Dual Task Exercise: Outcome on Gait and Balance of Elders

 

Mrs. Stalin Shiny V¹, Mrs. Sheeba Chellappan²

¹Post Graduate Student, Christian College of Nursing, Neyyoor and Post, Kanyakumari Dist, Tamilnadu

²Associate Professor, Christian College of Nursing, Neyyoor and Post, Kanyakumari Dist, Tamilnadu.

(Published work is a part of the Tamilnadu Dr. MGR Medical University, Chennai)

 

ABSTRACT:

Introduction: Gait and balance disorders are common in older adults and are a major cause of falls in this population. Dual task exercise is most important for elderly with balance and gait patterns problem. It improves the strength and tone of the muscles and controls the knee and helps to stabilize and protect knee joint. Dual task exercise helps to improve cognitive function, standing and walking. The aim of the study is to assess effect of dual task exercises on balance and gait pattern of elderly in selected old age homes at Kanyakumari district.
Methods: A quantitative approach with pre-experimental one group pre-test- post-test design was used to assess the effect of dual task exercises on balance and gait pattern of elderly.  Thirty elderly who fulfilled inclusion criteria were selected by non probability purposive sampling technique. Pre-test was done using Berg Balance Scale and Functional Gait Assessment Scale. Then Dual task exercises were administered individually twice in a week for 4 weeks. Post-test was done using same scale on 5^th week. Results: At pre-test, 86.7% of subjects had high fall risk and 13.3% had medium fall risk. At post-test, cent percent of subjects had low fall risk. During pre-test, 40% of them had moderate impairment and 60% of them had mild impairment. In post-test, 80% had mild impairment and 20% had normal ambulation. The Berg Balance Score (BBS) at pre-test was 17.9±2.5 and at post-test was 52.4±2.3. The improvement was 34.5± 3.6 and it was statistically highly significant (P<0.001). The Functional Gait Assessment Score (FGAS) at pre-test was 12.0±3.3 and the post-test mean was 28.4±2.2. The improvements from pre-test to post-test was 16.4±4.3 and it was highly significant (P<0.001). Hence research hypothesis (H1) was accepted. Discussion: The dual task training program was effective in improving balance and gait pattern of elderly. It is the responsibility of the nursing personnel to train elders in performing dual task exercise which helps to improve their balance and gait. This in turn reduces the risk of falling.

 

 

 

 

INTRODUCTION:

“The strength of the elderly is in the ears and on the lips”

Old age refers to ages nearing or surpassing the life expectancy of human beings. The other terms used are old age people, seniors, senior citizens, older adults, the elderly and elders. Old people often have limited regenerative abilities and sickness than younger adults. The organic process of aging is called senescence.

 

The medical study of the aging process is called gerontology and the study of disease that affects the elderly is called geriatrics. The elderly also face other social issues around retirement include loneliness and ageism. The old age is not a definite biological stage, as the chronological age. Old age varies culturally and historically. As per maintenance and welfare of parents and senior citizens act 2007 of the United Nations,  elderly are the person who is of age 60 years or above. According to population censes 2011, there were nearly 104 million elderly persons living in India. International day of elderly people celebrated at Sunday of October 1^st week highlights the important contributions that the older people make to society and raise awareness of the issues and challenges of  aging in today’s world.¹

 

These people are usually retired from work and spend their time in other ways like taking care of small children. The reason for this is that body is slowly deteriorating, so they have more problems especially with moving. Gait and balance disorders are common in older adults and are a major cause of falls in this population. A balance disorder is a disturbance that causes an individual to feel unsteady while standing or walking. It may be accompanied by feeling of giddiness or wooziness or having a sensation of movement, spinning or floating. About one third of the older population reports difficulty with balance and walking and the number increase significantly after the age of 75 years. Men and women are affected equally.^2,3

 

Decline in gait speed appears as one of the most consistent age associated changes. Slow walking of older adults was related to fear of fall, muscle weakness and impairment of motor control.⁴ Kitazawa has suggested that aerobics or strengthening exercises may be challenging for older adults. Therefore it is necessary to consider the type and level of physical activities suited for them to improve their cognitive and gait function. Regular exercises help to improve the flexibility of the body and improve the strength of the muscles and joints. Exercises can give energy to sleep better, make bones and muscles stronger and prevent from the balance and gait problem. Gait or balance impairment increases with age. Community dwelling older adults of age 70 years and older had a prevalence of gait disorders of 35%.⁵

 

NEED FOR THE STUDY:

Walking is a common activity of daily living and at the same time, it is very complex. It involves all levels of the nervous system and many parts of the musculo-skeletal system. A person’s gait pattern is strongly influenced by age, personality and mood. The prevalence of gait and balance disorders markedly increase with age around 10% between the ages of 60 and 69 years to more than 60% in those above 80 years.⁶

 

Gait impairment may greatly affect the quality of life and restrict the personal independence of those affected. More over balance and gait problem may be precursors of falls which are the most common cause of severe injuries in the elderly. Walking is a sensitive indicator of overall health status and the self-walking speed closely correlates with individual life expectancy in elderly persons. Nevertheless, gait disorders and falls are largely under diagnosed and often receive inadequate evaluation. The causes of gait disorders include neurological conditions (e.g. stroke and Parkinson’s disease) and medical condition (e.g. heart failure, respiratory insufficiency, peripheral arterial occlusive disease and obesity).⁷

 

Almost one third of all persons over the age of 65 years fall every year, among them more than half fall more than once. Approximately 10-15% of these falls lead to serious injuries such as traumatic brain injury and hip fractures. It has been estimated that fall injuries are the fifth most common causes of death in elderly persons.^7,8,9

 

Dual task exercise is most important for elderly with balance and gait pattern problem. It improves the strength and tones of the muscles and controls the knee and helps to stabilize and protect knee joint. Dual task exercise helps to improve cognitive function, standing and walking.^9,10,11 From experience it was noticed that the balance and gait problems are common in elders. But there is only limited studies related to dual task exercise. Literature shows that dual task exercises are effective in treating problems with gait pattern. So the investigator planned to conduct a study to assess the effectiveness of dual task exercise on improving balance and gait pattern among elderly.

 

AIM OF THE STUDY:

The aim of the study is to assess effect of dual task exercises on balance and gait pattern of elderly in selected old age homes at Kanyakumari district.

 

OBJECTIVES OF THE STUDY:

1.       To assess the pre-test and post-test level of balance and gait pattern among elderly.

2.       To compare the pre-test and post-test level of balance and gait pattern among elderly.

3.       To associate selected demographic variables with pre-test level of balance and gait pattern among elderly.

 

HYPOTHESES:

H1:  There will be significant difference between the pre-test and post-test level of balance and gait pattern among elderly.

H2:  There will be significant association between selected demographic variables with pre-test level of balance and gait pattern among elderly.

OPERATIONAL DEFINITION:

Effect:

Effect in this study refers to the expected outcome of dual task exercises on improving balance and gait pattern of elderly (Mean difference between the pre-test and post-test level of balance and gait pattern) which was measured used Berg Balance Scale and Functional Gait Assessment Scale respectively.

 

Dual task Exercise:

Dual task is defined as the ability to perform two or more cognitive and motor activities simultaneously while maintaining postural control. In this study dual task exercise refers to the activities which were taught to the elderly to improve their gait and balance including walking, counting the numbers while forward walking, counting the numbers while backward walking, walking between obstacles and figure of eight walking.

 

Balance:

Balance is the steadiness, stability and equilibrium. In this study, balance refers to the ability of the elderly to maintain stable position without falling which was assessed by Berg Balance Scale.

 

Gait pattern:

It is the pattern of walking or moving on foot. In this study gait refers to the pattern of walking which was assessed by Functional Gait Assessment Scale.

 

METHODOLOGY:

Research approach:

A quantitative approach was adapted to assess the effect of dual task exercises among elderly.

 

Research Design:

In this study, pre-experimental one group pre-test- post-test design was used.

 

Setting of the study:

The study was conducted at DM convent old age home, Pilankalai in Kanyakumari district and DM convent old age home at Matthar in Kanyakumari district. Both are governed by Roman Catholic Diocese, Kottar.  The total number of inmates in DM convent old age home, Pilankalai was 63. The total number of inmates in DM convent old age home at Matthar was 30.

 

Variables under study:

Independent variable:

In this study, the independent variable was the dual task exercises.

 

Dependent variables:

In this study, the dependent variables were the balance and gait of elderly.

 

Extraneous variables:

In this study, the extraneous variables include age, sex, income, religion, education, marital status, previous occupation, exercise pattern and health information medias, which would influence the dependent variables.

 

Population:

In this study, the population included all the people aged above 60years residing in DM convent old age homes at Pilankalai and Matthar in Kanyakumari district.

 

Sample:

In the present study, the sample included 30 elderly persons between the age of 60 and 80 years, who had mild to moderate balance and gait problem.

 

Sampling technique:

In order to achieve the objectives of the study, the investigator adopted non probability sampling method with purposive sampling technique to select the sample. A total of thirty elderly (20 samples from DM convent old age home, Pilankalai and 10 from DM convent old age home, Matthar) were selected.

 

Criteria for sample selection:

Inclusion criteria:

Elderly people those who

·       Were staying in old age home.

·       Had mild to moderate gait and balance problem.

·       Could speak in Tamil.

·       Were willing to participate in the study.

 

Exclusion criteria:

Elderly people who

·       Had severe gait problem.

·       Not able to follow instruction.

·       Was on treatment for any other medical conditions such as myocardial infarction, cerebro-vascular accident.

 

Description of tool:

Section A:

Demographic data consisted of age, sex, education, previous occupation, marital status, religion, income, exercise pattern and their health status.

 

Section B:

The Berg Balance Scale was used to assess the balance which consisted of 14 items. Each item was scored from 0 to 4. The minimum attainable score was 0 and maximum score was 56. High score indicated low risk of fall.

 

The total score was interpreted as follows.   

0-20    : High fall risk

21-40  : Medium fall risk

41-56  : low fall risk

 

Section C:

The gait was assessed using Functional Gait Assessment Scale. The scale consisted of 10 items. Each item was scored from 0 to 3. The minimum attainable score was 0 and maximum score was 30. High score indicated normal gait. The total score was interpreted as follows:

0-9          : Severe impairment

10 -19    : Moderate impairment

20- 29    : Mild impairment

30           : Normal

 

Data collection procedure:

The study was conducted for 6 weeks. The study was conducted at DM Convent Old age Home at Pilankalai and DM Convent Old age Home at Matthar. After getting formal permission from the Director of the old age homes, data were gathered. Each day the researcher interviewed about 3-4 elderly people based on the inclusion criteria. The interview lasted for 30-40 minutes for a sample. The data was collected in three phases.

 

Phase I:

The investigator introduced herself and developed rapport with the elderly. After explaining the purpose of the study, the investigator obtained oral consent from elderly people. The demographic variables of the elderly were collected by face to face interview using structured questionnaires. The gait and balance of elderly were assessed using Berg Balance Scale and Functional Gait Assessment Scale.

 

Phase II:

Dual task exercises were administered to individually twice in a week for 4 weeks.  There were 4 session of training. Each session lasted for 30minutes.

I Session	-	Number counting while forward walking
II Session	-	Number counting while backward walking
III Session	-	Walking between obstacles
IV session	-	Figure of Eight Walking,

 

After teaching to the elderly, they were allowed to practice under the supervision of the investigator for 4 weeks.

 

Phase III:

Post-test was done on 5^th week of data collection using Berg balance Scale and Functional Gait Assessment Scale.

 

Plan for Data analysis:

The data analysis was analyzed according to the objectives and hypotheses of the study by using descriptive and inferential statistics.

 

Ethical consideration:

·         The study was conducted after the approval of the dissertation committee of Christian College of Nursing, Neyyoor. 

·         Formal permission was obtained to conduct the study from the Director of the old age home at Pilankalai and Matthar.

·         Oral consent was obtained from the elderly after explaining the purpose of the study.

RESULTS:

Participants’ Characteristics:

Among 30 elderly included in the study, the maximum of (43.3%) were in the age bracket of 60-64 years. The male and females were 60% and 40%. In respect of their educational status, 96.7% of them had studied in the school level. Maximum of 63.3% of them had worked in the private sector. In respect of religion, 66.7% were Christians. Cent percent of the subjects had income <5000 per month. The information sources of them were TV (63.3%) and paper (36.7%). Regarding the marital status, 86.7% were married and the remaining 13.3% were unmarried. Majority (90%) of the subjects had exercise pattern as none.   

 

Based on Berg Balance Score:

At pre-test, 86.7% of subjects had high fall risk and 13.3% had medium fall risk. At post-test, cent percent of subjects had low fall risk (Fig 1).

 

 

Figure 1 Distribution of elderly according to Berg Balance Score

 

Based on Gait Score:

During pre-test, 40% of them had moderate impairment and 60% of them had mild impairment. In post-test, 80% had mild impairment and 20% had normal ambulation (Fig 2).

 

Figure 2: Distribution of elderly according to Functional Gait Assessment score

Table-1: Effectiveness of dual task exercise on improving balance and gait pattern                                   N=30

 

Effectiveness of the Dual Task Exercise program:

The Berg Balance Score (BBS) at pre-test was 17.9±2.5 and at post-test was 52.4±2.3. The improvement was 34.5± 3.6 and it was statistically highly significant (P<0.001). The Functional Gait Assessment Score (FGAS) at pre-test was 12.0±3.3 and the post-test mean was 28.4±2.2. The improvements from pre-test to post-test was 16.4±4.3 and it was highly significant (P<0.001). Hence research hypothesis (H1) was accepted (Table1).

 

Association between demographic variables with Berg Balance Score:

There was no association between age, gender, education, occupation, marital status, religion and information sources with Berg Balance Score. There was no association between age, gender, education, occupation, marital status, religion, exercise pattern and information sources with functional gait assessment score.

 

DISCUSSION:

The study showed that among 30 elderly, majority (43.3%) were in the age between 60 and 64 years. About 60% of them were male and 96.7% of them had school education. Regarding previous occupation 63.3% of them were coolies and 66.7% of them belonged to Christian by religion. Almost 66.3 % of them were getting information through TV and 36.7% through paper. Regarding the marital status 86.7% were married. These study finding were supported by the study done by other researchers who described that the elderly were between the age group of 65 to 80 years.^1,2

 

At pre-test, 86.7% of subjects had high fall risk and 13.3% had medium fall risk. At post-test, cent percent of subjects had low fall risk. During pre-test, 40% of them had moderate impairment and 60% of them had mild impairment. In post-test, 80% had mild impairment and 20% had normal ambulation. The finding is in line with another study done by Silsupadal where the elderly who participated in dual task exercise improved significantly in all outcome measures. There was a significantly greater balance confidence fall risk and sensory integration.⁸

 

The pre-test mean Berg Balance Score was 17.9 ± 2.5 and the post-test score was 52.4 ± 2.3 with’ t’value 53.227 (p< .001). The mean gait pre-test score was 12.0 ± 3.3 and post- test score was 28.4 ± 2 with ‘t’ value 20.756 (p< .001). The finding is supported by the study done by Shin S which described that KMMSE score of 25.4 ± 97 the fall index value of the NDBT group was significantly better than the STB group. The study revealed that motor dual task balance training improved balance and walking ability.⁹

 

CONCLUSION:

These results support that, the dual task training program was effective in improving balance and gait pattern of elderly. So the research hypothesis was accepted and concluded that the dual task exercise was effective in improving gait and balance of elderly.

LIMITATION OF THE STUDY:

·       Sample size was only 30.

·       Data collection was only six weeks.

 

REFERENCES:

1.      Ministry of Statistic and Programme Implementation, Elderly in India- Profile and Programme.2016. Available in URL: http://mospi.nic.in/sites/default/files/publication_reports/ElderlyinIndia_2016.pdf

2.      Liebherr et al, Dual –tasking and aging –About multiple perspectives and possible implementations in interventions for the elderly, Journal of cogent psychology, 2016.

3.      Gregory, M.C. Dual-task gait training and aerobic exercise training improves cognition in older adults, Current sports medicine reports, 2013. 12:256-271.

4.      Yang Y.R, Dual task exercise improves Walking ability in chronic stroke, Journal of stroke research and treatment, 2007.538-602.

5.      Liu Y.C, Cognitive and Motor dual task gait performance after stroke, A functional near-infrared spectroscopy study, 2015. 10 (12).

6.      Plummer.S, Effects of physical exercise interventions on gait related dual task interference, Journal of Achieve of physical medicine rehabilitation. 2014.88. 1236-1240.

7.      Shin.S.S, The effect of motor Dual task balances training on balance and gait, Journal of physical therapy science. 2014. 269-281.

8.      Hiyamizu.M, Does a multi component exercise program improve dual task, Clinical rehabilitation.2012. 26, 58-67.

9.      Silsupadol.P. The effect of motor dual task balance training program regarding balance and gait for people with stroke, Journal of physical therapy.2006.86, 269-281.

10.   Whitney SL. Effect of physical –cognitive Dual task training on executive function and gait performance in older adults, American journal of occupational therapy, and 1998.52,666-671.

11.   Trait J.L. Influence of Sequential vs. Simultaneous Dual task exercise, Journal of frontiers in aging neuroscience. 2017. 9.368.

 

 

 

Received on 25.01.2019         Modified on 18.02.2019

Accepted on 06.03.2019      ©A&V Publications All right reserved