BACKGROUND
Falls among older adults are a serious public health problem in the United States. Each year, one-fourth of people 65 years and older experience a fall, leading to complications ranging from minor injury to death (Centers for Disease Control and Prevention [CDC], n.d.). Falls among older adults are the most common cause of hospital admissions (CDC, 2020). Fall prevention programs and the integration of preventative services have been shown to decrease falls (Rubenstein & Josephson, 2006; Tinetti, 1994). The CDC (2015) issued guidance on successful interventions and evidence-based programs that health care professionals and community-based organizations can use to reduce falls, which includes A Matter of Balance (MOB).
MOB, established at the Roybal Center for Enhancement of Late-life Function at Boston University, is an evidence-based program that has been found to reduce the risk of falls and fear of falling among older adults. It acknowledges the risk of falling and emphasizes practical coping strategies to reduce this fear. Usefulness of the MOB program was tested originally through a randomized clinical trial, which demonstrated positive improvement in both physical activity and mobility control among participants (Tennstedt et al., 1998). A lay-leader train-the-trainer model for MOB was developed based on the original research and validated through subsequent research (Healy et al., 2008). This model has been adapted for widespread community dissemination in various health care and community settings (Healy et al, 2008; Mehta et al., 2014). The lay-leader model was found to have varying degrees of success across age groups, but it was consistently effective in the older adult (age >65) population.
To maintain fidelity of the MOB program, each organization has a Master Trainer who is responsible for training coaches and ensuring consistency. A certified Master Trainer completes a 16-hr initial training, attends quarterly conference calls, and attends an annual update session hosted by MOB. To become a certified coach, an individual must attend an initial 8-hr training session and an annual update session presented by a Master Trainer. Each MOB course may be taught by a Master Trainer, two coaches, or a Master Trainer and a coach. The individual course is presented in 2-hr sessions for a total of eight classes (Batra et al., 2013; Yoshikawa et al., 2020).
Programs led by lay facilitators, specifically MOB, have limited research concerning objective measures of functional outcome to support evidence-based fall prevention programs in the community (Chen et al., 2015; Cho et al., 2015; Geyer & Thompson, 2021; Mehta et al., 2014). Balance and flexibility-based gait speed and agility tests are available to assess functional performance across a variety of settings. The Functional Reach (FR) and Timed Up and Go (TUG) tests are standard and validated measurements utilized to assess functional performance across a variety of settings (Bennie et al., 2003; Cho et al., 2015; Roedl et al., 2016).
Objective
The purpose of this study was to measure improvement of FR and gait speed among adults older than 65 years following completion of MOB. It was hypothesized that, after completing MOB, participants would increase their functional reach and decrease their gait speed scores. Results of this study may benefit older adults who are at risk for falls. As such, persons working within injury prevention roles may also benefit from these results.
KEY POINTS
* The A Matter of Balance program is widely utilized for fall reduction.
* Objective measures of A Matter of Balance are necessary for replication across research studies.
* The current study found improvements in functional reach and gait speed in participants older than 65 years following completion of A Matter of Balance.
* Participants who improved did not differ from those who did not improve by any variable studied (age, sex, health status, preexisting conditions, or delivery site), suggesting potential for widespread utility.
METHODS
Setting and Sample
This was an interventional study. Multiple MOB classes were held in south-central Pennsylvania within a 30-mile radius of our Level I trauma center, which is the cornerstone of a health care system serving more than 1 million residents annually. Delivery site locations for the community-based classes included community centers, fitness centers, health care facilities, faith-based centers, and senior living centers. Approval was granted by the health care system's institutional review board (WellSpan Health IRB) prior to conducting the study.
Participants were eligible if they were English-speaking adults, older than 65 years, mentally capable of finding solutions to their personal fall risk factors, and able to ambulate independently, with or without an assistive device. Exclusion criteria were non-English speaking persons, 65 years and younger, cognitively impaired to the point that they could not participate, or were wheelchair bound.
Participants were recruited by advertising MOB classes via websites, social media, and literature distributed at facilities throughout the health care system. Flyers were also distributed at business locations that were members of the local fall prevention coalition. Participants interested in MOB contacted an established hotline to register for the program. During this initial contact, participants were asked whether they were interested in participating in the accompanying research study. Inclusion criteria and exclusion criteria for study participation were the same as those for participation in the MOB program; however, research study participants needed to consent to study participation beforehand.
Outcomes and Measurement
The FR test assesses balance and flexibility. Participants stand perpendicular to a wall with their feet hip-width apart. A yardstick is taped to the wall at shoulder height. The arm nearest to the wall is outstretched at shoulder height without touching the wall. This position is considered the neutral position and is recorded. Participants are instructed to reach as far forward as they are safely able to reach without losing their balance. A second measurement is taken before the participant returns to the neutral position. The difference between the two measurements is the participant's functional reach. The process is repeated three times with the numeric average recorded as the measure (Bennie et al., 2003; Bohannon et al., 2017; Ramnath et al., 2018; Williams et al., 2017). An FR of 10.04-11.38 inches is standard (Bohannon et al., 2017; Williams et al., 2017). An FR less than 10 inches indicates an increased risk for falls. If FR is less than 6.0 inches, a participant's fall risk is considered highest (Williams et al., 2017).
The TUG test measures gait speed and agility. Participants sit in a chair with armrests. A line is designated on the floor 10 ft away from the chair. When instructed to "go," the participant must get up from the chair, walk to the 10-ft line at a comfortable pace, then return to the chair. Their time is recorded from "go" (standing up) to sitting back down (Bennie et al., 2003; Cho et al., 2015; Kumar & Biswas, 2020). A time more than 12 s is indicative of fall risk (Bohannon et al., 2017).
Intervention
Participants completed the first session survey during the registration process, as required by the MOB program. This survey assessed participant demographics and included two additional investigator-developed questions. The first was on general health: "Would you say that, in general, your health is ...?" Response options were "poor," "fair," "good," "very good," or "excellent." The second question was, "Do you have any of these chronic problems ...?" Response options were "heart disease," "lung problems," "diabetes," "strokes," or "falls." Participants were instructed to circle their responses. These two questions were included to determine whether a participant's perceived health status or preexisting conditions would have an impact upon improvement.
Participants were administered preprogram FR and TUG assessments prior to the first MOB class. At the end of the 8-session program, participants completed postprogram FR and TUG assessments. Data collectors for the study received training on how to perform both the FR and TUG by the principal investigator. They were required to repeatedly demonstrate that they could perform each measure independently prior to participation. The same four data collectors were used throughout the study to maintain consistency. Two coaches performed each of the classes for the eight-session program with oversight by the Master Trainer.
Data Analysis
Descriptive statistics, including means and standard deviations for normally distributed continuous variables, medians, and interquartile range for nonparametric continuous variables, and frequencies and percentages for categorical variables, were conducted prior to performing inferential statistics. A one-tailed paired t test was used to compare pre- and postprogram FR mean differences. A one-tailed Wilcoxon signed-rank test was used for comparing median differences of pre- and postprogram TUG scores. Effect sizes (Cohen's d for FR and matched-pairs rank biserial correlation for TUG) were computed for tests found to be statistically significant at p < .05.
Participants were stratified by improvement, defined as having improved their scores from Week 1 to Week 8. Two-tailed independent-samples t tests and two-tailed Pearson's [chi]2 tests were used to determine whether participants who improved scores differed by age, sex, health status, preexisting conditions, or delivery site from participants who did not improve scores. Analyses were performed using IBM SPSS Version 25.0 (Armonk, NY). All reported figures were rounded to the nearest decimal.
RESULTS
There were 120 participants in the study. The mean age was 78 years (SD = 6.9; range = 66-104 years), and participants were mostly female (93/120; 77.5%). The majority of participants were White (116/120; 96.7%). Two reported being non-White, and two did not report their race. No participants reported ethnic minority status.
Mean FR was 8.38 inches (SD = 2.88) pre-program and 8.98 inches (SD = 2.95) post-program. Postprogram - preprogram differences in FR scores (n = 120) were found following MOB completion (t(119) = 2.94, p = .002; d = 0.2). The mean difference in FR scores was 0.6 inches (SD = 2.21); see Figure 1. An average change in FR of 7.2% occurred from pre- to postprogram. Participants who improved their FR scores (n = 73) did not differ from those who did not improve (n = 47) by any characteristic studied; see Table 1.
Median TUG was 11.9 s (interquartile range [IQR] = 4.4) pre-program and 10.65 s (IQR = 3.7) post-program. Postprogram - pre-program differences in TUG scores (n = 119) were observed following MOB [Z =-7.21, p < .001, r = .76]. The median difference in TUG scores was 1.25 s (IQR = 2.39); see Figure 2. An average change in TUG of -10.5% occurred from pre- to postprogram. Participants who improved their TUG scores (n = 92) did not differ from those who did not improve (n = 27) by any assessed characteristic; see Table 2.
DISCUSSION
The FR and TUG tests are physical assessments that can be utilized to determine an individual's fall risk. Our research supports the use of MOB to increase FR while decreasing TUG. Geyer and Thompson (2021) found comparable results with a smaller sample (n = 33) using the FR and five times sit-to-stand tests. Our study's findings indicate an opportunity for older adults to improve their functional reach and gait speed with the MOB program.
Mehta et al. (2014) also examined the functional outcomes, specifically FR and balance, of participants who completed MOB. Their research found no statistically significant improvement in FR or balance while completing a single task, but an improvement was noted while participants completed a dual task. Although our study focused on the assessment of FR when participants were stationary and not completing an additional task, the results showed clinical improvement. This difference may be attributed to the difficulty needed to maintain one's balance while focusing on additional instructions.
Improvements were also noted in gait speed among participants. Geyer and Thompson (2021) again found corresponding results, although participants were assessed using a different intervention from the current study. The finding that gait speed improved after completing the MOB program with multiple assessment tools lends credibility to the program's potential to improve physical outcomes in older adults.
MOB has been successfully implemented across many sites and has been found to decrease falls and fall-related injuries for older adults (Chen et al., 2015; Katrancha & Bonachea, 2020; Mazza et al., 2021). The current study found no differences between sites or personal characteristics for participants who improved versus those who did not improve. Our findings expand on those of Chen et al. (2015), as they support the potential for MOB to positively impact a large patient population regardless of age, sex, health status, preexisting conditions, or delivery site. As such, we posit no preferred setting or participant population for MOB classes.
Limitations
There were several limitations of this study. There was a lack of diversity in the sample across sex, race, and ethnicity, limiting generalizability. The study utilized a convenience sample, and there was no control group. Lastly, the within-subject design could have led to biased results, as participants self-selected to participate.
CONCLUSIONS
Following completion of the MOB program, participants displayed improvements in FR and TUG scores. Improvement was not attributable to differences of age, sex, health status, preexisting conditions, or delivery site. This study adds further value to the fall prevention literature, as it provides objective measurements supporting the widespread use of MOB for improving physical outcomes. It is suggested that the limitations of the current study be addressed within future studies. Specifically, it is suggested that a more diverse population of sex, race, and ethnicity be assessed for possible differences that may have been undetected within this study's sample. Furthermore, future research using a randomized, controlled design may help determine whether improvements in functional reach and gait speed are sustainable or whether they continue to improve at long-term follow-up.
REFERENCES