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1 Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
2 Neve Ram Institute for People with Special Needs, Rechasim, Israel.
3 Qwitman Residential Center, Kfar Saba, Israel.
4 National Institute of Child Health and Human Development, Division of Community Medicine, Ben Gurion University of the Negev, Beer-Sheva, and Office of the Medical Director, Division for Mental Retardation, Ministry of Labour and Social Affairs, Jerusalem, Israel.
5 Department of Anatomy & Cell Biology, Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel.
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Abstract |
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Methods. The study included 13 women and 4 men, aged 50–67 years (mean age 56.5 years) residing in a residential care center. Five clinical tests were used to determine the "real" picture of the locomotor function and balance before and after the training protocol. Baseline values were determined using 2 control groups of age-matched adults with and without ID. The tests included modified get-up-and-go, full turn, forward reach, sit-to-stand, and one-legged standing. Therapeutic training for 6 months included dynamic ball exercises and treadmill walking with a 2–3% positive inclination.
Results. Participants in the program showed little to no improvement in terms of their static and dynamic balance compared to their initial values. Thus, only 2 of the tests showed statistical significance.
Conclusions. Lack of improvement was noted in both postural and balance control in adults with mild ID as a result of 6 months of intervention by means of ball exercise and treadmill training.
Clinical procedures commonly used to determine levels of physical functioning have 2 main functions: detection of specific impairments and identification of individuals with a greater probability of disease than that found in the general population (7,8). Various clinical assessment methods, including balance testing and isokinetic muscle strengthening, have been successfully used to determine general physical functioning and mobility in the elderly (9–11). Two main therapeutic physical exercise approaches have been used to improve balance and functional independence: dynamic ball activities (12) and treadmill walking (13).
The main purposes of the present study were to evaluate the effects of 6 months of training with dynamic ball exercises and treadmill walking on improving balance in middle-aged adults with intellectual disability. More specifically, this study also measured the effectiveness and degree of correlation between the 5 different balance tests, thereby determining the "real" functional level as well as ascertaining which of these tests are the most relevant and meaningful.
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Methods |
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, mean age 60.3 years). The range of their IQ was comparable with that of the ID group. Control group B consisting of volunteers from a local kibbutz (communal settlement) (
, mean age 60.5 years).
Balance Test Procedures
On each occasion, 5 balance tests were undertaken on 3 separate occasions: pretraining (week 0), midtraining (week 12), and posttraining (week 27). On each occasion the 5 different balance tests were performed on separate days during the same week. As far as the authors are aware, there is no existing information that determines correlation among the tests. Each test reflects different functional capabilities and different psychomotor control mechanisms. Each test was performed twice, and the best score was recorded. The experimental rationale to include 5 different tests was (a) to evaluate in which motor area the participants showed greatest improvement following the training program and (b) to evaluate the interclass correlation (ICC) between the various tests. The same rater recorded the measurements, usually at the same time of the day on each occasion.
Timed up-and-go test (TUG).-- This test was used to measure a mixture of four different locomotor tasks (modified from the test described by Mathias and colleagues (15). Briefly, participants were asked to rise from a chair, walk 9 meters, turn around, return to the chair, and sit down again. Times were measured using a manual stopwatch. The target time to complete this test for older adults with a good level of independence is between 22 and 26 seconds, as indicated by Wall and colleagues (16), who revised and expanded the test. The advantages of the test are that it is functional, simple, requires simple tools, is quick to perform (under 30 seconds), and can be performed by participants who use walking aids such as a walker, cane, or crutches. The procedure was experimentally tested and found to be a highly reliable tool with a nondisabled aging population to measure a complex chain of the four consecutive movements (17).
Full turn (FT).-- The 360° (FT) turn test [described in detail by Berg and colleages (18)] measures the ability to perform a full turn, with shoes off. The test depends on successful integration between the vestibular–proprioceptive and visual systems. The number of steps and times to complete a full turn in one place and in both directions is recorded on a 5-level graded scale (in seconds), as used by Berg and Norman (19). The validity and reliability of this test was reviewed by Whitney and colleagues (1) and found to be high (ICC 0.83–0.96).
Forward reach (FR).-- The FR test [described by Duncan and colleagues (20)] measures the ability of an individual to shift the central of mass of the body by bending forward as far as possible without taking a step. Each participant was given three attempts, and the best score was recorded. Validity and reliability were found to be high (ICC 0.56–0.65) (17).
Sit-to-stand (StS) (Czuka test).-- The StS test involves repeatedly getting up from a chair (48-cm height, armless), standing, then sitting again for 20 seconds [as described by Liang and Cameron (21)], and the test measures the ability to transfer body weight upright and then down by use of knee extensor muscles and back muscles.
One-legged standing (OLS).-- This test [described by Bohannon (22)] measures the ability to maintain balance while standing still on one leg on a firm floor, with shoes off, eyes open, and crossed arms gripping the shoulders, for 20 seconds. Participants failed the test if any one of the following conditions occurred: touching the floor with the raised leg; trunk swaying across the midline; or arms releasing their grip on the shoulders.
Exercise Activities
All participants participated in the ball exercise and in the walking program 5 days a week for 27 consecutive weeks. However, the first week (week 0), week 12, and the last week (week 27) were designated for completion of balance assessments only. The treadmill program started on the second week (week 1) and continued through week 26, for 3 times a week. From a methodological point of view of gradual progress of the intervention, the ball exercises started only on the third week (week 2) and continued through week 25, twice a week.
Treadmill walking.-- A treadmill-walking program was designed to increase walking tolerance and muscle power in individuals. Five minutes of active stretching exercises were undertaken prior to each walking session and included prolonged and progressive stretching of the Achilles tendons, the hamstrings, and the quadriceps muscles. The treadmill program consisted of individually prescribed low-endurance walking at 0% incline, as previously recommended (23,24). The walking distance and speed protocol followed the systematic approach recommended by Fernhall and colleagues (25), which emphasizes heart and respiratory rate. Participants walked on the treadmill 3 times per week for 24 weeks, initially for 5–15 minutes, as tolerated, and then gradually for as long as 30 minutes, with a 2–3% positive inclination of the treadmill as endurance capabilities improved. Participants walked at speeds below the thresholds of breathlessness but as fast as they could comfortably tolerate, and if necessary, participants were allowed to grab the handrails for walking balance adjustments.
Treadmill walking was conducted between 9:30 AM and 11:30 AM indoors under controlled conditions (23°C, 40% humidity). Monitors stood by the walkers as a safety precaution in case of unexpected dizziness or to prevent a fall. Immediately following the completion of the walking, participants were seated, and heart rates and blood pressure were measured. For monitoring purposes, heart pulse (1 minute), blood pressure (in mmHg), and respiration rates were recorded before and after each training session.
Ball exercises.-- Large gymnastic balls made of thick vinyl were used for the therapeutic exercises. These balls function as important aids in achieving normal movement and equilibrium. Two ball sizes were chosen according to the height of the participants: a green 65-cm ball (for those of 1.60–1.70 m height) and a red 75-cm ball (for taller individuals, from 1.70–1.80 m in height). As recommended by Mayer (12), a series of 40 ball exercises was selected out of 270. Three physical therapists with 3–4 years' experience participated on a "one-to-one" basis (i.e., individual exercise). The ball exercises were all performed individually in standing, sitting, and lying positions on 5-mm–thick shock-absorbing mats. Typical exercises included supine trunk curl, prone trunk extension, and side-lying lateral flexion. The ball exercises were designed to improve control of postural alignment, balance, and also to strengthen specific muscle groups. Ball exercises involving whole-body activities help improve midline orientation while forcing the body to make rapid compensatory movements. The ball exercises integrate body strengthening with the mobility and coordination needed for everyday functional activities. The ball distributes body weight over relatively large, yet dynamic, support and lowers the height of the body, allowing equilibrium reactions and difficult movement patterns to be elicited at a relatively safe distance from the floor. Ball exercises condition physiological "stimulus-response interactions" of the neuromuscular system. The ball exercises were given twice a week for 23 weeks, starting on week 2 and concluding 1 week earlier than the treadmill-walking program. Each session of ball exercises lasted 20–30 minutes, as tolerated by individual participants.
Data Analysis
All data were analyzed with SPSS 7.2 for Windows 2000 (SPSS, Inc., Chicago, IL). Means and standard deviations were calculated for all variables. Dependent t tests were run to compare the 2 training programs to the 5 different balance items. The 5 different tests were combined to determine overall balance by using analysis of variance. The correlation coefficient used for the 5 tests was Spearman rank. The critical value for statistical significance was assumed at an alpha level <.05.
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, as was also found in a previous publication of Carmeli and colleagues (26). The correlation analysis of the pretraining program indicated the following: TUG test determinations showed a high positive correlation (
) with measurements of the FT test. A strong positive correlation was also found between the FR and OLS tests (
). The StS measurements showed only moderate correlation with the TUG (
), FR (
), and OLS (
) tests.The correlation analysis of the post-training program compared with pretraining (Table 1) demonstrates a higher correlation coefficient between the 5 tests as well as a particularly elevated correlation between StS and the other four tests. The performance results for each clinical test are shown in Table 2. The training program positively influenced the results for all 5 tests. Post-training measurements were significantly better than those of pretraining in FR and StS tests. The posttraining improvements ranged from 9.5% (StS) to 18% (FR-Max)—post-training compared with pretraining values. Table 2 demonstrates the differences in test scores between pre- and post-training and the control group. |
Discussion |
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Evidence about the effect of walking training on aerobic capacity, on general health status, on reaction, and on movement time has been previously reported (27). The question of whether walking and ball exercises can effect balance performance as well as inquiry into which balance test would be more affected by 6 months of training have never before been investigated. The question of whether walking and ball exercise could positively effect balance as much as specific functional activities do is a valid concern. Thus, regardless of the lack of evidence-based practice, clinicians often train their clients on a treadmill and ball to improve those systems that are apparently directly and indirectly involved in maintaining balance.
Measurements of the physical and clinical capabilities of adults with ID are both challenging and informative for the therapist (28). Such methods can provide objective, quantifiable, and variable indications of physical performance. Moreover, the combination of several different tests reduces possible discrepancies between what the participant can actually do and how the therapist interprets the results. The use of several different tests improves the overall validity of assessing physical capabilities, as was recommended by Rikli and Jones (29).
The relative lack of mobility and the high prevalence of falls in adults with ID requires that physical and functional assessment tests include a reliable, comprehensive, and easily administered test for balance. Several measures have been developed in order to assess balance and static and dynamic postural control (8,30). Using just 1 or 2 clinical tests to assess balance may provide misleading indications of actual capabilities.
In this study we used 5 tests that are inexpensive, precise, repeatable, and safe to perform. Each test measures different components of balance mechanisms and control. Thus, the combination of the 5 tests provides an excellent means to determine overall balance characteristics and functional capabilities of individual participants. It is important to undertake both static and dynamic assessments in order to determine the following: ability to remain upright with minimal support (OLS), anticipation and preparation for multifactorial tasks (TUG), impaired coordination of postural adjustments of lower extremities (FT), weak muscles of lower limbs (StS), and postural sway (FR) (31). The question that should be addressed is "What can be learned from a combination of balance assessments?" Balance assessment using 5 different, but specific, tests provides a more accurate determination of balance control (28). For example, a participant who gets a "good" score on the TUG test may not necessarily perform at an identical level in the StS test. Lower scores on this test may indicate specific weakness of the lower limbs that requires lower-leg muscle strengthening.
The effects of walking on balance performance and on improving leg power in older adults have been reported (32–34). In the present study, following 24 weeks of treadmill walking and a program of ball exercises, results of all of the 5 balance tests showed little or no improvement. Specifically, only 2 (FR and StS) were significantly improved (
). Gustafson and colleagues (35) reported that walking training and balance training could improve one-legged standing and postural sway.
The reason or reasons for the disappointing finding in this study remain unclear. On the one hand, this negative outcome could indicate that the sample size provided insufficient power to detect a treatment effect, and even when significant differences were obtained (i.e., on the FR and StS tests), the magnitude of the differences were, unfortunately, clinically insignificant. On the other hand, one can claim that the lack of improvement could indicate that the treatment was not intensive enough. We believe that if after 6 months of treatment the results were not positive, it would seem that this approach was not effective. A surprising result in our study was that only 2 of the 5 balance tests were significant. The possible explanation would imply that there exists a difference among adults in terms of their ability to acquire motor skills (36), a difference that is related to age, gender, fitness, and cognitive level. The mechanism by which to understand this theory is future investigative studies. It is important to point out that the post-training values of the ID study group were still inferior to the baseline values of the control group B (non-ID), but the values were superior to those of control group A.
Two major limitations of this study need to be addressed. First, the small sample size of the study does not allow for generalization of the outcomes. Future studies should utilize at least 31 participants in order to obtain a more statistically significant result. Second, the absenteeism rate of 2 participants might influence the outcome interpretations.
Conclusions
In summary, the results of this study showed that use of a combination of 5 different clinical assessment tests to detect balance and mobility impairments can provide a highly accurate overall assessment of balance capabilities in adults with intellectual disabilities. It is possible that not all of the 5 tests are necessary to reach accurate conclusions, based on the correlation found between specific tests. The strong correlation between the TUG and FT tests and between the FR and OLS tests may indicate that there is an option to eliminate one of each pair of tests during clinical evaluation for balance.
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Acknowledgments |
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Received November 14, 2002
Accepted November 14, 2002
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| All GSA journals | The Gerontologist |
| Journals of Gerontology Series B: Psychological Sciences and Social Sciences | |
