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Rhythmic stepping exercise under cognitive conditions improves fall risk factors in communitydwelling older adults: Preliminary results of a cluster-randomized controlled trial a

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Minoru Yamada , Buichi Tanaka , Koutatsu Nagai , Tomoki Aoyama & Noriaki Ichihashi a

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Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan

Available online: 17 Jun 2011

To cite this article: Minoru Yamada, Buichi Tanaka, Koutatsu Nagai, Tomoki Aoyama & Noriaki Ichihashi (2011): Rhythmic stepping exercise under cognitive conditions improves fall risk factors in community-dwelling older adults: Preliminary results of a cluster-randomized controlled trial, Aging & Mental Health, 15:5, 647-653 To link to this article: http://dx.doi.org/10.1080/13607863.2010.551341

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Aging & Mental Health Vol. 15, No. 5, July 2011, 647–653

Rhythmic stepping exercise under cognitive conditions improves fall risk factors in community-dwelling older adults: Preliminary results of a cluster-randomized controlled trial Minoru Yamada*, Buichi Tanaka, Koutatsu Nagai, Tomoki Aoyama and Noriaki Ichihashi Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan

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(Received 9 September 2010; final version received 21 December 2010) Objective: The purpose of this pilot trial was to evaluate whether a 24-week program of rhythmic stepping exercise (RSE) would be effective in improving physical function and reducing fear of falling in older adults. Participants: Four units (n ¼ 52) randomized into an RSE group (two units, n ¼ 25) and a non-rhythmic stepping exercise (NRSE) group (two units, n ¼ 27) participated in a pilot cluster randomized controlled trial. Methods: Each exercise group received 60 min group training sessions once a week for 24 weeks. Measurement was based on the difference in physical functions between the RSE and NRSE groups. Results: Significant differences were observed between the two groups for locomotive function with significant group  time interaction. Relative risk was calculated as 2.778 (95% CI: 1.030–7.492) for fear of falling for participants in the NRSE group compared with patients in the RSE group (p ¼ 0.037). Conclusions: The results of this pilot trial suggest that the RSE program is more effective in improving locomotive function and fear of falling. Keywords: rhythmic stepping exercise; fall risk; older adults

Introduction Approximately half of the community-living older population experiences fear of falling (Fletcher & Hirdes, 2004; Howland et al., 1998; Tinetti, Richman, & Powell, 1990; Yardley & Smith, 2002). The wide range of prevalence estimates for fear of falling (29–77%) may be due to differences between sample groups with respect to age, sex, activity level, history of falls, measures of fear, and other comorbidities (Arfken, Lach, Birge, & Miller, 1994; Friedman, Munoz, West, Rubin, & Fried, 2002; Lachman et al., 1998; Lawrence et al., 1998; Tinetti, Mendes de Leon, Doucette, & Baker, 1994; Vellas, Wayne, Romero, Baumgartner, & Garry, 1997). Several studies have indicated that people who are afraid of falling appear to enter a debilitating spiral of loss of confidence, restriction of physical activities and social participation, physical frailty, falls, and loss of independence (Arfken et al., 1994; Cumming, Salkeld, Thomas, & Szonyi, 2000; Delbaere, Crombez, Vanderstraeten, Willems, & Cambier, 2004; Friedman et al., 2002; Howland et al., 1993; Lachman et al., 1998; Yardley & Smith, 2002). In addition to the adverse effects often displayed by individuals who suffer from fear of falling, there are also consequences for public expenditure as healthcare utilization increases (Cumming et al., 2000). It is therefore considered important to reduce fear of falling by targeting the downstream factors, such as increasing physical functioning (Delbaere et al., 2004), or predictors of those factors, such as the use of improved medication

*Corresponding author. Email: yamada@hs.med.kyoto-u.ac.jp ISSN 1360–7863 print/ISSN 1364–6915 online ß 2011 Taylor & Francis DOI: 10.1080/13607863.2010.551341 http://www.informaworld.com

(Friedman et al., 2002). As older people with fear of falling often adapt their gait, commonly described as ‘cautious’ or ‘fearful’ gait (Giladi, Herman, Reider-Groswasser, Gurevich, & Hausdorff, 2005), this fear can lead to imbalance during walking. In contrast to static balance, however, little is known about dynamic balance in older people, which may be more important and directly related to falls and fear of falling (Maki, 1997), since most falls occur during movement. In real-life situations, the requirements for stepping commonly occur under more complicated circumstances with cognitive attention focused on a particular task, such as watching traffic or reading street signs or advertisements, rather than performing a specific motor task (Chen et al., 1996). With advancing age, the performance of daily life activities in addition to walking becomes increasingly difficult, and can often lead to complex multi-task situations, which increases the risk of falling (Bloem, Valkenburg, Slabbekoorn, & Willemsen, 2001). Hence, it is considered that certain falls result from the inability to recover from a misstep during an additional attention-demanding task during daily life activities. Mobility involving concurrent cognitive or motor tasks, such as talking or carrying objects, is crucial in daily life. Due to the increasingly recognized role of cognition in postural control and gait, a number of researchers have used dual-task (DT) paradigms that incorporate a concurrent cognitive task (CT) to improve fall risk assessment (Woollacott & Shumway-Cook, 2002).


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Dual tasking requires individuals to divide their attention, which may interfere with gait and balance control (Shumway-Cook & Woollacott, 2000). Based on Gaze’s study on the influence of anxiety on attentional demands during walking, it is thought that the fear of falling reduces the amount of cognitive resources available for gait and balance control (Gage, Sleik, Polych, McKenzie, & Brown, 2003). The effect of fear of falling on gait and balance may therefore be more apparent when people perform a second task during walking, as often occurs in daily life. However, the effect of training on the incidence of falls and ability under DT conditions in older adults remains unclear. The ability to modulate attention may also play an important role in the acquisition of multiple-task coordination skills. We proposed that rhythmic stepping exercise (RSE) under cognitive conditions may help improve DT ability, as RSE simultaneously requires both cognitive (reaction, short-term memory, etc.) and motor function (step to multi-direction). In this trial, we evaluated whether a newly developed 24-week RSE program would be effective in improving physical function and reducing fear of falling in community-dwelling older adults. We hypothesized that physical function would be improved to a greater extent in elderly individuals who performed RSE than those who did non-rhythmic stepping exercise (NRSE).

Methods Participants Participating institutions were recruited by means of an advertisement in the local press. Four living areas in Kyoto, Japan, including 62 community-dwelling older adults participated in a 24-week randomized controlled trial. From each living area, defined as a cluster, individuals were selected according to the following inclusion criteria: age 65 years or older, community dwelling, had visited a primary care physician within the previous three years, a Rapid Dementia Screening Test (Kalbe, Calabrese, Schwalen, & Kessler, 2003) score of 8 or greater, ability to walk independently, willingness to participate in group exercise classes for at least six months, access to transportation, minimal hearing and vision impairments, and no regular exercise in the previous 12 months. We also used an interview to exclude participants based on the following exclusion criteria: severe cardiac, pulmonary, or musculoskeletal disorders; pathologies associated with increased risk of falls, such as Parkinson’s disease or stroke; osteoporosis; and the use of psychotropic drugs. After the collection of baseline data, a researcher not involved in the study allocated clusters using computer-generated randomization lists. We obtained written informed consent from each participant who was included in the trial in accordance with the guidelines approved by the Kyoto University

Graduate School of Medicine (Approval number: E-547) and the Declaration of Human Rights, Helsinki, 2000.

Intervention All participants received 60-min group training sessions once a week for 24 weeks. Participants were randomly assigned to one of the two training groups: (1) a standardized training with RSE group and (2) a standardized training with NRSE group. The exercise classes were individualized for each group and were supervised by a physiotherapist. Each exercise class used a standardized format that included 15 min of moderate–intensity aerobic exercises, 15 min of progressive strength training, 10 min of flexibility and balance exercises, and 10 min of cool–down activities, followed by exercises known to improve muscle strength and balance (Buchner et al., 1997; Gardner, Robertson, & Campbell, 2000). The stepping exercises were performed on a thin elastic mat (150  150 cm) that was partitioned into five squares (50 cm each) to form a cross (Figure 1A). The stepping exercises included forward, backward, and sideways step patterns. In the RSE group, the participants were required to step at a tempo of 60–120 beats per min according to the accompanying rhythm sound, and step into the square indicated verbally by the supervisor (e.g., ‘right,’ ‘forward,’ ‘back,’ etc.) (Figure 1C). For the RSE group, a cognitive function (reaction, short-term memory, etc.) and motor function (step to multi-direction) were simultaneously required of the participants. In order to vary the levels of difficulty, the instruction method transposed not only direction, but also an index of a color (e.g., ‘red,’ ‘blue’) or a number (e.g., ‘3,’ ‘7’) (Figure 1B). Participants completed five sets of one min per set of stepping exercises between weeks one and eight, which were then increased to three sets of three min per set between weeks 9 and 16, and three sets of five min per set between weeks 17 and 24. The instructions given at the beginning of each class were as follows: ‘Please step as correctly as possible, and avoid making mistakes to the best of your ability’. During the exercises, the number of mistakes made during the stepping tasks was not recorded. NRSE was a simple reaction stepping task. The participants were required to maintain a standing position, and step into the indicated square as quickly as possible after a verbal command from the supervisor (e.g., ‘right,’ ‘forward,’ ‘back,’ etc.) (Figure 1D). These sessions were designed as controls for the additional element of physical activity and reaction training in the RSE session. Participants completed five sets of 10 steps per set of stepping exercises between weeks 1 and 8, which were then increased to three sets of 30 steps per set between weeks 9 and 16, and three sets of 50 steps per set between weeks 17 and 24. The instructions given at the beginning of each class were


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Figure 1. (A) Schematic representation of the stepping exercises. The stepping exercises were performed on a thin elastic mat that was partitioned into five squares (50 cm each) to form a cross shape. The stepping exercises included forward, backward, and sideways step patterns. (B) Schematic representation of the version which made directions the ‘color.’ The participants were required to step into the square indicated verbally by the supervisor (e.g., ‘red,’ ‘yellow,’ ‘blue,’ etc.). (C) Schematic representation of the RSE. In the RSE group, participants were required to step at a tempo of 60–120 beats per min according to the accompanying rhythm sound, and step into the square verbally indicated by the supervisor (e.g., ‘right,’ ‘forward’). The instructions were as follows: ‘Please step as correctly as possible, and avoid making mistakes to the best of your ability’. The RSE required simultaneous cognitive (reaction, short-term memory, etc.) and motor function (step to multi-direction). (D) Schematic representation of the NRSE. In the NRSE group, participants were required to maintain a standing position and step into the indicated square as quickly as possible after a verbal command from the supervisor (e.g., ‘right,’ ‘forward’). The instructions were as follows: ‘Please step as quickly as possible, and avoid making mistakes to the best of your ability’. The NRSE required separate cognitive (reaction, short-term memory, etc.) and motor function (step to multi-direction).

as follows: ‘Please step as quickly as possible, and avoid making mistakes to the best of your ability’. The NRSE required cognitive function (reaction, shortterm memory, etc.) and motor function (step to multidirection) separately. Fear of falling We assessed fear of falling by asking the single yes or no question ‘Are you afraid of falling?’, which has a high test–retest reliability (Reelick, van Iersel, Kessels, & Rikkert, 2009). This question was asked at the preand post-intervention. The test–retest reliability using the Kappa coefficient was 0.960.

Secondary outcome measures All participants underwent nine measurements upon entry into the study (pre-test), which included: body

weight, height, 10-m walk under a single-task (ST) condition (ST walking; Lopopolo, Greco, Sullivan, Craik, & Mangione, 2006), 10-m walk under a cognitive-task condition (CT walking; Beauchet et al., 2007), 10-m walk under a manual-task condition (MT walking), timed up and go (TUG) test (Podsiadlo & Richardson, 1991), and functional reach (FR; Duncan, Studenski, Chandler, & Prescott, 1992). In CT walking, participants walked 15 m at an individually comfortable speed while counting numbers aloud in reverse order starting at 50. In MT walking, participants walked 15 m at an individually comfortable speed while carrying a ball (7 cm in diameter, 150 g in weight) on a tray (17 cm in diameter, 50 g in weight). The ST gait speed was subtracted from the CT (MT) gait speed to represent CT (MT) cost as a percentage, which was then further divided by the ST gait speed to produce a percentage change in performance with the addition of a second task. A physiotherapist blinded to the group


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M. Yamada et al. Assessed for Eligibility (four units) Individuals, n =62 Excluded (n =5) • Four did not meet inclusion criteria

One refused to participate

Four units randomized Eligibility, n =57

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Rhythmic stepping exercise group (n =27)

Non-rhythmic stepping exercise group (n =30)

Withdrew n =2

Withdrew n =3

25 in analysis

27 in analysis

Figure 2. Flow chart showing the dispositions of participants throughout the trial.

allocations administered these measures at baseline and upon completion of the 24-week intervention.

Statistical analysis We designed the effect size of this study to detect 0.8. With a significance level of 0.05, a power of 80%, and a large effect size (0.8), 26 participants were needed in both the intervention and control groups. Accounting for a potential 10% attrition rate, a total of 58 participants were targeted for this study, which was large enough to detect statistically significant differences. We first compared baseline characteristics between the RSE and NRSE groups to examine comparability between the two groups. Differences in the data of physical function variables between the RSE and NRSE groups were analyzed by the Student’s t-test or chi-squared test. The Kolmogorov–Smirnov and Mann–Whitney U-tests were used to test the normality of distributions and differences in physical function variables between the groups, respectively. We analyzed the effect of exercise on outcome measurements using a mixed 2 (group: RSE and NRSE groups)  2 (time: pre-intervention, post-intervention) ANOVA. Tukey’s post hoc tests were used to assess which group or time periods showed significant differences. Relative risk was then calculated, and the chi-squared test was used to evaluate the effect of intervention on fear of falling. Data were entered and analyzed using the Statistical Package for Social Science (Windows Version 18). p 5 0.05 was considered statistically significant for all analyses.

Results We enrolled 57 of the 62 screened individuals (91.9%) who were eligible for this study (Figure 2). Of those who did not meet the inclusion criteria (n ¼ 4), most were excluded because they had exercised regularly during the six months prior to screening. Three people who were eligible for the study declined after the initial telephone screening. Of the 57 selected subjects, 52 (91.2%) completed the study protocols and returned for their exit interviews and final testing (mean age, 71.8  4.5 years; range, 65–79 years). All 24 of the scheduled intervention sessions were completed. The median relative compliance was 100% (25th–75th percentile, 95.8–100%) for the RSE group and 95.8% (91.6–100%) for the NRSE group. No health problems, including cardiovascular or musculoskeletal complications, occurred during the training sessions or testing. Minor problems observed in both groups included aching muscles after initial training sessions and fatigue; however, all problems were easily managed through adjustments of the intervention, and subsequently improved during intervention.

Baseline characteristics The RSE and NRSE groups were comparable and well-matched with regard to their baseline characteristics (Table 1).

Effect of the exercise program on secondary outcome measures Pre- and post-intervention group statistics and group time interactions are summarized in Table 2.


Aging & Mental Health Table 1. Baseline characteristics of study participants by randomized RSE and NRSE groups.

Characteristic Age (y) Body weight (kg) Height (cm) Gender, female, n (%) Walking aids, n (%)a Falls in the last year, n (%)b RDST (point)

RSE (n ¼ 25)

NRSE (n ¼ 27)

70.8  4.6 50.1  4.8 152.1  4.2 20 (80.0%) 0 (0%) 7 (28.0%)

72.8  4.3 54.4  8.1 154.8  9.6 20 (74.1%) 0 (0%) 8 (29.6%)

0.571

9.8  1.7

9.6  2.0

0.270

p 0.120 0.068 0.157 0.431

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Notes: RSE, rhythmic stepping exercise; NRSE, nonrhythmic stepping exercise; RDST, rapid dementia screening test; and values represent the mean  standard deviation. a Number (percentage) of participants who used walking aids b number (percentage) of participants who experienced one or more falls in the last year.

Participants in the RSE group had significantly greater improvements in outcome measures including ST 10-m walking time, CT 10-m walking time, CT cost, MT 10-m walking time, and TUG (p 5 0.05).

Effect of the exercise program on fear of falling In the pre-intervention period, fear of falling was 44.0% and 37.0% for the RSE and NRSE groups, respectively. The relative risk was calculated as 0.842 (95% CI: 0.434–1.631) for fear of falling for participants in the NRSE group compared with patients in the RSE group (p ¼ 0.778). In the post-intervention phase, fear of falling had reduced to 16.0% for the RSE group and had slightly increased to 44.4% for the NRSE group. Relative risk was calculated as 2.778 (95% CI: 1.030–7.492) for fear of falling for participants in the NRSE group compared with patients in the RSE group (p ¼ 0.037).

Discussion The RSE under cognitive condition program requires the use of multiple domains, such as reaction, shortterm memory, and stepping to multi-directions, that when impaired, have been shown to increase fall risk among elderly individuals (Dite & Temple, 2002; Melzer, Kurz, Shahar, Levi, & Oddsson, 2007; Sturnieks, George, Fitzpatrick, & Lord, 2008; Yamada & Ichihashi, 2010). Our cluster-randomized controlled trial demonstrated that RSE, which represents a novel exercise program, was more effective than simple reaction stepping exercise for improving ambulatory function under ST and DT conditions in older adults. Furthermore, perceived fear of falling was significantly improved in the RSE group upon completion of the 24-week exercise program. The RSE program is postulated to have effects on ambulatory

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function under ST and DT conditions that might directly affect fear of falling. In this study, significant improvements in walking ability under CT and MT conditions following the RSE program were identified. These results indicate the importance of instructions when step training under complex-task conditions, and also suggest that effectively improving these functions leads to decreased fear of falling. The RSE program requires simultaneous cognitive and motor functions, and therefore represents training under DT conditions. Previous research on cognitive–sensory–motor DT situations has shown that older participants have reduced DTrelated performance compared to young adults, and tend to focus their attention more strongly on the sensory–motor task when presented with two demanding tasks (Rapp, Krampe, & Baltes, 2006). Another explanation for the observed improvements in the RSE group might be that traditional exercise regimens emphasize balance training under ST conditions, and therefore only improve functions for ST conditions. This speculation is supported by a study of Silsupadol, Siu, Shumway-Cook and Woollacott (2006), who found that the elderly can improve their balance under DT conditions, but only following DT balance training. Taken together, these findings suggest that explicit instructions which serve to focus attention should be provided during balance training under complex-task conditions. It is important to note that walking ability improved under both CT and MT conditions despite using a CT during exercise, such as verbal fluency. This result suggests that the elderly are able to improve their walking performance under DT conditions only after specific types of training. Improvement in DT walking may therefore be the result of automatization of an individual task and the development of task coordination skills. As the participants in the RSE group improved in the multiple tasks through the course of the study period, they may have learned to efficiently coordinate performances between the multiple tasks, leading to improved walking ability. These results indicate the importance of instructions when training under multiple-task conditions, as participants may learn to allocate their limited attention between motor and CTs during RSE. Improvements in division of attention may then positively impact DT walking ability. This study demonstrated that our devised RSE program promotes training across different DT modalities (cognitive and manual), leading to improvements in divided attention. In addition to the beneficial results identified in this study, RSE could potentially be used as a means of public health promotion as it has a number of advantages over conventional exercise programs. First, it is possible for fewer staff members to simultaneously supervise several older adults because the RSE training can be performed within a small indoor space. Second, outdoor walkers can substitute walking with RSE during periods of inclement weather.


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M. Yamada et al. Table 2. Functional fitness items by group at pre- and post-intervention.

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Item

Pre-intervention

ST 10-m walking time (sec) RSE 7.65  0.71 NRSE 7.61  1.27 CT 10-m walking time (sec) RSE 10.01  3.76 NRSE 10.41  3.82 CT cost (%) RSE 21.14  25.76 NRSE 25.63  31.41 MT 10-m walking time (sec) RSE 8.69  1.64 NRSE 9.17  1.82 MT cost (%) RSE 11.21  19.17 NRSE 17.74  18.64 TUG (sec) RSE 7.57  1.38 NRSE 7.85  1.78 FR (cm) RSE 26.18  3.74 NRSE 28.69  4.37

Post-intervention

F-value Time effect Group  Time

6.90  0.34a 7.73  0.95a

3.75 7.26*

7.47  0.51a 10.52  1.28a

4.54* 5.32*

7.86  3.37a 30.34  15.87a

1.29 5.71*

6.79  0.45a 8.90  2.08a

9.56** 5.45*

2.08  7.15a 12.50  17.80a

7.54** 1.43

6.43  0.61a 7.85  1.36a

4.28* 4.31*

33.29  10.04 33.37  6.49

21.11** 0.89

Notes: Columns indicating pre– and post–intervention values are expressed as mean  standard deviation. As calculated by group comparison. **p 5 0.01; *p 5 0.05.

a

Third, the RSE program requires limited materials and can be implemented with minimal cost. Increasing the number of feasible exercise options for elderly individuals is considered important for health promotion. In this context, the RSE program presented in this study represents a promising new form of exercise for older adults. There are several limitations of this study that warrant mention. First, no follow-up was conducted. Second, these findings should be considered as preliminary because of the relatively small sample size (n ¼ 57). Third, statistical analyses were performed for each of the nine outcome measures separately, including the physical performance tests, which increased the possibility of false-positive findings (type 1 error). Finally, as indicated by their willingness to participate in this study, participants in both groups may have had higher motivation and interest in health issues and fall risk than the general elderly population.

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Prevention falls  

Articulo sobre el uso de la actividad fisica y la prevencion de caidas

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