Scholarly article on topic 'The Effectiveness of the Exercise Education Programme on Fall Prevention of the Community-dwelling Elderly: A Preliminary Study'

The Effectiveness of the Exercise Education Programme on Fall Prevention of the Community-dwelling Elderly: A Preliminary Study Academic research paper on "Educational sciences"

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Abstract of research paper on Educational sciences, author of scientific article — Moonyoung Chang, Yan-hua Huang, Heyyoung Jung

Abstract Objective The purpose is to identify the effects of the exercise education programme on fall prevention of community-dwelling elderly. Methods A single blind preliminary randomized control trial was conducted. Participants (N = 10) in the experimental group was assigned to an exercise education programme which consisted of 28 sessions, 30∼40 minutes per day for 4 weeks and a self-management telephone monitoring programme once every two days. Participants (N = 8) in the control group received no intervention. The effectiveness of exercise education programme was measured by fall index, balance confidence scale, and balance scale. Results The fall risks decreased from moderate to minimum in the experimental group (p < .001). Balance confidence scores increased, especially 6 items measured statistically significant increases (p < .05). However, balance scores did not show statistically significant improvement. Conclusion The exercise education programme might be effective for fall prevention of community-dwelling elderly.

Academic research paper on topic "The Effectiveness of the Exercise Education Programme on Fall Prevention of the Community-dwelling Elderly: A Preliminary Study"

Hong Kong Journal of Occupational Therapy (2011) 21, 56-63

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ORIGINAL ARTICLE

The Effectiveness of the Exercise Education Programme on Fall Prevention of the Community-dwelling Elderly: A Preliminary Study

Moonyoung Chang a*, Yan-hua Huang b, Heyyoung Jungc

a Department of Occupational Therapy, College of Biomedical Science and Engineering, Inje University, Gimhae, South Korea

b Department of Occupational Therapy, School of Health and Human Services, College of Professional Studies, California State University, Dominguez Hills, California, USA

c Department of Occupational Therapy, Suncheon First College, Suncheon, South Korea

Received 15 March 2011; received in revised form 29 June 2011; accepted 13 October 2011

KEYWORDS

community-dwelling;

elderly;

exercise;

fall prevention;

self-management;

telephone monitoring

Abstract Objective: The purpose is to identify the effects of the exercise education programme on fall prevention of community-dwelling elderly.

Methods: A single blind preliminary randomized control trial was conducted. Participants (N = 10) in the experimental group was assigned to an exercise education programme which consisted of 28 sessions, 30~40 minutes per day for 4 weeks and a self-management telephone monitoring programme once every two days. Participants (N = 8) in the control group received no intervention. The effectiveness of exercise education programme was measured by fall index, balance confidence scale, and balance scale.

Results: The fall risks decreased from moderate to minimum in the experimental group (p < .001). Balance confidence scores increased, especially 6 items measured statistically significant increases (p < .05). However, balance scores did not show statistically significant improvement. Conclusion: The exercise education programme might be effective for fall prevention of community-dwelling elderly.

Copyright © 2011, Elsevier (Singapore) Pte. Ltd. All rights reserved.

* Corresponding author. Department of Occupational Therapy, College of Biomedical Science and Engineering, Inje University, 607 Obang-dong, Gimhae-si, Gyeongsangnam-do 621-749, South Korea. E-mail address: myot@inje.ac.kr (M. Chang).

Introduction

Due to the recent population ageing, rises in diseases in the elderly population and in medical expenses are coming to the forefront as important social problems (Lee et al., 2009). In Korea, 15% of total deaths of the elderly are due

1569-1861 /$36 Copyright © 2011, Elsevier (Singapore) Pte. Ltd. All rights reserved. doi:10.1016/j.hkjot.2011.10.002

to accidents; of these accidental deaths, 70% are due to falls (H.K. Kim, 2009). The medical expenses for those aged 65 years or older are about 30% of the total medical costs in Korea. The treatment costs related to fractures in the elderly due to falls is known to be the highest (Kim, Bae, Park, Gu, & Hong, 2003). Falls due to ageing is ranked as the fifth cause of death among the elderly population (Hansen, Morild, Engesaeter, & Viste, 2004). Although falls may occur at any time across a person's lifespan, they occur more frequently in persons 60 years or older (Kannus, Sievanen, Palvanen, Jarvinen, & Parkkari, 2005). Around one-third of community-dwelling elderly individuals experience falls every year (Fong, Siu, Au Yeung, Cheung, & Chan, 2011), and one of every 40 elderly persons who experience a fall is hospitalised. In Korea, 50% of elderly patients hospitalised due to falls survived less than 1 year (Ryeom, Kim, So, Park, & Lee, 2001).

Falls may occur without any external cause while performing activities of daily living; individuals may unintentionally lose balance or stability resulting with part of the body coming in contact with the ground (Lord, Clark, & Webster, 1991). When elderly people experience falls, the physical damage causes a reduction in their physical ability; however, even if their physical abilities are restored, the fear of falling again may reduce general physical activity and increase their dependency on others (Jeon, Jeong, & Choe, 2001). This decreases their skills for activities of daily living and eventually lowers their quality of life (Hill & Schwarz, 2004). Occupational therapy expertise is valued for its fall prevention interventions such as assertiveness training, exercise programmes, home evaluations and modification, functional assessments, assistive device training, and risk-reduction education (Caldeira & Reitz, 2009). In addition, exercise and home visits performed by occupational therapists will facilitate self-reflection and improve awareness of the risk factors of the environment surrounding the patient in order to prevent future falls (Caldeira & Reitz, 2009; Cumming et al., 1999).

The prevention of falls in elderly patients includes monitoring factors that may contribute to fall prevention such as age, sex, marital status, amount of medication taken, a history of previous disease, previous fall experiences, and physical strength (Chu, Chi, & Chiu, 2005; Fong et al., 2011; Whooley et al., 1999). Physical strength is one variable that can be controlled (Gu, Jeon, & Eun, 2006), and, if physical factors such as muscular strength, agility, balance, flexibility, endurance, or athletic abilities decrease, they may cause falls (Judge, Linsay, Underwood, & Winsemius, 1993).

The most common fall prevention method for elderly individuals is exercise. Exercise education programmes in fall prevention will affect physiologic variables such as flexibility, balance, endurance, coordination, gaits, and reaction time, as well as psychological variables such as anxiety, depression, life satisfaction, self-esteem, and a sense of efficacy against falls (Calderia & Reitz, 2009; Sung, 2007). Robertson, Devlin, Gardner and Campbell (2001) used muscle-strengthening exercises and balance training programmes on elderly persons to measure their fall preventing effects. The American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopedic Surgeons Panel on Falls Prevention (2001)

presented exercise programmes that included balance training as recommendations for preventing falls in elderly persons. Also, the Centers for Disease Control and Prevention (2007) determined that improving strength and balance exercise may reduce falls among the elderly. However, most of the exercise education programmes on fall prevention are limited to aerobic exercises performed in groups such as eurhythmics or dance programmes. There is a lack of exercise education programmes that individuals can practice on their own during their daily living activities (S.H. Kim, 2009).

Self-management refers to the individual's ability to manage his physical and psychosocial functions and to develop preventive strategies (Barlow, Wright, Sheasby, Turner, & Hainsworth, 2002). Self-management is a form of health promotion. In self-management, patients solve their health problems as an active participant (Sohng, Kim, & Cho, 2001). Self-management programmes in the elderly have been studied in people who have diabetes mellitus, hypertension, and osteoarthritis, and it has been proven to improve self-efficacy (Chodosh et al., 2005). However, the development of self-management programmes for fall prevention in the healthy community-dwelling elderly population is currently insufficient.

In this respect, the purpose of this study was to determine the effectiveness of an exercise education programme on fall prevention for this elderly population. The hypothesis was that there would be statistically significant differences between the experimental group and the control group in fall risk, sense of balance, and sense of efficacy.

Methods Research design

The study was a single-blind, preliminary randomised control trial aimed at examining the effects of fall prevention exercise programmes on the elderly populations risk of falls, sense of balance, and sense of efficacy against falls.

Patients

Patients were community-dwelling elderly persons who were using a social welfare centre facility located in G City in Gyeongsangnam-do, South Korea. Convenience sampling was used. The inclusion criteria included: (a) persons aged 65 or older who were using the social welfare centre facility, (b) no serious foot problems (Tinetti, Speechley, & Ginter, 1988), (c) no deficiencies in cognition, and those who scored at least 24 points in a Mini-Mental State Examination—Korean version (MMSE-K) (Kwon & Park, 1989), (d) elderly persons with no experience in falls in the past 12 months, and (e) elderly persons who understood the purpose of this study and agreed to participate.

Twenty patients were randomly divided into an experimental group of 10 patients and a control group of 10 patients by a social worker of an institution who did not know the contents of the experiment. During the conducting evaluation, two patients in the control group did not participate in a re-evaluation; thus, the final number of

Exercise education programme on fall 4 weeks (30-40 mill/daily) Telephone monitoring

Post-test (Tetrax Interactive Balance System, Berg Balance Scale, Activity-specific Balance Confidence Scale)

Figure 1 Research procedures.

enrolees was 18 in total including 10 in the experimental group and 8 in the control group (Fig. 1). All of the patients enrolled in the experimental group (N = 10) were women. All of the 18 patients had an education level higher than elementary school. Based on the results of the cognitive function evaluation using the MMSE-K, the majority of the patients scored 28—30 points in both groups (Table 1). This study was conducted for a total of 4 weeks (28 days) from July 26, 2009, through August 20, 2009.

Outcome measures

using the Berg Balance Scale, and (3) "senses of efficacy against fall" was measured using the Activity-specific Balance Confidence Scale (ABC).

Fall risk

We used the Tetrax Interactive Balance System to measure fall risk, and the system's test—retest reliability was good (r = .89) (Schwesig & Mueller, 2003). The Tetrax Interactive Balance System used in the study objectively evaluated balancing abilities in eight different postures and showed fall indexes in numerical outcomes so that fall risk could be predicted in relation to various situations that may occur while the patients performed activities of daily living skills. The tool is composed of a safety bar, a force plate, a monitor, and a balance test programme. The fall indexes are obtained through the weight ratios, weight distribution indexes, and pressure patterns entered into each footplate that reflected the degrees of coordination and efficiency. The fall indexes are divided into 0—35 points as minimum fall risks, 36—57 points as moderate fall risks, and 58—100 points as maximum risks. The eight postures measured are a method used in previous studies and the reliability and reproducibility of the method has been proven (Kohen-Raz, 1991; Kohen-Raz & Hiriatborde, 1979). The eight postures measured are a normal position, with eyes open (NO); a normal position, with eyes closed (NC); eyes open, on pillows (PO); eyes closed, on pillows (PC); head turned right and eyes closed (HR); head turned left and eyes closed (HL); head bent backward about 30 degrees and eyes closed (HB); and head leaning forward about 30 degrees and eyes closed (HF).

The outcome measures were evaluated in three domains: (1) "fall risk" was measured using the Tetrax Interactive Balance System, (2) "senses of balance" was measured

Sense of balance

The Berg Balance Scale has been developed to measure an elderly person's static and dynamic balancing abilities, and the scale is divided into three areas including sitting, standing, and posture changes. It is composed of a total of 14 items (Berg, Maki, Williams, Holiday, & Wood-Dauphinee, 1992). This is a five-point scale to be scored minimum 0 through maximum 4 and its full score is 56 points (Shumway-Cook, Baldwin, Polissar, & Gruber, 1997). The time required is around 15 minutes and higher scores mean better degrees of balance. It has been reported that if the total score of a person is 0—20 points, the person must use a wheelchair; if 21—40 points, the person can walk using aiding tools; and if 41 points or higher, the person can walk completely independently. Persons with scores of 40 points or higher are not likely to fall (Berg et al., 1992). The Berg Balance Scale's reliability values within measurers and between measures are r = .97 and r = .99 respectively (Berg, Wood-Dauphinee, & Williams, 1995).

Sense of efficacy against falls

In order to measure the psychological effects of the fall preventing exercises, we measured senses of efficacy against falls using the ABC. This scale was developed by Powell and Myers (1995) to measure an elderly person's fear of falls. The questions are composed of a total of 16 items regarding not only indoor activities but also outdoor activities (Jang, Cho, Ou, Lee, & Baik, 2003). The patients are asked how confident they are to do individual works without falling or losing balance, and the answers can be given by checking anywhere

Table 1 Demographic Characteristics

Characteristics Experimental Control

(N = 10) (N = 8)

N (%) N (%)

Sex (n) Man 0(0) 1 (12.5)

Woman 10 (100.0) 7 (87.5)

Age (y) 65—70 5 (50.0) 3 (37.5)

70—75 3 (30.0) 4 (50.0)

75—80 0(0) 0(0)

80—85 2 (20.0) 1 (12.5)

Education (y) 0 0(0) 0 (0)

>Elementary 10 (100.0) 8 (100.0)

school

MMSE (score) 24—27 3 (30.0) 2 (25.0)

28—30 7 (70.0) 6 (75.0)

Marital status Married 10 (100.0) 8 (100.0)

Single 0(0) 0(0)

Caregiver Yes 8 (80.0) 4 (50.0)

No 2 (20.0) 4 (50.0)

y = Year.

between 0% (not at all confident) and 100% (completely confident). The average of the scores to the 16 questions becomes the final total score. During the study, the validated Korean language version of the ABC was used and its Cron-bach's a = .99 (Jang et al., 2003). We also tested the reliability of the Korean language version of the ABC in our study and the results showed high internal consistency of Cron-bach's a = .949.Therefore, the measurement outcome of this version of the ABC is adequate for this study.

Intervention programme

Exercise programme

The programme used in this study was composed by a professor of the Department of Occupational Therapy who specialises in elderly rehabilitation and an occupational therapist. Together they reviewed previous studies of exercise education programmes on fall prevention. The exercises were configured so that they can improve self-perception of risk factors based on the belief that exercise intervention, balancing exercises, and muscular strength exercises are effective at preventing falls (Barnett, Smith, Lord, Williams, & Baumand, 2003; Gu et al., 2006).

The American College of Sports Medicine (1995) advised that, although an elderly person's frequency of exercise may vary with the levels of physical strength, each interval between exercises should not exceed 48 hours and exercises should be performed at least three times a week to be effective. It was also advised that for the desired effects of exercises, exercises should be continued for at least 20—30 minutes, warming-up exercises and cooling-down exercises for around 5—10 minutes, and main exercises for around 20—30 minutes were appropriate. Based on this guidance, the time for one session of the exercise education programme on fall prevention in this study was composed of approximately 30—40 minutes, which included warming-up exercises, cooling-down exercises for around 5—10 minutes, respectively, and main exercises for around 20—30 minutes (Table 2). The warming-up and cooling-down exercises were composed of stretching, and the main exercises were composed of upper and lower extremity muscle strength and balancing exercises.

Self-management telephone monitoring

We used a manual with explanations and drawing of the exercise programme, a self-checklist, and stickers. Participants were asked to attach a sticker to the self-checklist every time they finished exercises in order to enable the

participant to perform and manage exercises by themselves continuously every day. Telephone monitoring was conducted once every 2 days by the researcher, and that call took about 5 minutes. The telephone appointments were scheduled based on each participant's availability after he or she completed the first exercise programme. The researcher called the patients in the experimental group to check if they were implementing the exercise programme and also encouraged them to continuously implement the programme.

Procedures

On Day 1 of the study, a preintervention baseline evaluation of the entire study population was conducted. The 10 patients in the experimental group were educated by an occupational therapist on the exercise educational programme on fall prevention for 1.5 hours. During this session, the occupational therapies gave the patients manuals with explanations and pictures of the exercises for them to practice by themselves at home. On the last day of the study, a postintervention evaluation was conducted (Fig. 1).

Data analysis method

Data were analysed using the SPSS/WIN 12.0 programme (SPSS Inc.). Amounts of changes in the senses of balance and the senses of efficacy against falls in the experimental and the control group were analysed using Mann-Whitney tests. Changes in the risks of falls in the experimental group and the control group between before and after the intervention were compared and analysed using the fall indexes presented in the static balance tester. The statistical significance level was a = .05.

Results

There were no statistically significant differences in age, cognitive function, baseline scores of the fall index, balance scores, or sense of efficacy scores between the two groups by independent t test (p > .05). Therefore, the baselines between the two groups were equal. After treatment, we found a statistically significant result in fall risk (p < .001), but there were insignificant results in sense of balance and sense of efficacy between the two groups. However, six out of the 16 items within the sense of efficacy measurement showed a statistically significant difference.

Table 2 The Components of Exercise Education Programme on Fall Prevention

Warming-up exercises

Main exercises

Upper extremity muscular strength exercises Lower extremity muscular strength exercises Balancing exercises

Cooling down exercises

Shoulder rotating, neck stretching, arm stretching, moving two arms laterally, arm rotating, back bending, enfolding, wrist rotating and extending, making circles

Lifting the body from a chair, ball grabbing, ball side pressing, ball rolling and pressing, vertically pressing a ball

Lower extremity flexion, lower extremity extension, ankle rotating and lifting, standing on the toes and the heel, knee lifting

Three-stage gaits, standing on one foot, fixing one foot and moving the other foot laterally, walking along one line, writing letters with a foot The same as the warming-up exercises

Table 3 Group Comparison of Pre-post Test of Fall Index and Fall Risk Score

Experimental

Control

Patient Pre Post Difference (Post-Pre) Fall risk score difference (Pre-Post)

1 36 23 -13 Moderate-Minimum

2 46 22 -24 Moderate-Minimum

3 16 16 0 Minimum-Minimum

4 46 24 -22 Moderate-Minimum

5 48 41 -7 Moderate-Moderate

6 28 20 -8 Minimum-Minimum

7 80 62 -18 Maximum-Maximus

8 65 51 -14 Maximum-Moderate

9 58 40 -18 Maximum-Moderate

10 68 59 -9 Maximum-Maximum

Mean (SD) 49.1 35.5 -13.30 (7.44)** Moderate-Minimum

1 34 42 8 Minimum-Moderate

2 16 24 8 Minimum-Minimum

3 10 20 10 Minimum-Minimum

4 38 46 8 Moderate-Moderate

5 22 50 28 Minimum-Moderate

6 80 84 4 Maximum-Maximum

7 42 40 -2 Moderate-Moderate

8 60 68 8 Maximum-Maximum

Mean (SD) 37.75 46.75 9.00 (8.55)** Moderate-Moderate

* Statistically significant result as p < .05.

** Statistically significant result as p < .001.

Physical effects Fall risks

The mean score of the fall index as evaluated by the Tetrax Interactive Balance System conducted before and after the treatment for both the experimental and control groups (Table 3). The fall risks decreased from moderate to minimum in the experimental group. There was a statistically significant difference (p < .001) between the two groups. The experimental group has decreased fall risks when compared with the control group.

Sense of balance

The Berg Balance Scale values of the two groups did not show any statistically significant differences (Table 4).

Psychological effects

Sense of efficacy against falls

Senses of efficacy against falls were evaluated using the ABC. There were statistically significant results found in six of the 16 items. In the remaining 10 items, senses of efficacy against falls increased in the experimental group that

Table 4 Comparison of Mean Differences of Berg Balance Scale Between Two Groups After Training

Experimental (N = 10) Mean (SD) Control (N = 8) Mean (SD) P value

1 Sitting to standing 4.00 (0.000) 4.00 (0.000) 1.000

2 Standing unsupported 4.00 (0.000) 3.94 (0.250) .765

3 Sitting unsupported 4.00 (0.000) 4.00 (0.000) 1.000

4 Standing to sitting 3.75 (0.786) 3.75 (0.683) .937

5 Transfers 3.80 (0.616) 3.63 (0.806) .671

6 Standing with eyes closed 3.95 (0.224) 3.94 (0.250) .962

7 Standing with feet together 4.00 (0.000) 4.00 (0.000) 1.000

8 Reaching forward with outstretched arm 4.00 (0.000) 4.00 (0.000) 1.000

9 Retrieving object from floor 4.00 (0.000) 4.00 (0.000) 1.000

10 Turning to look behind 4.00 (0.000) 4.00 (0.000) 1.000

11 Turning 360 degrees 3.80 (0.616) 3.38 (0.957) .290

12 Placing alternate foot on stool 4.00 (0.000) 4.00 (0.000) 1.000

13 Standing with one foot in front 3.85 (0.671) 4.00 (0.000) .814

14 Standing on one foot 3.70 (0.923) 3.81 (0.544) .912

Total score 57.85 (2.134) 54.44 (2.449) .539

* Statistically significant result as p < .05.

participated in the exercise educational programme on fall prevention compared with the control group, although the differences were not statistically significant (Table 5).

Discussion

The occupational therapist—led exercise education programme on fall prevention in community-dwelling elderly patients might be effective according to the results of this study. Elderly individuals had a decreased fall risk in the physical factors and an increased sense of efficacy against falls in the psychological factors. The uniqueness of in this study is that telephone monitoring was conducted so that the community-dwelling elderly patients could manage the exercise educational programme on fall prevention on their own.

The physical effects of the exercise educational programme on fall prevention were tested using the Tetrax Interactive Balance System. This tool is expensive and cannot be easily used in clinics (Shin, An, & Lee, 2005), but it is advantageous because it integrates risk factors for falls and provides objective fall indexes. Based on the results of this study, the mean fall index of the experimental group decreased from a moderate falls risk at 49.1 points to a minimum falls risk at 35.5 points. These results indicate that the exercise educational programme on fall prevention was effective on patients with moderate or higher falls risks. These results are consistent with a report by Hahm and Lee (2009) that indicated that the programme was effective on patients with higher falls risks. These results also support the results of studies indicating that muscular exercises performed by elderly persons were effective in preventing future falls (Kim & Bae, 2002), and that the implementation

of muscular strength and balancing exercises reduced the risk of falls by 35% (Robertson et al., 2001). Although this exercise programme significantly reduced fall risks, it did not produce any statistically significant differences in any items of senses of balance measured using the Berg Balance Scale. The Berg Balance Scale is a tool to measure balancing abilities, which may be used to predict fall risks (An, Lee, Cho, & Shin, 2007). However, Bogle Thorbahn and Newton (1996) advised that although the Berg Balance Scale is very sensitive to patients with high fall risks, it is not very sensitive to patients with low fall risks. In particular, persons who scored 41 points or higher could walk completely independently and persons who scored 40 points or higher were not likely to fall (Berg et al., 1992). The individuals in this study scored at least 40 points when measured using the Berg Balance Scale; thus, they were patients who were not likely to fall. It may be possible that the enrolees showed ceiling effects in this balancing test and thus did not show any significant results after training.

The psychological effects of the exercise educational programme on fall prevention were measured using the ABC. Based on the results, senses of efficacy against falls increased in general in the experimental group. In particular, statistically significant results were shown in walking up and down stairs, standing on toes in order to grab objects located overhead, walking up and down slopes, walking around in crowd shopping malls, walking around crowded places, and walking along escalators without holding handrails. It has been reported that senses of efficacy against falls is a major cause that affects falls (Jung, Lee, & Chung, 2006). As senses of efficacy against falls increase, the quality of life related to physical health is improved (Lim et al., 2007). Yoo and Choi (2007) advised that the higher the senses of efficacy against falls, the lower the frequency

Table 5 Group Comparison of Mean Differences of Activity-Specific Balance Confidence Scale

Variables Experimental Control p value

(N = 10) (N = 8)

Mean (SD) Mean (SD)

1 .Walk around the house? 96.00 (8.207) 90.00 (13.662) .262

2 .Walk up or down stairs? 84.00 (20.365) 62.50 (23.523) .009*

3 .Bend over and pick up a slipper from the front of a 92.00 (9.515) 84.38 (12.633) .077

closet floor?

4 .Reach for a small can off a shelf at eye level? 95.00 (10.000) 88.13 (14.705) .168

5 .Stand on your tiptoes and reach for something above your head? 93.50 (14.609) 78.75 (20.936) .028*

6 .Stand on a chair and reach for something? 88.00 (10.563) 75.00 (23.094) .062

7 .Sweep the floor? 89.00 (16.827) 75.00 (23.094) .053

8 .Walk outside the house to a car parked in the driveway? 90.00 (11.239) 82.50 (19.833) .352

9 .Get into or out of a car? 89.50 (11.910) 83.75 (19.279) .539

10 .Walk across a parking lot to the mall? 93.00 (9.234) 85.00 (17.889) .262

11 .Walk up or down a ramp? 86.50 (16.311) 65.63 (16.317) .001*

12 .Walk in a crowded mall where people rapidly walk past you? 91.00 (13.727) 80.00 (15.492) .033*

13 .Are bumped into by people as you walk through the mall? 91.00 (14.105) 75.00 (18.619) .012*

14 .Step onto or off an escalator while you are holding onto a 93.50 (8.751) 83.13 (19.906) .140

railing?

15 .Step onto or off an escalator while holding onto parcels such that you 86.50 (14.965) 70.63 (18.428) .009*

cannot hold onto the railing?

16 .Walk outside on icy sidewalks? 62.50 (14.096) 53.75 (30.523) .422

*P < .05.

of falls. Therefore, in this study, the statistically significant increase in senses of efficacy against falls proved that the intervention of an exercise programme might be useful.

Effective programmes for preventing the risk of falls aimed to enable elderly persons to live independently and reduce their risk of falls should include educational factors for promoting behavioural changes (Desai, Zhang, & Hennessy, 1999). In the research of Clemson et al. (2004), they used a small-group educational programme to promote personal control and problem solving. In this study, education was provided so that elderly persons could implement the exercise programme for preventing falls continuously by themselves and they were encouraged to maintain the programme through telephone monitoring. Recently, as attention is paid to cost effectiveness and patient-oriented service environments, programmes implemented at home are being emphasised (Song, 2005). One of the approaches to fall prevention programmes implemented in home settings is telephone monitoring. This method is the most convenient method to easily access patients in their home settings and is effective in providing opportunities to have continuous contact with these elderly patients (Muller, Vuckovic, Knox, & Williams, 2002). Riegel et al. (2002) stated that telephone monitoring should be done at least once a week to be effective. In this study, telephone monitoring was conducted by an occupational therapist once every 2 days to check that the patients were implementing the exercise programme, to discuss any difficulties in implementing the programme, and to encourage the patients to continue to follow the exercise programme in order to prevent future falls. The exercise education programme and the telephone monitoring method guided by an occupational therapist for this community-dwelling elderly population were unique because, to our knowledge, it might be the first study in occupational therapy to combine exercise and follow-up self-management through telephone monitoring.

Limitations

This study has four limitations. First, the number of the participants in this study is 18 in total. This study may not be generalised due to the small sample size. Second, although the Berg Balance Scale is widely used in clinics to measure the effects of fall prevention intervention (Bergetal., 1992), it is not a sensitive tool when evaluating community-dwelling elderly patients with good functions. Therefore, more sensitive tools should be used in future studies to test the effectiveness of fall prevention programmes. Third, the exercise education programme was only 4 weeks. Future longitudinal studies should follow-up these healthy elderly individuals. Fourth, the method of telephone monitoring had not been standardised because its time intensities have not been clearly defined (Song, 2003). Future studies may further formalise implementation methods and the required time of the telephone monitoring method.

Conclusion

The 4-week exercise education programme with self-management telephone monitoring method might be

effective for the prevention of falls in the community-dwelling elderly population. Elderly patients who participated in this programme had a decreased fall risk and an increased sense of efficacy against falls. The uniqueness of this study is not only the use for the exercise education programme but also the use of the telephone monitoring method to follow-up the study participants. This exercise education programme with self-management telephone monitoring is recommended for future fall prevention programmes and studies for the community-dwelling elderly population.

Acknowledgements

This work was supported in 2010 by the Inje Research and Scholarship Foundation.

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