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ORIGINAL ARTICLE
886
887
Randomized
(15 long-term care residences)
FW (7 residences)
130 participants:
80 allocated to intervention group
50 allocated to control group
IB (8 residences)
148 participants:
94 allocated to intervention group
54 allocated to control group
Excluded from A1
2 in intervention group
1 in control group
Included in A1
64 (80%) in intervention group
43 (86%) in control group
Excluded from A2
12 in intervention group
3 in control group
Included in A2
54 (68%) in intervention group
41 (82%) in control group
Excluded from A1
2 in intervention group
1 in control group
Included in A1
78 (83%) in intervention group
47 (87%) in control group
Excluded from A2
10 in intervention group
5 in control group
Included in A2
70 (75%) in intervention group
43 (80%) in control group
Fig 1. Flowchart of the participants who were entered in the analyses of the fall data (A1) and the analyses of physical functioning and
disability measures (A2).
general, would you say your health is: excellent, very good,
good, fair, or poor? Cognitive status was assessed using the
Mini-Mental State Examination (MMSE).25 The physical functioning and vitality subscales of the SF-36 were scored.24 The
physical functioning subscale consists of 10 functional items. It
measures to what extent health status has limited the ability to
carry out the items in the previous 4 weeks. The vitality subscale
consists of 4 questions referring to the previous 4 weeks, covering
feelings of being worn-out, tired, and energetic.
Frailty indicators. The 5 frailty indicators were adapted
from the ones described by Fried et al10:
Unintentional weight loss. Weight loss could not be calculated as body weight was only assessed at baseline. As an
alternative, BMI of less than 18.5kg/m2 was used as the
criterion for this indicator.12
Weakness. Instead of operationalizing weakness by means of
grip strength, the SF-36 physical functioning score with a
cutoff score of 75 points was used.11
Exhaustion. Exhaustion was deemed present when the SF-36
vitality scale score was less than 55 points.11
Slowness. Slowness was assessed by means of walking
speed using sex- and height-corrected cutoff scores.10
Arch Phys Med Rehabil Vol 87, July 2006
888
889
890
FW (n66)
IB (n80)
Control (n92)
Age (y)
Sex (% women)
BMI (kg/m2)
MMSE (range, 030)
Living situation (% living alone)
Education level (% only primary school)
Alcohol consumption
None
17 glasses weekly
7 glasses weekly
Medication
No. 4 per day (% yes)
Incontinence (% yes)
History of stroke (% yes)
Self-reported dizziness (% often)
Self-reported visual impairment (% yes)
Pain (% severe)
General health perception
Poor
Fair
Good
Very good
Excellent
Use of a walking aid
% yes, indoors
% yes, outdoors
Physical activity (min/d)
SF-36
Physical functioning (range, 0100)
Vitality (range, 0100)
85.45.9
53 (80.3)
27.45.1
25.04.1
58 (87.9)
27 (40.9)
84.46.4
61 (76.3)
29.05.4
25.04.0
67 (83.8)
31 (38.8)
84.95.9
74 (80.4)
27.44.9
25.13.7
83 (90.2)
41 (45.1)
31 (54.4)
10 (17.5)
16 (28.1)
5.32.8
44 (73.3)
14 (25.0)
15 (27.3)
10 (15.2)
17 (25.8)
11 (16.7)
39 (54.9)
17 (23.9)
15 (21.1)
4.93.0
47 (63.5)
27 (36.5)
18 (24.7)
9 (11.4)
17 (21.3)
14 (17.5)
45 (55.6)
17 (21.0)
19 (23.5)
5.13.1
57 (63.3)
27 (30.3)
17 (19.3)
11 (12.0)
19 (20.7)
14 (15.4)
1 (1.5)
24 (36.4)
28 (42.4)
9 (13.6)
4 (6.1)
2 (2.5)
25 (31.3)
35 (43.8)
13 (16.3)
5 (6.3)
0 (0.0)
35 (38.0)
39 (42.4)
13 (14.1)
5 (5.4)
51 (77.3)
61 (92.4)
6452
61 (76.3)
68 (85.0)
5950
63 (68.5)
79 (85.9)
6746
45.623.7
55.321.8
36.825.1
53.219.5
44.227.8
54.620.5
graphic and clinical characteristics for each group of participants are presented in tables 1 and 2. No significant differences
between the 3 groups with regard to these characteristics were
found.
Preintervention scores SD for the secondary outcome
measures are presented in table 3. The average POMA score
was 19.75.1. None of the participants scored 0 points on
the physical performance score, whereas 14 (6.7%) scored
the maximum of 16 points. Twenty-two (10.6%) participants
scored less than 4 points on the physical performance scale,
Frailty indicator
Low BMI (% yes)
Exhaustion (% yes)
Physical inactivity (% yes)
Slow walking speed (% yes)
Weakness (% yes)
Frailty phenotype
Not frail
Pre-frail
Frail
FW
(n66)
IB
(n80)
Control
(n92)
0 (0.0)
34 (52.3)
42 (62.6)
29 (44.6)
57 (86.4)
0 (0.0)
39 (48.8)
41 (63.8)
35 (43.8)
72 (90.0)
1 (1.1)
40 (44.4)
48 (52.7)
39 (43.3)
75 (83.3)
4 (6.2)
25 (38.5)
36 (55.4)
4 (5.0)
33 (41.3)
43 (53.8)
7 (7.8)
47 (52.2)
36 (40.0)
891
Table 3: Results for the POMA, Physical Performance Scale (PPS), and GARS: The Confounder-Adjusted Effects of the Interventions,
Calculated in Multilevel Linear Regression Models, per Intervention Relative to the Control Group and Adjusted for Baseline Values
Group
FW (n54)
Pre
Post
IB (n70)
Pre
Post
EX (n124)
Pre
Post
Control (n84)
Pre
Post
Intervention effects
EX vs control: FW vs control
IB vs control
EX vs control
FW vs IB (P value)
Frailty EM (P value)
Intervention effects
EX vs control: Frail subgroup
EX vs control: Pre-frail subgroup
20.24.5
22.14.9
9.44.2
9.84.5
40.613.4
40.012.9
19.24.9
21.25.0
8.23.8
8.34.1
44.312.0
44.112.2
19.74.7
21.64.9
8.74.0
9.04.3
42.712.7
42.312.6
19.85.6
20.35.8
8.74.6
8.74.7
40.313.7
41.414.8
NS
NS
NOTE. Values are pre- and postintervention group mean SD and effects (95% CI). For POMA and PPS, higher scores indicate a better
performance; for GARS, lower scores indicate a better performance.
Abbreviations: EM, effect modification; EX, exercise; NS, not significant.
*P.05.
P.01.
0.6
IB (n78)
Control (n90)
24 (37.5)
9 (14.1)
10 (15.6)
5 (7.8)
16 (25.0)
40 (62.5)
499
3.35.6
1.92.2
33 (42.3)
20 (25.6)
8 (10.3)
8 (10.3)
9 (11.5)
45 (57.7)
4514
2.44.6
2.03.6
42 (46.7)
18 (20.0)
10 (11.1)
3 (3.3)
17 (18.9)
48 (53.3)
4811
2.54.6
1.62.2
0.5
Proportion of Fallers
Outcome
No. of falls
0
1
2
3
4
No. of fallers
No. of follow-up weeks
Fall incidence rate*
Recoded
0.4
0.3
0.2
0.1
0.0
12
16
20
24
28
32
36
40
44
48
52
Follow-Up (wk)
892
FW
IB
Exercise
Frail subgroup
Total period
Pre-frail subgroup
Total period (wk)
12
12
Intervention Effect
1.59 (1.042.44)*
1.09 (0.721.64)
1.36 (0.941.96)
2.95 (1.645.32)
0.62 (0.291.33)
1.18 (0.552.54)
0.39 (0.180.88)*
P.001.
893
894
Pelvis exercises
1. Forward and backward rotation of the pelvis while sitting, without leaning against the back of the chair. Focus
on the activating impulse from the buttocks, more specific the tuber ischiadicum.
2. Lifting the left and right buttock alternating while sitting
and pushing the buttock into the chair.
3. Making clockwise and counterclockwise circles on the
ischia by pelvic rotation.
4. Walking back and forth on the buttocks while sitting on
a chair by lifting the left and right buttock alternating.
5. Forward and backward rotation of the pelvis while standing with the knees slightly bended, emphasizing a relaxed execution.
For all exercises: 5 repetitions. For exercise 1 4: the impulses of the movement are generated by the tuber ischiadicum.
This causes a powerful and effortless execution.
Foot and ankle exercises, sitting on a chair
1. Moving the toes, including spreading out and grasping,
first for each foot separately and later with both feet
simultaneously.
2. Making circles with the forefoot by ankle rotation, while
keeping the heel on the floor (5 repetitions to the left and
5 to the right).
3. Pro- and supination of both feet simultaneously while
sitting and standing holding a chair (5 repetitions to both
sides).
4. Circling movement with the foot: touch the heel on the
floor, then go further to the outside of the foot touching
the floor, then the toes, lifting the heel and at the end the
inside of the foot touching the floor. Repeat this circlelike movement 5 times. Do the same with the other foot,
both feet simultaneously and in standing position with
support of a chair.
For all exercises: movements are made slowly and as big as
possible, feeling the stretch.
Leg strengthening
1. Pushing the heel firm in the ground while sitting and
hold this position for 6 9 seconds, then relax (8 repetitions for both legs separately).
2. Front knee strengthening while sitting in a chair and
lifting the leg straight for 8 seconds (8 repetitions).
3. Knee bending while standing with the feet shoulder
width apart (8 repetitions).
4. Lowering the weight in 1 foot bending the knee and
simultaneously stretching out the other leg to the front,
touching the heel on the floor.
5. Standing with both feet more than shoulder-width apart
and then bending the knees and lowering the trunk and
coming back up (5 repetitions).
Balance exercises
1. Rubbing firmly ones legs and ankles with the hands.
2. Walking over bags filled with beans, pasta, or chestnuts,
while sitting.
3. Standing with the feet shoulder width apart and trying to
relax the back, supported with relaxed breathing. Lumbar back relaxation by slightly lowering the os coccygis
reaching to the floor.
4. Standing with the feet shoulder width apart and making
a slow and easy swinging movement bringing body
weight alternately to the left and right limb. The movement starts with lowering the weight slightly to 1 leg
895
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