Ahmadali Akbari Kamrani, MD; Farhad Azadi; Pourandokht Pejmanfard;
Saeed Siadat; Marjan Akbari Kamrani; Asghar Dadkhah, PhD.
University of Welfare and Rehabilitation Science; Iranian Research Center on Aging
Mehrdad Sheikhvatan, MD
University of Tehran, Medical Sciences

Correspondences:
Dr Asghar Dadkhah,
Iranian Research Center on Aging,
University of Social Welfare and Rehabilitation,
Evin, Kudakyar Avenue,
Tehran 19834, Iran
E-mail: asgaredu@uswr.ac.ir

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INTRODUCTION

Both the incidence and severity of falls related complications rise steadily after the age of 60. Thirty five to forty percent of the community dwelling population aged 65 and older fall annually so that 50% of those 80 and older, fall each year around the entire world (Gillespie, 2003). Also, falls account for approximately one quarter of all emergency department visits per year (Burt & Fingerhut, 1998). The majority of patients who fall are children or the elderly. In those older than 65 years, the risk of falling has been found to be greater than 20% per year and carries a significant mortality rate (Tinetti, Speechley, & Ginter, 1988; Mackenzie, & Fowler, 2000). Falls result from a variable combination of intrinsic health problems, extrinsic environmental and task related hazards, and the effects of medication - many of which can be ameliorated. Risk factors for falling are classified as intrinsic or extrinsic. Intrinsic factors are internal to the individual. Increased age, a history of falls, impaired balance, poor muscle strength including ankle strength, and slow walking speed are examples of intrinsic risk factors (Mustard, & Mayer, 1997; Davis, et al, 1999). Other intrinsic risk factors include age-related physiologic changes and chronic conditions of various body systems, particularly cardiovascular, neurologic, musculoskeletal, and urologic conditions (Tinetti, et al 1988; Edwards, & Lee, 1998). There is now good evidence that a range of interventions can be effective in reducing falls rates among older people. The interventions best supported by evidence include: professionally prescribed muscle strength and balance retraining, professionally prescribed home hazard assessment and modification, and exercises. Older adults benefit from exercise of various types, including muscle strengthening exercises, flexibility training, aerobic exercises, and walking, to offset declining strength or to increase muscle strength and to improve balance and gait velocity (Chandler, & Hadley, 1996). Romberg exercise is one of the recommended exercises for balance assessment, because this type of exercise is simple and without need of special instruments. However, this method was used for clinical assessment of balance, not for balance improvement. The aim of this survey was to study the impact of Romberg exercise on balance improvement in elderly persons.

MATERIALS AND METHODS

In this study, 70 elderly persons (= 65 years old) with the history of two or more falls during recent three months were selected from Kahrizak nursing home in Tehran between November 2005 and March 2006. Patients with neurological diseases or limitation on physical activity, were excluded. Also persons who used neurological or psychiatric drugs, or drugs which affected balance, were excluded. Individuals who agreed to participate met with the researcher or research assistant who explained the purpose of the study and obtained informed consent. Ethical committees in Tehran University of Welfare and Rehabilitation Science have approved this study. Persons were divided randomly into two groups: 38 persons as the training group and 32 persons as the control group. The structured interview consisted of questions including general characteristics, past medical history, drug history, and numbers of falls during the past six months. Then, Romberg exercise was done in a training group every other day (45 minutes per day once a day) for 3 months. This exercise was guided by a physiotherapist in the mornings.
To do this exercise, one foot of person was placed directly in front of the other (heel to toe) in a corner with the physiotherapist's hands on the patient's hips and this position was held for 60 seconds. Then the position of the person feet was switched and the exercise was repeated.
Among all persons involved, 20% in the training group and 34% in the control group were excluded for the reason of death, admission to the ward, or discharge. Other persons were followed for 6 months and then the incidence and frequency of falling was assessed during this time and compared between the two groups.
Results were reported as the mean ± standard deviation (SD) for quantitative variables and percentages for categorical variables. Groups were compared using the Student's t test for continuous variables, the ?2 test for dichotomous variables, and the Mann-Whitney U test for skewed variables. P values of 0.05 or less were considered statistically significant. All statistical analyses were performed by using SPSS version 13 and SAS version 9.1 for windows.

RESULTS

General characteristics of elderly persons are summarized in Table 1.The mean age of persons undergoing Romberg exercise and the control group was similar. Male/female ratio was 0.84 and 1.9, respectively.

Table 1: General characteristics of elderly persons

The mean of body mass index was also similar between the groups. Orthostatic hypotension was found in 8.8% and 16.7%, respectively. After the first three months duration, 28 and 21 persons in training and control groups were followed up for 6 months. After this period, no significant differences in frequency and incidence of falling between the two studied groups was found (Table 2).

Table 2. The incidence and frequency of falling in Romberg exercise and control groups

The incidence of one or more falls in men in training and control groups were 31.3% and 47.6% and in women was 57.9% and 27.3%, respectively. Also, the mean of frequency of falling was similar between the two studied groups in both genders (Table 2). We found no significant relationship between gender and the incidence of falling (P=0.460). Also, there was found no significant relationship between age and incidence (P=0.554) and between age and frequency of falling (P=0.144) in elderly persons.

DISCUSSION

Effective preventive strategies require better understanding of the causes of, and risk factors for, falling among the elderly. The risk factors identified may be helpful to those planning fall prevention initiatives within long-term care settings. One of the most important risk factors for injury among those who fell, was altered mental state and physical balance. Patients who have fallen more than once or who have problems during initial balance and gait testing should be referred to physiotherapy or an exercise program. Physiotherapy and exercise programs can be done at home if patients have limited mobility. Physiotherapists customize exercise programs to improve balance and gait and to correct specific problems contributing to fall risk. Several general exercise programs in health care or community settings can improve balance and gait. Older adults benefit from exercise of various types, including muscle strengthening exercises, flexibility training, aerobic exercises, and walking to offset declining strength or to increase muscle strength and to improve balance and gait velocity (Chandler & Hadley, 1996). There is evidence that exercise can also reduce falling and risk of falling in older people. A review of controlled clinical trials reported that studies successfully reduced falls or risk of falls when strength and balance retraining, and endurance training were used (Gardner et al., 2000).
A Medline search from 1966 to 2007 using the key words "Romberg exercise" produced 12 articles. A large number of articles were related to the role of exercise in improvement of balance disturbance in elderly patients such as patients with multiple sclerosis or neurological disorders and the diagnostic role of Romberg test, but they were not directly linked to the curative role of Romberg exercise.
In this study, we considered the effectiveness of Romberg exercise on improvement of balance in elderly patients with history of falling. In our study, mean age of persons in two study groups was 78 years old, whereas mean age of persons with history of falling in the Friedman study was lower (72.6 years old) and in the Robertson study was higher (81.1 years old) than our study (Robertsonet al., 2001; Friedman et al., 2002). It seems that the mean age of falling in elderly persons is different in other societies and related to several factors. Also we found no relationship between increasing age and incidence of falling. In the Omert et al study, it is demonstrated that age did not impact on injury severity or outcome of falling and the Injury Severity Scores and mortality rates for both young and older groups were low (2004).
Sex ratio of falling in studies was different so that in our study, male to female ratio was 0.84 and 1.9 in Romberg exercise and control groups, respectively. This ratio in Friedman (2002), Omert (2004), and Robertson (2001) studies was 0.7, 3, and 0.5, respectively. In the Prudham study, the rate of falling was twice as high in women as in men and rate increased with age, but more steeply in men as in women (Prudham & Evans, 1981).
The impact of exercise on improvement of muscle weakness and decrease of falling rate was assessed in several studies and results were different. In our study, no significant differences in frequency and incidence of falling between the two studied groups were found. In the Mulrow study, although the rates of falls after exercise did not decrease, the experimental group did show a 15% improvement in mobility and a reduced use of assistive devices and wheelchairs (Mulrow et al., 1994). Also, in the Robertson et al study, falls were not reduced by the exercise program in a sample of women and men aged 65 years and older who were taking psychotropic drugs, however in other persons, a 46% reduction in the number of falls during the trial for the exercise group compared with the control group was found (Robertson et al., 2001).
Several studies of exercise interventions to improve muscle strength have been done with mixed results in persons living in institutions. In one uncontrolled study of an 8-week exercise program among frail nursing home residents with a mean age of 90 years, remarkable increases in muscle strength, a 9% increase in the mid-thigh muscle area, and a 48% increase in mean tandem gait speed were seen (Fiatarone et al., 1990). In addition to physical therapy or exercise training programs, simple walking programs may also improve strength and function. Residents should be encouraged to be as physically active as possible, even if that only consists of walking with assistance a few minutes each day, as long as it can be done with reasonable safety (Robenstein et al., 1994).

CONLCUSION

Although in our study, the impact of Romberg exercise on improvement of balance disturbance and decrease of incidence and frequency of falling was not demonstrated, there is a need for additional studies with larger sample sizes and longer follow-up time, which could reveal the effect of Romberg and other exercise programs in decreasing falls in elderly persons. This would enable nursing home managers to make the correct choice of suitable treatment strategies.

ACKNOWLEDGEMENTS

This research project has been supported by Iranian Research Center on Aging. We would like to thank Farzan institute for technical assistance and statistical analysis. The authors would like to thank the interviewers who collected the information, the general practitioners who volunteered their practices for the study, and the participants who gave up their time for the study.

Burt, C.W., & Fingerhut, L.A. (1998). Injury visits to hospital emergency departments: United States, 1992-95. Vital Health Stat, 13, 1-76.
Chandler, J.M., & Hadley, E.C. (1996). Exercise to improve physiologic and functional performance in old age. Clinics in Geriatric Medicine, 12, 761-784.
Davis, J.W., Ross, P.D., Nevitt, M.C., & Wasnich, R.D. (1999). Risk factors for falls and for serious injuries on falling among older Japanese women in Hawaii. Journal of the American Geriatrics Society, 47, 792-798.
Edwards, B.J., & Lee, S. (1998). Gait disorders and falls in a retirement home: A pilot study. Annals of Long-Term Care, 6,140-143.
Fiatarone, M.A., Marks, E.C., Ryan, N.D., Meredith, C.N., Lipsitz, L.A., & Evans, W.J. (1990). High-intensity strength training in nonagenarians. Effects of skeletal muscle. JAMA, 263, 3029-3034.
Friedman, S.M., Munoz, B., West, S.K., Rubin, G.S., & Fried, L.P. (2002). Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. JAGS, 50, 1329-1335.
Gardner, M.M., Robertson, M.C., Campbell, A.J. (2000). Exercise in preventing falls and fall related injuries in older people: A review of randomized controlled trials. British Journal of Sports Medicine, 34, 7-17.
Gillespie, L. (2003). Interventions for preventing falls in elderly people. Cochrane Database System Review, 4, CD000340.
Mackenzie, E.J., & Fowler, C.J. (2000). Epidemiology. In: Mattox KL, Feliciano DV, Moore EE, eds. Trauma. New York: McGraw-Hill :33-34.
Mulrow, C.D., Gerety, M.B., Kanten, D., Cornell, J.E., DeNino, L.A., Chiodo, L., et al. (1994). A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA, 271, 519-524.
Mustard, C.A., & Mayer, T. (1997). Training -control study of exposure to medication and the risk of injurious falls requiring hospitalization among nursing home residents. American Journal of Epidemiology, 145, 738-745.
Omert, L., Zakhary, S., Wilson, R., Diminno, C, Rodriguez., J. (2004). Falling down and falling out: management and outcome analysis. J Trauma, 56, 58-63.
Prudham D, Evans JG. Factors associated with falls in the elderly: a community study. Age Ageing 1981; 10:141-146.
Robenstein, L.Z., Jozephson, K.R., & Robbins, K.S. (1994). Falls in the Nursing Home. Ann Int Med, 121:442-451.
Robertson, M.C., Devlin, N., Gardner, M.M., & Campbell, A.J. (2001). Falls 1: Randomised controlled trial delivered home exercise program to prevent: Effectiveness and economic evaluation of a nurse. BMJ, 322, 697- 699.
Tinetti, M.E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology,, 45, 239-243.
Tinetti, M.E., Speechley, M., & Ginter, S.F. (1988). Risk factors for falls among elderly persons living in the community. N Engl J Med, 319:1701-1707.