THE ASSOCIATION BETWEEN EXERCISE INTENSITY AND POSTURAL BALANCE IN ELDERLY

NEUROLOGY | ORIGINAL RESEARCH

THE ASSOCIATION BETWEEN EXERCISE INTENSITY

AND POSTURAL BALANCE IN ELDERLY

ABSTRACT

Increased life expectancy in Indonesia brings about an increase in the number of elderlies. The aging process leads to various health consequences, one of which being postural imbalance. Gymnastics for the elderly may be one of the options to improve the balance system and the quality of life of elderly. This study aims to determine the effect of the intensity of exercise on postural balance in elderly. This experimental study was conducted at Dr Kariadi Hospital in Semarang in the period of August-October 2019. The subjects of the research were subjects aged 60-74 years old. Postural balance was measured using the Berg Balance Scale (BBS). Association between the intensity of exercise and the change of BBS was analyzed using Mann-Whitney test. Independent predictors were investigated using multivariate linear regression. Thirty-nine subjects were divided into two exercise groups: group 1 with exercise frequency of once a week and group 2 with exercise frequency of three times a week. The majority of subjects in this study were women (89,7%). There were significant differences in post-experimental BBS and change of BBS between two groups (p<0,001).

KEYWORDSberg balance scale, elderly, gymnastics for elderly, postural balance

Introduction

Aging has become one of inevitable health consequences. The increase in life expectancy causes increasing number of elderlies in Indonesia. Statistics projected that there will be 27 million elderlies in 2020, 33,6 million in 2025, 40,9 million in 2030, and 48,2 million in 2035.[1,2]

The aging process refers to physiological changes leading to accelerated degeneration of the nervous and/or musculoskeletal system, including the progressive decline in one’s functional capacity. A sedentary lifestyle brings about the decline in neu-romuscular function, including muscle weakness and delay in reaction time. The decline in sensory function, muscle weakness of lower extremity, and delay in reaction time may contribute to postural instability and fall risk in elderly.[3]

Copyright © 2021 by the Bulgarian Association of Young Surgeons DOI:10.5455/IJMRCR.POSTURAL-BALANCE-IN-ELDERLY First Received: September 09, 2020

Accepted: October 20, 2020 Associate Editor: Ivan Inkov (BG);

1_{Neurology Resident, Medical Faculty Diponegoro University/ Dr. Kariadi General} Hospital Semarang, [email protected]

A healthy lifestyle, including well-established dietary inter-vention and physical activity, is essential for healthy ageing.[4] Nevertheless, in elderly patients, several aspects need to be con-sidered prior to performing any physical activities: safety, health issues, possible the need for any exercise modification, and pa-tient’s comorbidities. Thus, a pre-exercise screening, which com-prises of cognitive assessment, carotid auscultation, inspection of hernia, balance assessment, and mobility assessment, must be done before starting any physical activity in elderly. The program also needs to be individually arranged with respect to preexisting conditions in elderly such as osteoarthritis, cardio-vascular diseases, obesity, and diabetes mellitus. Gymnastics for the elderly may improve the function of balance and postural stability, hence reducing the fall risk in elderly.[3]

phosphocreatine, which promotes the aerobic and anaerobic metabolism and generates energy as well as muscle strength. The augmented muscle strength makes the body more robust in supporting body weight and maintaining movement, and even-tually, promotes postural stability.[5–7] Gymnastics for elderly has also been proven to exert positive effects on propriocep-tive receptor function, thereby contributing to postural balance improvement.[3,8] American College of Sports Medicine and American Heart Association recommended moderate-intensity aerobic exercise (e.g. brisk walking or gymnastics) for at least 30 minutes in 5 days a week, or high-intensity aerobic exercise (e.g. running) for at least 20 minutes in 3 days a week.[9] This study aims to determine the effect of intensity of gymnastics on postural balance in elderly. Through the improvement in postural balance, gymnastics for the elderly may improve the quality of life.

Research Design And Methods

This non-randomized, controlled pre- and post-experimental study was conducted in the period of August to October 2019 at Kariadi Hospital, Semarang. The inclusion criteria were subjects aged 60-74 years old who were still able to perform daily activi-ties independently, Berg Balance Scale of 20 or more and/or low fall risk, range of systolic blood pressure of 100-150 mmHg and diastolic blood pressure of 70-90 mmHg, bilateral visual acuity of at least 6/60, and no signs of cataract in both eyes. Data collected from history taking and physical examination included patient’s identity, vital signs examination, general examination, neuro-logical examination, and visual analogue scale (VAS). Subjects who met the inclusion criteria were divided into two groups: group 1 with gymnastics intensity of once a week and group 2 with gymnastics intensity of three times a week. Each session of gymnastics lasted for 30 minutes. The degree of osteoarthritis of the knee was measured using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), as well as mea-surement of postural stability using Berg Balance Scale before and after intervention. Bivariate analyses were performed using Mann-Whitney test to determine statistical difference in BBS between both groups before and after intervention. Multivariate analyses using multiple linear regression were performed on covariates with p value < 0,25 based on bivariate analyses to determine factors which influenced BBS independently.

Results

A total of 39 subjects (20 subjects included in group 1 and 19 subjects included in group 2) met the inclusion criteria (Table 1). The majority of subjects were female (89,7%) and non-diabetics (93,3%). Statistically significant differences were found in BBS and∆ BBS (the difference in BBS before and after intervention) between both groups (Table 2), where post-intervention BBS and ∆BBS in group 2 were greater than the values in group 1. In addition, significant differences between pre-intervention and post-intervention BBS were also found in both groups (Table 3). In the context of degree of osteoarthritis, we found a difference in∆ WOMAC between both groups (Table 4), where a greater decrease in WOMAC score was observed in group 1.

Table 5 shows that no difference was found between possible confounding factors (age, body mass index,∆ WOMAC, gender, and diabetic status) and∆BBS. Multivariate analysis using multi-ple linear regression was performed on covariates with p value < 0,25 based on bivariate analyses. Table 6 shows that intensity of

Table 1Basic characteristics of subjects Variable Group 1 (n=20) n (%) Group 2 (n=19) n (%) p Age Mean ± SD 63,7 ± 5,0 64,9 ± 4,2 0,204a Median (min-max) 61 (60-74) 64 (60-74) Gender Male 3 (15) 1 (5.3) 0,322b Female 17 (85) 18 (94.7) Diabetic status Yes 2 (10) 1 (5.3) 0,520b No 18 (90) 18 (94.7) BMI Mean ± SD 27,1 ± 5,1 24,7 ± 4,3 0,204a Median (min-max) 25,9 (21,8-4,22) 25,1 (18,2-32,4) Baseline WOMAC score Mean ± SD 15,4 ± 13,6 10,6 ± 11,6 0,184a Median (min-max) 13 (1-57) 5 (0-33) a_{Mann Whitney U test}

b_{Fisher’s Exact test}

gymnastics is an independent predictor of∆ BBS. Subjects who performed gymnastics three times a week were associated with greater∆BBS compared to subjects who performed gymnastics once a week (p<0,001).

Discussion

This experimental study was conducted in Kariadi Hospital, Semarang, in the period of August to December 2019, with respective mean subject’s ages in group 1 and group 2 of 63,7 ± 5,0 and 64,9 ± 4,2 years old. This result was in accordance with Barnedh et al (2006) who observed that increasing age is associated with higher fall risk.[10] The majority of subjects in this study were women (89,7%). According to Hassinen et al (2005), the incidence of falls was found higher in women as a consequence of more rapid muscle loss and poorer ability to gain postural stability.[11]

Table 2Differences in Berg Balance Scale between both groups.

BBS Group 1 Group 1 Group 2 Group 2 P Median (range) Mean ± SD Median (range) Mean ± SD Pre 50,5 (40-54) 49.9±3.6 51 (45-54) 50.53±2.4 0,687 Post 53 (45-56) 52.5±2.7 56 (51-56) 51.0±1.6 0,001* Delta -2 (-5-(-1)) 2.6± 1.14 -5 (-6-(-2)) 4.53± 1.21 <0,001*

* Mann Whitney U test

Table 3Differences between pre-intervention and post-intervention BBS in both groups.

BBS Pre Pre Post Post P

Median (range) Mean ± SD Median (range) Mean ± SD Group 1 50,5 (40-54) 49.9±3.6 53 (45-56) 52.5±2.7 <0,001 Group 2 51 (45-54) 50.53±2.4 56 (51-56) 51.0±1.6 <0,001

* Mann Whitney U test

(2013) revealed better equilibrium in subjects who performed higher intensity of exercise, where the equilibrium is measured by stabilographic parameters, including oscillation amplitude of pressure center in X and Y axis, as well as pressure center speed in X and Y axis.[13] Brooke-Wavell et al (2018) also observed bet-ter postural stability in subjects who did regular brisk walking for > 40 minutes a day compared with those who performed physical activity less than 20 minutes per day, indicated by lower body sway.[14]

Sedentary lifestyle accelerates the decline in functional ca-pacity and results in muscle weakness, diminished flexibility, decreased coordination, and disturbance in muscle control, all of which predispose the elderly to postural instability. Reduced telomerase activity has also been shown in individuals who are physically inactive, thereby accelerating aging process. Telom-erase is a reverse transcriptase enzyme responsible for protecting chromosome ends from shortening. As a consequence, acceler-ated aging accentuates the decline in functional capacity, which leads to postural instability in sedentary individuals.[15] In con-trast, physical activity may give rise to neuromuscular adapta-tion and muscle control, thereby gaining better postural stability and lower fall risk.[13]

In general, postural instability in the elderly is associated with greater motoric variability, indicated by increased body sway. Motoric variability that rises along with age is associated with several factors. Sarcopenia, one of the hallmarks of aging characterized by the shrinkage of muscle tissue, is associated with lower muscle strength, flexibility, mobility, and postural balance.[16] In this study, we found no significant association between age and∆ BBS. This inconsistency may be explained by a meta-analysis by Downs et al (2014), which demonstrated significant decline in BBS after 70 years of age.[17]

Anson et al (2018) and Benavent-Caballer et al (2015)

demon-strated that there was a negative correlation between BMI and BBS, which means that higher BMI is associated with higher fall risk and poorer postural stability.[18,19] Some BMI-related variables are known to be capable of mediating the elevated fall risk, including sedentary lifestyle, cardiac disease, diabetes mellitus, and sedative or hypnotic drugs. Moreover, Valentina et al (2019) proved that the closer the BMI to normal values, the lower the risk of falls would be.[20] In this study, we found no significant correlation between BMI and∆ BBS, presumably due to the disproportion in the BMI between subjects.

Diabetes mellitus is a chronic progressive disorder accom-panied with multi-organ complications which may impair bal-ance function. Patients with diabetic neuropathy may encounter poor depth perception of lower leg position due to the impair-ment of skin sensory function and proprioception, hence higher risk of postural imbalance and falls. Diabetic neuropathy also contributes to the degree of postural instability. Along with higher amplitude of anteroposterior and mediolateral devia-tion, diabetic patients also tend to experience loss of vibration and pressure sensitivity, which were also associated with risk of falling.[21] The reason why we did not find any significant correlation between history of diabetes and postural instability may be because of the small number of diabetic subjects in this study (n=3).

Table 4Differences in WOMAC score between both groups.

WOMAC Group 1 Group 1 Group 2 Group 2 P Median (range) Mean ± SD Median (range) Mean ± SD Pre 13 (1-57) 15.40±13.58 5 (0-33) 10.63±11.61 0,184 Post 7,5 (0-32) 9.75±8.75 4 (0-29) 7.89±9.63 0,322 Delta 3,5 (0-25) 5.65± 6.02 2 (0-15) 2.74± 3.60 0,018*

* Mann Whitney U test

Table 5Correlation between confounding factors and∆BBS Variable rho p Age -0,025 0,878a BMI -0,151 0,359a ∆WOMAC 0,282 0,082a Gender Male (n=4) Female (n=35) 0,522b Diabetic status Yes (n=3) No (n=36) 0,280b

a_{Spearman’s rank correlation test} b_{Mann Whitney U test}

muscle weakness or atrophy may decrease muscle spindle sensi-tivity. Other potential causes have also been hypothesized for proprioceptive disorder in osteoarthritis, including OA-related inflammation.[22]

This study found no significant correlation between ∆WOMAC and ∆BBS (p=0,082). However, there was a signif-icant difference in∆WOMAC between both groups (p=0,018). A greater decrease in WOMAC score was observed in group 1, which suggests that gymnastics intensity of once a week yielded better improvement of osteoarthritis compared to gymnastics in-tensity of three times a week. Some weight-bearing movements in gymnastics for the elderly is thought to be the reason behind this unanticipated result. Land-based weight-bearing activi-ties, such as walking, jogging, and aerobic dancing, may cause joint damage and increase pain in the elderly with knee OA.[23] Therefore, elderly with knee OA should not be recommended to perform high-intensity gymnastics exercise, and aquatic ex-ercise might be recommended in conjunction with gymnastics for elderly. Aquatic exercise has been proven to yield greater reduction in postural sway and pain, and greater increase in muscle strength compared to land-based exercise in the elderly with knee OA.[24]

We acknowledge that there are several limitations in this study. Not every factor which influences the postural stability was evaluated in this study, including history of medication,

Table 6Multivariate analysis using multiple linear regression Variable Regression

co-efficient ( r ) t-value p Constant -0,814 ∆WOMAC 0,016 0,418 0,678 Intensity of exercise -1,879 -4,707 0,000* F-value = 12,776 R Square = 41,5%

affective and psychologic disorders, and other musculoskeletal disorders (e.g. lower back pain). We also acknowledge that there is a disproportion between subjects’ gender and a small number of diabetic subjects in this study.

Conclusion

Gymnastics for the elderly with the intensity of three times a week yielded better postural stability compared to those with the intensity of once a week.

Patient Informed Consent

Patients are willing to become participants in the study by sign-ing informed consent.

Ethics Committee Approval

This study has ethical clearance number 226/EC/KEPK-RSDK/2019, issued on May 20th, 2019 by the Research Ethics Commission of FK Diponegoro University / Dr Kariadi Hospital Semarang.

Funding

This study received no fund.

Conflict of interest

There are no conflicts of interest to declare by any of the authors of this study

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