensitivity and specificity was observed at 86.3% and 87.3%. ABC scale mean scores for adult with falls reported as (52.6±8.1) which was significantly lower than that of the non-fallers score of 73.1±12.2. The ideal cutoff value for identifying fallers and non-fallers in Indian adults was reported as ≤ 58.13²⁵. For elderly more than 75 years, who were independently able to walk 10m with intact cognitive abilities, a score of less than 67% was considered to be classified as Fear of Falling. These individuals exhibited a slower gait velocity and compromised functions requiring dual task ability²⁶ with significant concerns of falls²⁷. The results of the present study showed borderline improvement around 67% in balance related confidence after 8 weeks of progressive strength training. A prospective study with resisted and agility training on women with low bone density, reported changes from 68% to 83% in ABC scores¹⁸. The patient population in that study was prone to falls resulting in fractures which would have impacted to certain degree of fear of fall. However the changes in ABC scores dint co relate with physical activity and fear of falls, which implied that it could be due to personal accomplishments, socialization or mere enrollment in exercise intervention. Even though the baseline and post intervention ABC scores were statistically significant, the mean difference was not adequate enough to influence a desirable clinical significance relevant to balance and falls in the elderly participants.

Lack of confidence in physical activities has been associated with greater functional impairment, increased disability in essential activities and psychological factors. Thus satisfaction and confidence levels can be largely linked domains in elderly and the exercise protocols that may benefit in improving satisfaction with physical performance may advance with enhanced quality of life. The outcome measures for self confidence correlated with functional parameters, proposing that lower physical performance scores are strongly significant with reduced satisfaction and confidence levels in elderly individuals especially in high fall risk category⁵.

A study with 405 elderly above 60 years living in residential care homes reported 88.2% with fear of falls²⁸. Moreover it was also found that individuals with psychological problems²⁹, associated co morbidities like osteoporosis, osteoarthritis, poor eye sight etc demonstrated diminished self confidence and self efficacy in performing the usual activities which are actually related to fear of falls²⁸. A systematic review with 16 studies reported that resisted training improved health related quality of life in physical and mental domains in older adults. Strength training was recommended for improving quality of life and its effect on HRQOL evidenced in various populations like cancer, lung diseases etc¹. The present study showed similar results with improved mobility, self care, usual activities etc especially on the physical aspects in elderly. The percentage of improvements in the mobility and self care activities were greater compared to other dimensions of EQOL. Adults between the age group of 50-69 with better mobility showed higher self reported quality of life measured with EQ-5D-5L. A 5.2% changes in the quality of life was significant and similar results have been observed for age groups of 60 years and above³⁰.

Studies indicated that improvement in the functional performance was associated with decrease in the fear of fall³¹. Older adults with ABC scores less than 50% were 2.6 times more likely to be depressed, 3.8 times more likely to show slower walking and 5.4 times more likely to show impaired balance, gait than individuals³². The results of the present study showed poor correlation between balance related self confidence and quality of life scores. The possible reasons could be the improvement in the balance related confidence was not clinically adequate to produce a positive impact with the quality of life variables. A study reported significant improvements in balance confidence with resisted exercises in high risk elderly population in spite of marked risk of fall. This is of specific importance as this may guide the individual to take part in activities beyond their real physical abilities. It has been noted that the balance confidence was deceitfully increased due to socialization during group exercise sessions and just with the exercise classes’ participations. Also entities like social dilemma and personal identity takes over the fear of fall in older adults.¹⁸

Hence attention required in designing the intervention and strategies to target the balance confidence in elderly population which deliberately influence the realistic aspect of quality health in older adults. Exercises targeting the factors of fear of falls with specificity³³^,³⁴, multi modal approaches with psychological entity and fall educational models may be more effective. However, older adults trained with progressive resisted exercise intervention showed significant improvements with health related quality of life and self confidence levels of balance. As the scores of these parameters are self rated by the participants, given the chance of ambiguity in reporting the real abilities and the positive psychological effect with the exercise intervention, which would have also contributed to the improvements in balance related confidence and quality of life along with the physiological changes.

CONCLUSION:

Strengthening exercises can be recommended as one of the integral part in geriatric treatment targeting health related quality of life with due consideration to establish intervention for balance confidence in accordance with QOL in elderly with impaired balance.

No funding was obtained for this research.

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Received on 04.12.2020 Modified on 24.04.2021

Research J. Pharm.and Tech 2022; 15(3):1169-1174.

DOI: 10.52711/0974-360X.2022.00196