Randomized Controlled Trial

Critical Appraisal about RCT

There are few studies which have been developed in regard to the balance training aimed at the improvement of the elderly persons' mobility and wellbeing who are affected by balance problems. The article presents a study which demonstrates a program on training on balance improvement spanning for a period of six weeks. The program proved to be quite beneficial in the progress of functional balance and static mobility and lowering the older persons' fall frequencies (basically those having problems with balance). In the study, the progress based on the objective of functional balance was established by the improvement in the score of BBS as recorded in the ultimate appraisal for the cluster handed over to the team of interventionists. The same outcomes were recorded in the research done by Melzer et al. whereby the balance training program patient participants recorded a progress of 64 percent within a period of three months. The authors of this article demonstrated that the cluster which undertook the balance training program showed an improved performance. Such programs which put emphasis on balance training are more effective in the improvement of balance than those which consisted of primary aerobics, strengthening of muscles and exercises aimed at improving flexibility. Even though evaluating the effectiveness of different exercise forms is a complex venture, results show that balance training has proved to be of much benefit with near zero probability of risks. In studies of the same kind by Carter et al. an improvement was recorded on static balance when using muscle strength instead of balance training, however, the improvement was only on 6.3 percent of the patients. Therefore, the methodology used in the article proposes that balance training eventually points to an apparent progressive outcome than it does in muscle strength training.

Relative to the functional mobility, there was an improvement which was demonstrated by a decline in the patients handed over to the intervention team. The relevance of these results are undoubted since from the research, compromised mobility led to an increase in the risk-dependency at an approximate of three to fivefold in the daily activities. This is not a surprise basing on the fact that unaided mobility is an essential daily life component processes of every individual. Mobility dependency may result in confinement and reduced quality of human wellbeing and existence. Having good balance and gait is considered essential for the mobility improvement and aids in preventing falls.

Alongside improvement in a functional evaluation, this methodology recorded an improvement based on the observed reduced fall frequency. Even though the impact of exercise in reducing the frequency of fall is not proved in this study, there are a number of studies which show that the risk can be reduced 40 percent through physical activity (Barnett et al., 2003). Similarly, in the accord to reduce the frequency of falls for the affected persons, the distinct form of exercises which are endorsed for the prevention of falls are the ones specifically target balance training. A number of studies showing balance and mobility improvement have presented results in their exercise which are similar to the current study. This is a suggestion that the exercise program's intensity and content possibly will be more significant than other variables in this intervention. Additionally, the variances in the adjudication of the exercise program, the specialized experiences of the participants of the program, the setting of the sessions and whether the exercises were carried out in a group setting or realized at an individual level are all the considerations which impact on the exercise program's success.

A very significant aspect of achievement illustrated in the study is the adherence to all the considerations as stated. In contrast with the study carried out by Forcan et al.'s statement that the adherence in the implementation program among the participating elderly persons is not sufficient. In this study, the methodology was effective as witnessed with almost half of the participants present at all the sessions of the program. This outcome as illustrated by the paper have similarities with other studies showing a 97percent measure of adherence. The attainment in adherence in this paper is possibly owed to the context where the sessions were carried out, from the social interaction to close relationship between the service providers and the patients - an environment which was pleasant for both the patients and the psychotherapists. Basically, the feeling of isolation was reduced by the secure environment, supervised sessions and the opportunity for close interactions. A system of social backing is deliberated as necessary in group exercises as well as helping in sustaining adherence and the efficacy of the program's sessions together with the adherence to the outdoor and indoor exercise programs. Robitaille et al. in a similar study illustrated that the exercise programs which were done in groups recorded improved performance in balance of the elderly.

Another important factor was the application of structured manual guidelines and instructions for the realization of the effectiveness of the indoor and outdoor exercises, which added up to the endurance and the adherence to the performed exercises. Each and every exercise session was under the prescription of a psychotherapist who additionally gave adequate support to the patient. In some studies similar to this, illustrated and descriptive pamphlets have been used to as a complement to home-based exercise programs which have had positive outcomes. The positive outcomes which are recorded in this study could also be associated with the state of health of the recruited persons who participated in the program. In this study, the participants were enrolled from the set of individuals at the multidisciplinary falls clinic who had the problems of concern to the study. All of them were put through a comprehensive medical assessment based on the consistent protocol where the potential factors for falls were put into concern. Among this were the neurological disorders, locomotor disorders, cardiovascular disorders and examination of any predisposing factor to falls. Inclusion was done if there was a continued balance problem subsequent to significant management of the probable predisposing factors, well-known as a Berg Balance Scale (BBS) score not exceeding forty-five. The amputees were also excluded in the study since this was a disability which could not be reversed through exercise. According to Buchner et al., exercises have beneficial impacts on the health of the elderly and on the risk of falls in some of this group of persons in the society.

The physical, as well as the psychological impacts recorded due to regularity in conducting the periods and the environmental setting, need not be undermined. The motivation and the demonstrated aptitude in transitions from one level to another, as a result, helps in maintaining interest during the performance of the exercises and safe practice in groups. Even though there was no use of the laboratory or biomedical equipment to validate the obtained effects, it is still able to prove this through reproducible and reliable tests and scales which are able to measure the success extents of all the trainings performed in every session under the supervision of the psychotherapists and complemented by the outdoor exercises. Furthermore, the reliability of the results is evidenced by the positive improvement of both the static and functional movement and balance, and lessening falls of the frequency in the affected persons. Moreover, ordinary clinical psychotherapists possessing equal experience and grade, who were under the guidance of a written protocol were responsible for the treatment of patients both in the CT and the EBT groups. These protocols clearly how the individual exercises in both the CT and EBT groups were performed. These protocols were in adherence to the national guidelines advocated for by the Chartered Society of Psychotherapists. In addition to the protocols, a comprehensive explanation and practical therapeutic demonstration were performed in order to orient the participating therapists on what ought to be done and the key contrasting elements between the two interventions.

In a similar case, this study was effective since it addresses both the physical and mental facets of remedying mobility and balance. For the treatment sessions which lasted for periods not exceeding forty-five minutes, there was a session dedicated for discussions on the behaviors and strategies which need to be used to avoid fall as well as those for dealing with a long time spent on the floor. The participants were also given instructions on how to get up from the floor after a fall. Even though the same therapists could offer both physical and psychological remedies, the effectiveness of the methodology was ensured by avoiding crossover effects which might have been caused by therapists' crossover.

Even though the reports of improvement are undoubted, the observations show that there needs to be an address on the important matters on the evaluation of the effectiveness of the interventions in diseases which are more chronic than the ones considered in the study. The first one is related to the appropriate selection of measures of outcome; what is more important to patients might be their increased confidence and wellbeing rather than the measures based on diseases, and doing so need to complement indicators on specific diseases such as speed in mobility or BBS in scientific perspective. More often than not, falls hardly ever end causing fatal injuries, rather, the victims lose confidence in themselves, reduce their mobility, because of depression and eventually leading to increased dependence. For this study, EBT recorded better results than CT thereby raising the question justifiability on whether to offer a different form of treatment based on the increased wellbeing and patient's confidence, even though there is lack of objective evidence to confirm the reliability of such interventions.

In conclusion, this study affirms that the exercise programs aimed at improving patient's balance and mobility are beneficial regardless of the applied strategy. Nonetheless, the reported stability, life's quality, increased mobility speed and increased confidence recorded a higher improvement in patients receiving EBT which a suggestion that the two approaches illustrated by the authors were significantly distinct in terms of their influence on the quality of life of the patient and confidence, therefore, more investigation needs to be done.

References

Barnett, A., Smith, B., Lord, S.R., Williams, M. and Baumand, A., 2003. Community based group exercise improves balance and reduces falls in at risk older people: a randomised controlled trial. Age and ageing, 32(4), pp.407-414.

Buchner, D.M., Cress, M.E., De Lateur, B.J., Esselman, P.C., Margherita, A.J., Price, R. and Wagner, E.H., 1997. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 52(4), pp.M218-M224.

Carter, N.D., Khan, K.M., McKay, H.A., Petit, M.A., Waterman, C., Heinonen, A., Janssen, P.A., Donaldson, M.G., Mallinson, A., Riddell, L. and Kruse, K., 2002. Community-based exercise program reduces risk factors for falls in 65-to 75-year-old women with osteoporosis: randomized controlled trial. Canadian Medical Association Journal, 167(9), pp.997-1004.

Forkan, R., Pumper, B., Smyth, N., Wirkkala, H., Ciol, M.A. and Shumway-Cook, A., 2006. Exercise adherence following physical therapy intervention in older adults with impaired balance. Physical therapy, 86(3), pp.401-410.

Melzer, I., Benjuya, N. and Kaplanski, J., 2005. Effect of physical training on postural control of elderly. Harefuah, 144(12), pp.839-44.

Robitaille, Y., Laforest, S., Fournier, M., Gauvin, L., Parisien, M., Corriveau, H., Trickey, F. and Damestoy, N., 2005. Moving forward in fall prevention: an intervention to improve balance among older adults in real-world settings. American journal of public health, 95(11), pp.2049-2056.

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