The effect of the Otago Exercise Programme on strength and balance in community dwelling older women.
Abstract: The Otago Exercise Programme (OEP) is a falls prevention programme developed in New Zealand to target the modifiable falls risk factors of lower limb weakness and impaired balance. There is strong evidence of the effectiveness of the OEP in reducing falls in older adults but evidence of the underlying clinical mechanisms is not as robust. This study aimed to explore the effect of participation in the OEP on clinical measures of lower limb strength and balance in community dwelling older women. In a clinical trial of community dwelling women over the age of 80 years who were participating in the OEP (n=19), and age matched women who continued with their normal activities of daily living and were not involved in an organised exercise programme (n=18), measures of strength and balance were compared. After 6 months participation in the OEP there were no statistically significant differences between the two groups in measures of strength and balance. Further research is required to ascertain the clinical mechanisms that contribute to the effectiveness of the OEP.

Binns E, Taylor D (2011): The effect of the Otago Exercise Programme on strength and balance in the community dwelling older women. New Zealand Journal of Physiotherapy 39(2) 63-68.

Keywords: Otago exercise programme, falls prevention, community dwelling, older adult, elderly
Article Type: Report
Subject: Exercise for the aged
Physical therapy for the aged
Adults
Exercise
Aged
Physical therapy
Therapeutics, Physiological
Middle aged women
Authors: Binns, Elizabeth
Taylor, Denise
Pub Date: 07/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: July, 2011 Source Volume: 39 Source Issue: 2
Product: Product Code: E121940 Adults
Accession Number: 288537987
Full Text: INTRODUCTION

For older adults falls and their consequences are a major health issue (Campbell et al 1997). In a 12 month period approximately one third of adults over the age of 65 years old will fall and with the ratio of older adults in society increasing globally (Kinsella & Phillips 2005), that poses a growing health problem by placing an increasing demand on health services and limited health resources.

Of the more than 400 risk factors for falls (Masud & Morris 2001), lower limb weakness and decreased balance are two of the most easily modifiable (Myers et al 1996). The Otago Exercise Programme (OEP) is a falls prevention programme which addresses the risk factors of poor balance and lower limb weakness with an individually prescribed, home based strength and balance exercise programme (Campbell et al 1997). A meta-analysis of four OEP trials demonstrated that the programme was effective in reducing falls by approximately a third in community dwelling older adults and was most effective in a subgroup of adults over the age of 80 years who had previously fallen (Robertson et al 2002). In all the Otago trials (Campbell et al 1999, Campbell et al 1997, Robertson et al 2001, Robertson et al 2001) strength and balance were measured using the 4-test balance scale and the 5 chair stand test. Close inspection of data from the four OEP trials indicate that there was no clinically significant difference between the intervention and control group scores on the strength and balance measures. There is limited evidence indicating that an increase in strength and balance is related in a causal manner to a decrease of falls (Todd & Skelton 2004). The aim of this study was to explore the effect of participating in the OEP for 6 months on clinical measures of lower limb strength and balance in community dwelling older women.

METHOD

Design

A clinical trial of two independent groups. A group of community dwelling women over the age of 80 years who were participating in the OEP and an age matched control group who did not participate in an exercise programme but continued with their normal activities of daily living, were used to assess the change in lower limb strength and balance after participating in the OEP for 6 months.

Participants

Exercise participants were recruited from women referred by their general practitioner to the OEP in West Auckland. The OEP nurse extended the invitation to take part in the study during the initial OEP visit. If the invitation was accepted the participant's details were then forwarded to the researcher. General practitioners had guidelines from the OEP funder as to which patients were likely to gain the most benefit (women over the age of 80 with a history of a previous fall). The process of general practitioner referral to the OEP was independent of the study. Control participants were recruited from women who responded to study posters on community notice boards in two residential communities for older adults in West and Central Auckland.

The inclusion and exclusion criteria replicated that used in the first OEP trial (Campbell et al 1997). Participants were female, 80 years or older, independently mobile, living in their own home and understood English (unless there was a family member or friend who was able to translate for them) and able to understand the requirements of the research (assessed by scoring no less than 27/30 on the Mini Mental State Examination (Folstein et al 1975). Potential participants were excluded if they were currently receiving physiotherapy, participating in an organised exercise programme or living in residential care (rest home or private hospital facility).

Participants were assessed by a blinded, independent assessor. At the first assessment the independent assessor gained written informed consent, administered the Mini Mental State Examination (Folstein et al 1975), the Modified Falls Efficacy Scale (Hill et al 1996) and completed the timed up and go test (Podsiadlo & Richardson 1991), the 30s chair stand test (Jones et al 1999), the step test (Hill et al 1996) and a gait velocity test (Bohannon 1986). OEP participants were assessed within 2 weeks of their initial OEP assessment. The participants then continued with the OEP or with their normal activities of daily living. After 6 months the Modified Falls Efficacy Scale and the strength and balance measures were reassessed (see Figure 1).

Ethical approval for the study was granted by the Northern X Regional Ethics Committee of the New Zealand Health and Disability Ethics Committee. All participants provided written informed consent.

[FIGURE 1 OMITTED]

Intervention

The OEP was delivered by practice nurses (Gardner et al 2001) who had completed the Ministry of Health funded OEP training programme and followed the OEP manual (Accident Compensation Corporation 2007). This process was independent of the study. The OEP was funded by a primary healthcare organisation through selected general practices in West Auckland as a population based health pilot initiative. The control group received no sham exercises or equivalent social visits and received only usual healthcare from their general practitioner.

Outcome measures

Lower limb strength, balance, mobility and falls self-efficacy were measured. Falls were not an outcome measured in this study as the original OEP trials provide strong effectiveness of the programme for reducing falls. The primary outcome was the step test with secondary outcomes being the 30 second chair stand test, the timed up and go test, gait velocity and the Modified Falls Efficacy Scale.

Dynamic balance was tested with the step test (Hill et al 1996). The participant was asked to step one foot up and down onto a 7.5cm step as many times as possible in 15 seconds. The number of steps completed was counted from the word "go". This test was completed with both the left foot and right foot. A score of 0 was awarded if any form of hand support was used to provide balance. The test was stopped if any loss of balance occurred and the number of completed steps counted. Testretest reliability in older adults is reported to be high (ICC>0.90) for this test (Hill et al 1996).

Functional lower limb strength was tested with the 30 second chair stand test (Jones et al 1999); which has been found to be a reliable (ICC >0.80) and valid test, with a moderate correlation to weight adjusted 1 repetition maximum leg-press strength (r>0.70) (Jones et al 1999). The participant was asked to stand up straight and sit down as many times as possible in 30 seconds from her dining room chair, with her arms crossed at the wrist and held against her chest. The number of stands completed in 30 seconds after the word "go" was counted. At the end of 30s if a participant was more than halfway up, the stand was counted. A score of 0 was awarded if any form of hand support was used. The test was stopped if any loss of balance occurred.

Functional mobility was tested with the timed up and go test (Podsiadlo & Richardson 1991). The participant was asked to stand from her dining room chair, walk at a comfortable speed to a cone on the floor 3 metres away, turn around and return to sit in the chair. The participant was timed from the word "go" until she returned to a sitting position and the result recorded in seconds. This test is reliable (ICC>0.90) (Hughes et al 1998) and valid in quantifying functional mobility and has been reported to be a useful measure for identifying community-dwelling adults who are at risk of falling (Steffen et al 2002).

Gait velocity was used as a performance measure of walking (Bohannon 1986; Menz et al 2003; Schiller et al 2000). Inside her home the participant was timed over the middle 3 metres of a 4 metre walk; this method has been found to have excellent repeatability (ICC = 0.97, 95% CI = 0.96-0.98) (Worsfold & Simpson 2001). Time taken to walk 3 metres was recorded with a stop watch and converted to a velocity (m/s). Test-retest reliability is high (ICC = 0.96) for this test (Rome et al 2003).

The Modified Falls Efficacy Scale (MFES) was used to measure the change in participants' confidence in completing daily activities without falling; this test has high internal consistency and high retest reliability value (ICC = 0.95) (Hill, Schwarz et al 1996).

Data analysis

A change of 2 points in the primary outcome measure (step test) was considered clinically important. With a sample size of 32 participants per group and assuming a variance of 1.0 this difference would be detectable at a power of 80% and alpha of 0.05. Data were analysed using the statistical analysis software programme, SPSS for Microsoft Windows (version 17.0, SPSS, Inc., Chicago, IL). Data analysis assumptions of normality were checked using Kolmogorov-Smirnov tests, and as the data were normally distributed independent sample t-tests were used to test the mean change in measures from baseline to 6 months for the two groups.

RESULTS

Thirty-seven women over the age of 80 years volunteered to participate in the study. The progress of the participants through the study is shown in Figure 1. Eight participants did not complete a 6 month assessment, resulting in a loss to follow up of 22%.

The OEP group and control group were of a similar age; the median age of the OEP group was 86 years, ranging from 80-91 years old and the control group had a median age of 84 years, ranging from 80-92 years old. Thirteen (68%) participants in the OEP group used an assistive device for walking which was slightly more than the 10 (56%) who used an assistive device in the control group.

Participants in both the OEP group and the control group had similar degrees of lower limb weakness, gait speed and functional mobility (see Table 1). The OEP participants had a slightly lower dynamic balance score at baseline than the control group although this was not a statistically significant difference (Right step t=-1.73; p=0.093; Left step t=-1.35; p=0.190). The OEP participants were more fearful of falling as measured by the MFES and this difference was statistically significant (t =-2.48; p=0.018) although to be expected as GPs were guided by the OEP funder to refer frail older women onto OEP. The mean time between OEP participants beginning the OEP and being assessed for the study was 12 (SD 14.1) days. Two OEP participants had a much longer time between commencing the OEP and being assessed for the study; one became unwell during the first week of OEP participation so stopped the programme and recommenced 7 weeks later and then completed the study initial assessment (66 days); another participant was not assessed for 32 days but no reason was given for the delay. Both participants were included in the analysis.

A total of 29 participants (OEP group n = 12, control group n = 17) were reassessed after 6 months with the MFES and the strength and balance assessments. The mean number of days between the baseline assessment and reassessment was 173 (SD = 12.8) days ranging from 148-199 days for the OEP participants and a mean of 171 (SD = 3.5) days ranging from 165-177 days for the control participants. The results for both groups are summarised in Table 1. There were no statistically significant change scores between the control and OEP groups at the 6 month assessment on any of the outcome measures.

DISCUSSION

The purpose of this study was to determine whether there were measureable differences in strength and balance in a group of community dwelling women over the age of 80 years participating in the OEP for six months compared to a control group of women matched by age. Results showed that there were no statistically significant differences between the groups for any of the outcome measures. It is of interest that the control group did not deteriorate significantly on any of the outcome measures although they received no formal input. This may be due to 6 months being an insufficient period of time in which to observe the manifestation of physiological changes associated with the ageing process; or that as community dwelling older adults they were active enough in their daily routine to maintain their strength and balance (Sherrington et al 2008).

The outcome measures used to assess strength and balance in this study were functional performance-based tests that identified functional limitations without necessarily identifying an underlying cause (Boulgarides et al 2003) and are therefore not direct measures of strength and balance. However, functional measures are typically used with older adults as they better relate to performance in everyday activities. Considering balance as a functional task it is appropriately scaled and timed muscle contractions that are required to maintain balance and not maximal muscle contractions (Gu et al 1996). Gait velocity and the 30 second chair stand test are correlated to lower limb strength (Bohannon 1986; Jones et al 1999; Menz et al 2003; Schiller et al 2000), but it is possible that these measures were not sensitive enough to detect subtle strength changes, or changes in neuromuscular control, that may occur as a result of participating in the OEP. Other fall prevention studies have used gait velocity as an outcome measure with mixed results. Buchner et al (1997) and Barnett et al (2003) similarly found no improvement in gait velocity but a significant decrease in falls. While Hauer (2001) found a significant improvement in gait velocity after an intense progressive resistance and functional training programme and Schlicht et al (2001) suggested intense strength training may improve maximal gait speed, neither of these studies demonstrated a significant decrease in falls. Other studies have significantly reduced falls in an intervention group without demonstrating significant improvements in strength and balance outcome measures (Barnett et al 2003; Tinetti et al 1994; Wolf et al 1997). It is also possible that the relationship between strength and balance is non-linear as with the relationship between strength and gait (Sherrington et al 2008).

This study has two main limitations. Firstly, insufficient participants were recruited in order to detect between-groups differences in the primary outcome measure. Recruitment was impacted by all the OEP nurses participating in a national roll out of a major health promotion launched in West Auckland halfway through the study, resulting in less time being allocated to working with people on the OEP. It was decided that increasing the length of the study would not result in successfully recruiting the required number of participants. These findings should then be interpreted with caution, however they do add to those of the original OEP trials to provide more evidence on the outcome of the OEP on clinical measures of strength and balance.

Secondly, participants were reassessed on all measures after 6 months participation in the OEP rather than after the full 12 months of the programme. Observable changes in strength can be expected within 10 weeks due to initial neural and neuromuscular adaptations (Steib et al 2010). However, as the OEP exercises are considered to be low to moderate intensity, the physical benefits that can be achieved may take longer, even 6 months maybe too short duration to have a measurable impact. Sherrington et al (2008) found a total exercise dose of more than 50 hours over a study period resulted in the greatest effect on falls rate. The OEP exercises are structured to be 30 minutes of exercise three times a week therefore the total dose of exercise over the 6 months of this study would have been 36 hours and short of Sherrington et al's recommendation. However exercise duration and compliance were not recorded for study participants so the actual total dose of exercise is not known. In the original OEP trials strength and balance were reassessed after 6 months participation, therefore our study results are comparable, that there were no significant differences in strength and balance even though different outcome measures were used. Future studies should assess strength and balance after the full 12 months of participation in the OEP as well as exercise compliance.

In a recent Cochrane review of interventions for preventing falls in community dwelling older people (Gillespie et al 2009) an individually prescribed multi-component home based exercise programme was one of the three exercise interventions identified as being effective in decreasing falls. The evidence that the OEP reduces falls is strong however identifying the clinical mechanisms of the programme which make it so effective is challenging. Participation in the OEP may maintain an older adult's current level of function rather than resulting in measureable increases in strength and balance; hence the lack of demonstrable changes in the strength and balance measures used in this study.

A systematic review of progressive resistance training in older adults over the age of 60 years concluded that progressive resistance training does result in strength changes in older adults (Latham et al 2004). Most of the trials included in this review used machines for strength training and found no clear effect of strength training on standing balance. Considering the specificity of training, weight machines tend to strengthen a muscle in isolation and often do not require the co-contraction of other muscles or postural stability to maintain balance during an exercise. Therefore, an improvement in balance could not be expected as balance was not a component of the exercise. The results of the systematic review were insufficient to be able to comment on the effectiveness of strength training in reducing falls risk. Similarly a recent systematic review and meta-analysis on muscle weakness and falls in adults over the age of 65 years living in institutions or community dwelling, identified that while decreased strength is a risk factor for falls, more trials are needed to ascertain the effectiveness of strength training in falls prevention (Moreland et al 2004). Strengthening exercises using body weight and general exercises have demonstrated sufficient intensity to improve strength in the lower limb and to decrease accidental falls in the exercising group compared to controls (Lord et al 1995). When considering a strengthening programme in conjunction with a balance retraining programme, it would appear that the most beneficial strengthening exercises are closed kinetic chain using body weight, as this would be task-specific and relevant to the functional task to be maintained, that is moving one's body around in the environment.

The five OEP strength exercises comprise both resistance and body weight exercises. At the time of the study the heaviest weight available as part of the OEP resources for hip abductor, knee flexor and knee extensor strengthening was 2kg, prescribed for 8-10 repetitions increasing to 2 sets. Compared to the American College of Sports Medicine exercise prescription guidelines for older adults (Nelson et al 2007) the OEP prescription may not be sufficient to apply overload specific to the individual in the strength exercises. Similarly the ankle plantar flexor and dorsiflexor exercises using body weight as resistance for 2 sets of 10 repetitions may not be sufficient overload for an individual.

The 12 OEP balance retraining exercises progress through 4 levels by either decreasing the amount of hand support used or increasing the number of sets of an exercise. At the lowest level all the balance exercises have hand support; no hand support is prescribed predominantly at level three exercises which some OEP participants never achieve. The use of hand support decreases the anticipatory postural adjustments of leg and trunk muscles whether it be a grasp, providing mechanical support, or light touch, providing perceptual input, on a surface (Slijper & Latash 2000). So it is possible that some OEP participants never completed the balance exercises without hand support which would result in no improvement on the clinical measure of balance used in this study (the step test). The initial hand support used in the OEP balance exercises is why the timeframe of up to 2 weeks between beginning the OEP and being assessed for the study was deemed acceptable for no significant changes in balance to have occurred. In future studies it would be of interest to record the level of exercise that participants achieve and their compliance with the programme.

Overall it is possible that improvements in strength and balance which may have occurred with participation in the OEP were too small to be detected by the clinical measures used in this study. It may be that in an aged population small improvements may summate over time to enable an individual to maintain functional independence and in her own home (Nelson et al 2004; Robertson et al 2002) and therefore reassessment after 6 months was too soon. This concept warrants further investigation as do the clinical tests which are used to assess changes in strength and balance in this population.

KEY POINTS

* Strength and balance are two falls risk factors which are modifiable.

* The relationship between improvements in strength and balance and falls reduction is unclear.

* Improvements in strength and balance which occur after participation in the OEP may be too small to be detected by current clinical measures.

* Task specificity is an important concept in exercise prescription for falls prevention.

ACKNOWLEDGEMENTS

Partially funded by a study grant from the Neurology Group of Physiotherapy New Zealand and AUT University. We would like to thank Jackie Chiplin, the practice nurses and the participants for their contributions to this study.

ADDRESS FOR CORRESPONDENCE

Elizabeth Binns, A-11, School of Physiotherapy, AUT University, Private Bag 92006, Auckland 1142, New Zealand. Email: liz. binns@aut.ac.nz Telephone +64 9 921 9785; Fax +64 9 921 9620.

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Elizabeth Binns (1, 2) MHSc (Neurological Physiotherapy), Dip Phys, MPNZ

Senior Research Officer

Denise Taylor (1, 2) PhD, MSc, MPNZ

Senior Lecturer

(1) Health and Rehabilitation Research Institute and (2) School of Physiotherapy, AUT University, Auckland, New Zealand
Table 1: Participant measures at baseline and 6 months
and the change in scores

                             Baseline            Baseline OEP
                             control

Measure                      (n = 18)            (n = 19)

MFES (%)                     91.81 (8.46)        80.74 (17.02)
Gait Velocity                 0.81 (0.29)         0.80 (0.31)
(m/s)
TUAG (s)                     14.04 (6.27)        15.67 (6.47)
30s Ch st score               9.22 (5.34)        10.05 (5.04)
R step test score            11.56 (3.99)         8.79 (5.57)
L step test score            11.61 (4.30)         9.37 (5.65)

                             6 month             6 month OEP
                             control

Measure                      (n = 17)            (n = 12)

MFES (%)                     87.82 (14.10)       81.42 (20.27)
Gait Velocity                 0.75 (0.28)         0.71 (0.19)
(m/s)
TUAG (s)                     14.40 (4.97)        12.39 (5.77)
30s Ch st score               9.24 (5.37)        11.08 (8.30)
R step test score            10.88 (4.05)        11.17 (5.04)
L step test score            10.65 (5.05)        10.92 (5.11)

                             Change scores       Change scores
                             over 6 months *     over 6 months*
                             control             OEP

Measure                      (n = 17)            (n = 12)

MFES (%)                     -4.44 (10.22)        0.42 (9.68)
Gait Velocity                -0.06 (0.15)        -0.16 (0.16)
(m/s)
TUAG (s)                      0.07 (3.90)         -1.79 (3.19)
30s Ch st score               0.35 (3.86)          0.00 (4.22)
R step test score            -0.47 (2.10)          0.92 (4.27)
L step test score            -0.71 (29.3)         -1.54 (5.56)

                             Independent
                             samples

Measure                      t (p)

MFES (%)                      1.29 (0.21)
Gait Velocity                -1.69 (0.10)
(m/s)
TUAG (s)                     -1.36 (0.19)
30s Ch st score              -0.23 (0.82)
R step test score             1.16 (0.26)
L step test score            -0.54 (0.60)

Data are mean (SD). OEP = intervention group. For MFES, gait velocity,
30 second chair stand, right step test and left step test a positive
value demonstrates an improvement in test performance.

For TUAG a negative value demonstrates an improvement
in test performance. * Change scores calculated for the individuals
who completed both assessments
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