VISUAL IMPAIRMENT, BALANCE AND MOBILITY

VISUAL IMPAIRMENT, BALANCE AND MOBILITY

Australia | China | India | UK

Affiliated with the University of Sydney

Improving physical functioning in older adults

with visual impairments to reduce the risk of falls

Michael Gleeson

Cathie Sherrington

Serigne Lo

Lisa Keay

A Randomized Controlled Trial

Rationale: Age-Related Changes

Nerve conduction speeds slow with age (Verdu et al, 2000)

Older adults have more difficulty maintaining balance


Rationale: Age-Related Changes

Rely more on vision

especially for dynamic balance control

Implications for those with visual impairments


Rationale: Visual Impairment

Exhibit increased postural sway

Greater use of hip strategy

Increased risk of falls on unstable

surfaces


(Ray et al, 2008)

Older Adults with Visual Impairments

Well designed exercise programs reduce falls in the general population

• (Sherrington et al, 2011)

Not found effective in the population with visual impairments – compliance?

• (Campbell et al, 2005)


The Current Research Question

“Training programs should be studied for their effectiveness in physiotheraputically increasing postural control in individuals with vision loss, thereby reducing the susceptibility for falls within this population” (Ray et al, 2008)


Proprioception is Crucial

Yoga, soft gymnastics have large proprioceptive component

Improve balance with eyes closed

Multimodal exercise and Tai Chi classes also beneficial

Multimodal exercise includes strength and balance training


Pilot Studies

"Tai Chi for people with visual impairments: a pilot study."

Journal of Visual Impairment & Blindness 98(1): 5-13. Miszko, Ramsey, and Blasch (2004)

"Yoga for persons with severe visual impairment: a feasibility study."

Alternative Medicine Studies 2(e5): 18 - 25. Jeter, Dagnelie, Khalsa, Haaz, and Bittner. (2012).


Systematic Review Community-dwellers

A factorial trial (n = 391) found a home-

safety program reduced the rate of falls

(incidence rate ratio 0.59, 95%CI 0.42

to 0.83)

a home-based exercise intervention did

not (incidence rate ratio 1.15, 95%CI

0.82 to 1.61). (Campbell et al, 2005)


No Evidence That Multimodal Exercise Prevents Falls

Systematic Review Residential settings

Multimodal exercise1,2 and Tai Chi3 improve physical functioning


1. Kovács et al, 20122. Cheung et al, 20083. Chen et al, 2012

Individual verbal and manual support provided

Meta-analysis: multimodal exercise trials 1,2

significant positive impact of multimodal exercise on the Berg Balance Score (Hedges’ g, 0.64, 95% CI, 0.13 to 1.14; P = 0.013)

not on the Timed Up and Go test (0.26, -0.14 to 0.67, P = 0.206).

One trial1 (n = 41) found a reduced time to first fall (p = 0.049) but larger sample sizes are needed to verify any impact on fall rates


Community-dwelling Adults with Visual ImpairmentsMany have difficulties with group setting

Travel to unfamiliar location

Increases exposure to risk of injury

Difficulty following directions

Need more individual attention

Have to practice unsupervised


http://www.birches.net/

The Alexander TechniqueA possible solution

Can be home-based

Hands-on: verbal feedback and guided movement

Does not require vision

Does not use repetitive exercises


RCT : Can the Alexander Technique Help?


Baseline 120 clients of

Guide Dogs NSW/ACT

Control (60) Usual care Guide Dogs

Intervention (60)

12 AT lessons, usual care

Re-assess at 12 weeks Re-assess at 12 weeks

12 month follow-up 12 month follow-up

Primary OutcomesShort Physical Performance Battery

(Guralnik, Simonsick et al. 1994)

Standing Balance Test

5 x Chair Stand Test

Timed 4 meter walk


Secondary Physical Outcomes

Maximal balance range test

Physiological Profile Assessment

Sway firm surface, eyes open and closed

Sway foam, eyes open and closed


Results: Short Physical Performance Battery


Between group differences after adjusting for baseline Main analysis Sub-group analysis 3 months 12 months 3 months 12 months Primary All participants Multiple fallers (≥ 2) Standing balance

No No Approached P =0.06

No

5 x chair stand test

No No No Yes P < 0.01

4 meter walk

No No Yes P = 0.02

No

Secondary Step length

Yes P <0.01

No Yes P < 0.01

No

Results: Other Secondary Outcomes


Between group differences after adjusting for baseline Main analysis 3 months 12 months Maximal Balance Range Test No Approached

P = 0.07 Physiological Profile Assessment Firm Surface Eyes Open

Yes P = 0.004

No

Firm Surface Eyes Closed

No No

Foam Surface Eyes Open

No No

Foam Surface Eyes Closed

No No

Effect size at 3 months

MAIN ANALYSIS

Step length (4 meters) (-0.90 steps, 95%CI: -1.56 to -0.23, p <0.01)

Sway: quiet standing (-29.59mm, 95%CI: -49.52 to -9.67, p = 0.004)

MULTIPLE FALLERS

4 meter walking speed (0.19m/sec, 95%CI: 0.03 t0 0.36, p = 0.02)

Step length (4 meters) (-2.20 steps, 95%CI: -3.79 to -0.62, p <0.01)


Effect size at 12 months

MAIN ANALYSIS

Maximal balance (1.14 cm, 95%CI: -0.09 to 2.38, p = 0.07)

MULTIPLE FALLERS

Chair stand test (-5.40 seconds, 95%CI: -8.78 to -2.02, p <0.01)


Effect size

Increased step length = improved walking confidence

reduced sway = improved balance confidence

0.10 m/s is a substantial meaningful change in gait speed

The study was powered to detect 0.10 m/s

Improvement of 0.19 m/s in the multiple fallers at 3 months


Falls : Primary Unadjusted Analysis(study not powered to measure the impact on fall rates)

33% lower rate of falls in the intervention group compared to the control group

(IRR = 0.67, 95%CI: 0.36 to 1.26, p = 0.22)

51% lower rate of injurious falls in the intervention group compared to the control group

(IRR = 0.49, 95%CI: 0.22 to 1.11, p = 0.089)

These results were not statistically significant


Falls : Adjusted for past falls(study not powered to measure the impact on fall rates)


(IRR = 0.79, 95%CI: o.44 to 1.42, p = 0.43)

40% lower rate of injurious falls in the intervention group compared to the control group

(IRR = 0.60, 95%CI: 0.28 to 1.29, p = 0.19)

These results were not statistically significant


Adjusted for past falls, duration of impairment and visual field status


(IRR = 0.64, 95%CI: 0.34 to 1.15, p = 0.13)

Not statistically significant

Conclusions

Improvements in quiet standing balance and step length in the intervention group suggest increased confidence

Improved gait speed and step length in the multiple fallers suggest improvement in physical function in the most vulnerable


Conclusions

Reduction in the rate of falls in the intervention group was similar for multiple fallers and non-multiple fallers (p = 0.71)

Suggest an effect of the Alexander Technique on fall rates in older adults with vision impairments

This requires verification in a larger trial


Funding Sources

In-kind support Guide Dogs NSW/ACT

Australian Postgraduate Award Scholarship

FM Alexander Trust –United Kingdom

AUSTAT – Australian Society of Teachers of the Alexander Technique


References

• Verdú E, Ceballos D, Vilches J J, Navarro, X.(2000). Influence of aging on peripheral nerve function and regeneration. Journal of the Peripheral Nervous System 5(4): 191-208.

• Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, Sharp DM, Hale LA. (2005). Randomised controlled trial of prevention of falls in people aged >=75 with severe visual impairment: the VIP trial. BMJ 331(7520): 817-925.

• Kovács É, Tóth K, Dénes L, Valasek T, Hazafi K, Molnár G, Fehér-Kiss, A.(2012). Effects of exercise programs on balance in older women with age-related visual problems: A pilot study. Archives of Gerontology and Geriatrics 55(2): 446-452.

• Cheung KKW, Au KY, Lam WWS, Jones AYM.(2008). Effects of a Structured Exercise Programme on Functional Balance in Visually Impaired Elderly Living in a Residential Setting. Hong Kong Physiotherapy Journal 26: 45-50


References• Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB.

(1994). A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. Journal of Gerontology: MEDICAL SCIENCES 49(2): M85-M94.

• Lord SR, Ward JA and Williams P. (1996). Exercise effect on dynamic stability in older women: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation 77(3): 232-236.

• Lord SR, Menz HB and Tiedemann A. (2003). A Physiological Profile Approach to Falls Risk Assessment and Prevention. Physical Therapy 83(3): 237-252.

• Perera S, Mody SH, Woodman RC, Studenski SA.(2006). Meaningful Change and Responsiveness in Common Physical Performance Measures in Older Adults. Journal of the American Geriatrics Society 54(5): 743-749.

• Sherrington, C., Tiedemann, A. et al. (2011). Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 22(4): 78-83.


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VISUAL IMPAIRMENT, BALANCE AND MOBILITY