Fall PReVentiOn aMOnG OlDeR aDults : case RePORts exeMPliFYinG the Value OF incORPORatinG luMBaR staBilizatiOn tRaininG DuRinG Balance exeRcises

Correspondence Author: Dr Petronella van der Merwe Dr. Petro van der Merwe Physiotherapy P.O. Box 684, Rivercresent, Witbank, South Africa Email: levouyvdm@mweb.co.za AbstrACt: background: Older adults are at risk of falling each year. fall injuries results in many health care expenses and disabilities, yet non­western countries lack the infra­structure and resources for prevention programs. Balance exercises have been found to be a cost effective evidence­based intervention in treating and preventing falls among older adults in western countries. Purpose: The aim of this report was to show that lumbar stabi­ lization exercises are not only a beneficial addition to a balance program for the prevention and treatment of falls in older adults, but to demonstrate that these exercise can more rapidly improve the functional status of older adults, limiting healthcare costs. Case description: Two high functional older adults with a history of falls presented with poor balance and fear of falling. Both patients received the same balance exercise regime however lumbar stabilization exercises were added to one of the patient’s exercise programs. Gait speed, lower extremity strength and balance were assessed with the Balance Evaluation systems test (BESTest), figure­of­eight, four­step­square (fSST), five­time­sit­to­stand tests (5TSTS) after two weeks and four weeks of treatment. outcomes. All the outcome measures showed statistically significant improvements. Greater improvements in vertical stability limits (14%), gait speed (9%), stability during gait (20%) and five­time­sit­to­stand test were seen with the addition of lumbar stabilization exercises. discussion. The addition of lumbar stabilization exercises during balance training is of value to improve gait speed, balance testing scores in stability in gait and vertical stability limits.

like South Africa 18% of the older adult population were counted as disabled in 2001.Three out of five of these older adults were hospitalized with fall risks due to frailty (Statistics South Africa 2001).Fall prevention and care however is neglected due to South African legislature which only allows 2% of the older population access to statesupported institutional facilities (Czerniewicz et al 2004).
Balance training is a cost effective fall prevention intervention in western societies (Madureira et al 2007).Balance challenged in three ways: reducing base of support, moving center BackGROunD One third of United States' older adult population has a risk of falling each year with the highest rate among 75 year olds.Healthcare cost escalated above $19 billion during 2000 accord ing to the Center of Disease Control and Prevention.In nonwestern societies of gravity and controlling body position are the most effective form of evidence based interventions.Standing exercises with reduced upper limb support have also been found to improve static and dynamic balance and decrease the risk of falling (Sherrington et al 2008).Additional lower extremity exercises improved center of pressure velocity, sensory interaction during balance, directional control, lower extremity strength and stability limits (Burke et al 2010).Evidencebased alternative balance training like Tai chi improves functional balance, directional control and walking velocity during gait, and postural stability (Li et al 2010).Postural stabilization training is also listed in the Guide to Physical Therapy Practice's Pattern 5A, as an evidencebased fall prevention intervention.Postural stabi lity especially plays an important role in controlling and improving changes in spinal load transfer patterns during perturbation (Muthukrishnan et al 2009).
Postural control exercises help to develop more efficient postural control strategies (Nagai et al 2012).Muscle weakness, a major fall risk factor, causes postural instability (Orr 2010).Dynamic lumbar stabilization training improves weight bearing distribution, gait and quality of life (Kaya et al 2012).Lumbar strengthening in functional positions are similar to regular balance exercises except that the transverse abdominus is constantly activated with the use of implicit motor learning techniques such as a biofeedback device and manual muscle activation (O'Sullivan 2000).The aim of this study was to demonstrate the value of additional lumbar stabili zation exercises during fall prevention balance training to lower fall risk.Both patients' exhibited swayback postures and pain free full lumbar spine range of motion.Upper and lower extremity muscle strength and range of motion were within normal limits as measured by the Kendall's manual muscle test, "backscratch" and "chairsitandreach" tests.The neu ro logical screening of sensation, upper and lower extremity myotomes and reflexes presented normal while the activestraightlegraise test in both patients revealed weakness of trans verse abdominus.The integumentary and foot screening showed bruised big toes of Patient A, varicose veins of Patient B and bilateral feet hammer toe formation of both patients.Vital signs were tested before and after the functional assessment tests (Table 1).

FunctiOnal assesMent tests
The Balance Evaluation systems test (BESTest) was used due to its' high validity and reliability in differentiating between biomechanical constraints, stability limits, anticipatory postural adjustments, postural responses, sen sory orientation and gait stability.The BESTest and gait speed have high sensitivity and validity in identifying fallers (Leddy et al 2011, Brach et al 2008).Greater step length and stance time variability are associated with poorer health and physical functional status (Brach et al 2008).In addition gait speed, figureofeight and foursquare steptests proved to be of high relia bility in measuring functional outcomes (Peters et al 2012, Whitney et al 2007).The foursquaresteptest is also a very effective balance assessment tool in identifying multidirectional movement performance deficits (Whitney et al 2007).The Figureof8WalkTest corre lates with step width variability and fear of falling (Hess et al 2010).The five timesittostandtest (5TSTS) correlates with lower extremity strength, gait and balance (Whitney et al 2005, Brown et al 1995).The baseline measured outcome values (Table 2) determined the patients' functional status according to normative values (Hess et al 2010, Guccione et al ).

DiaGnOses anD PROGnOsis
The author classified these patients according to the Guide of Physical Therapy Practice's Pattern 5A.The history of falls, medical history of osteoarthritis and hypertension, foot deformities, poor outcome values on the fivetimesittostand, foursquarestep and BESTest tests all confirmed that these patients were at high risk of fal ling.The patients had a good prognosis to achieve better balance outcomes, improve gait speed with the figureof eight and foursquarestep tests, and to maintain high functional independence living status with lower risk of repetitive falling episodes.The goal of physical therapy was to decrease the patients' risks of falling by improving their objective balance properties.

inteRVentiOn exercise prescription
Patients A and B target exercise heart rate was monitored to maintain 60% of their maximum HR.Patient A's reduced exercise tolerance and heart rate secondary to the beta blockers was assessed with the use of the rate ofperceivedexertion (RPE) scale at 1315/20.The one repetition maximum weight for the Theraband® was cal culated at 70% and progressed by 5% with good muscle tolerance at twelve repetitions.The patients received the rapy three times a week for 30 to 45 minutes.The exercise programs were conducted in twelve treatments over a four week period according to the Guide to Physical Therapy Practice.

exercise progression
Both patients were instructed in trans verse abdominus muscle activation at initial treatment and received the same biomechanical postural correction edu cation, static (figure 1), and dynamic (figure 2) balance exercise regime during therapy.They performed their exercises in front of a mirror for optimal corticospinal activation (Funasa et al, 2007).Patient B received balance

Results
The patients were reassessed after two and four weeks (Table 3).The statistical significance within each patient's outcome values in Table 4 were calculated with the use of the studentt test (Table 4).The paired ttest was used to calculate the 95% confidence intervals, mean and standard deviation and the two tailed pvalue difference between the two patients.
The single pvalue statistical difference between the patients was calculated with the Friedman test and Chi square approximation.
Both patients showed statistically significant improvements in all the outcome values except in vertical stability limits (  The anticipatory postural adjustments and sensory orientation outcome values showed a ceiling effect after two weeks.

DiscussiOn
Statistically significant improvements in the functional assessment tests' results showed the evidencebased effect of balance exercises.The equal improvement of figureofeight and foursquarestep tests, biomechanical constrains, anticipatory postural ad justments, postural responses and sensory orientation correlated with other high quality evidence based studies (Madureira et al 2007, Burke et al 2010).Balance exercises rather than additional lumbar stabilization significantly improved the patients' anticipatory postural adjustments abi lity.Balance training also can improve patients' ability to change position in multiple directions without any activation of the lumbar stabilizers (Nagai et al 2012).Anticipatory postural adjustments are considered the major "line of defence" against selfinflicted postural perturbations.Postural stability, body protection and focal movement performance during anticipatory pos tural adjustments are maintained by the central nervous system (Yiou et al 2012).The equal improvements in the biomechanical constraints, figureeight and fourstepsquare tests results in this study correlated with the anticipatory postural adjustments' ability to adapt to various constraints like biomechanical constraints, postural stability, task superimposition, physiological fatigue, temporal time pressure and psycholo gical fear of falling (Yiou et al 2012).The tonic activation of the transverse abdominus muscle throughout the gait cycle provides constant intersegmental stiffness and is the first line of defence against the cyclic internal and external lumbopelvic forces associated with gait (Saunders 2007).Balance is also controlled through the temporal relationship between trunk and lower extremity strength (Yen et al 2011).The improved fivetimessittostand test results showed that the additional lumbar stabilization exercises had an impact on lower extremity strength.The significant relationship which exists between knee extension force and gait speed correlate with this study's results (Brown et al 1995).Afferent input from the hip joints' load receptors play a crucial role in the generation of locomotion activity in the human spinal cord during loading phase (Dietz et al 2002).The use of body weight and control is especially important to facilitate the activity and load input in the extensor muscles (MacKayLyons 2002).It is hypothesized that the lumbar stabilizers might play a role in facilitating activity of the lower extremity extensor muscles due to prior activation and feed forward of the transverse abdominus muscle during gait initiation.The additional lumbar stabilization exercises during balance exercises showed that it may potentially add value to the patient's functional outcome.Future randomized control trials are recommended with a larger sample size of frail older adult population.

cOnclusiOn
The additional lumbar stability training during balance training has the potential to improve vertical stability, gait speed and gait stability at an earlier stage of treatment than just plain balance training alone.The improved fivetimesitto stand test values also showed that higher physical independence levels can be reach sooner.

Figure 1 :Figure 2 :
Figure 1: static balance exercises of Patient a and balance exercise incorporated with lumbar stabilization with a biofeedback device of Patient B