International Journal of Gerontology 8 (2014) 143e146

Contents lists available at ScienceDirect

International Journal of Gerontology

journal homepage: www.ijge-online.com

Original Article

Effects of Simple Balance Training on Balance Performance

and Fear of Falling in Rural Older Adults*
Ladda Thiamwong*, Jom Suwanno
School of Nursing, Walailak University, Walailak, Thailand

a r t i c l e i n f o s u m m a r y

Article history: Background: Poor balance is a major risk factor for falls and fear of falling, and exercise which specifically
Received 23 April 2013 challenges balance is the most effective intervention for preventing falls. This cohort study described the
Received in revised form effects of participation in a 3-month simple home-based balancing training program on measures of
23 July 2013
balance performances and fear of falling in Thai older adults.
Accepted 14 August 2013
Available online 19 August 2014
Methods: The participants included 104 older adults who were living in a rural area of Nakhon Si
Thammarat Province, Thailand. The exercise group participated in a 3-month simple home-based
balancing training program by trained nurses. Balance was measured by a functional reach test and
Keywords:
balance performance,
timed up-and-go test. Fear of falling was measured by Thai Falls Efficacy Scale-International (Thai FES-I).
fear of falling, Results: After 12 weeks of balance training, the participants in the exercise group showed a significant
older adults, difference when compared to baselines for both the functional reach test and timed up-and-go test. The
randomized controlled trial, results also showed that the exercise group performed significantly better than the control group in the
simple balance training functional reach test and timed up-and-go test after 3, 6, 9, and 12 months. In addition, fear of falling was
reduced in the exercise group after 3, 6, 9, and 12 months.
Conclusion: The simple home-based balance training program led by trained nurses is feasible for rural
older adults and was safe, effective, and acceptable to older adults and healthcare providers.
Copyright © 2014, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. All rights reserved.

1. Introduction
Balance is a critical component of most activities of daily living
among older adults. Good balance reach in older adults living
independently, productively, and proactively is important in
housework, cooking, shopping, and travel1. Maintenance of a
balanced independence is essential for staying healthy and for well-
being. Poor balance is a major risk factor for falls, a leading cause
of hospitalization and nursing home requirements; appropriate
exercise improved balance and reduced falls in older adults2.
Community-dwelling older adults with balance impairment had
two-fold increment risks for fall is associated with increased fall
risk in community-dwelling older adults with overall summary risk
value of relative risk 1.42 (1.08, 1.85) and odds ratio 1.98 (160, 2.46)3.
Preventing falls by improving balance in older people has been a
public health issue in many studies4e6. The FICSIT meta-analysis
*
Conflicts of interest: All contributing authors declare no conflicts of interest.
* Correspondence to: Ladda Thiamwong, School of Nursing, Walailak University,
Tasala District, Nakhon Si Thammarat Province 80161, Thailand.
E-mail address: tladda@gmail.com (L. Thiamwong).
found that the overall effect of any kind of exercise training was a
10% reduction in fall rates in the subsequent year. Balance training
of any type reduced falls by 17%, and the multimodal intervention
that trained balance, strength, corrected environment, and medi-
cations was the most effective FICSIT intervention5,7.
Several strategies have been tested to improve balance and
reduce falls, including home-based interventions, center-based
interventions, and self-selected sites of exercise8. Increasing evi-
dence suggests that an exercise intervention program that includes
strengthening of the lower extremities and functional training such
as balance training would improve the physical function and reduce
risks of falling of older Adults9,10. In addition, previous studies have
demonstrated the effectiveness of a home-based strength and
balance program in several trials11e14. Home-based exercise pro-
grams that included low-intensity strength and balance training
have improved balance and reduced fall rates by about 40%
compared to controls8.
In Thailand, there is a lack of research dealing with simple bal-
ance training and a shortage of physical therapists for rural older
adults who have limited access to quality healthcare services and
whose needs are unmet. A simple home-based exercise program

http://dx.doi.org/10.1016/j.ijge.2013.08.011
1873-9598/Copyright © 2014, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
144
that is effective, safe, and acceptable to older people, led by trained
nurses, and is sustainable in the long term may be needed. We
developed a clinical practice guideline for a simple home-based
balancing training among Thai rural older adults. This clinical
practice guideline is composed of three steps including: (1)
screening and assessing balance performances; (2) practicing the
simple home-based balance training; and (3) evaluating the bal-
ance outcomes15. This cohort study aimed to evaluate the effects of
this clinical practice guideline on measures of balance perfor-
mances, as well as fear of falling, in rural older adults.
2. Materials and methods
2.1. Samples and recruitments
This was a randomized, controlled trial with a 1 year follow up.
The participants included 104 older adults who were living in a
rural area of Tasala District, Nakhon Si Thammarat Province,
Thailand. Potential participants were recommended to the study by
their healthcare providers and an individual interview determined
eligibility using the following criteria: (1) aged
60 years; (2)
balance impairment (full tandem standing test < 10 seconds); (3)
independent mobility (walks outdoors with no more support than
a single point stick); (4) no cognitive impairment (testing by the
Chula Mental Test)16; (5) living in the community for 1 year; (6)
ability to be contacted via telephone; and (7) willingness to
participate in a 3-month simple balance training program.
The sample size calculation was based on the proportion of
older people who fell once or more in a 12 month prospective
community study, an expected reduction from 0.50 to 0.30, and 20%
allowance for dropouts11. Potential participants were informed
there was an equal chance they would receive the exercise program
or act as a control. A total of 104 community-dwelling older adults
were selected from two villages and randomized into two groups:
the exercise group, submitted for balance training; and the control
group, without intervention. The exclusion criteria for this inter-
vention were: (1) cerebral vascular or cardiovascular accidents re-
ported within the past 6 months; (2) acute liver problems or the
active phase of chronic hepatitis; (3) diabetic mellitus with a his-
tory of hypoglycemic attack, with fasting levels of plasma glucose
concentrations of
200 mg/dL, or with complications such as
retinopathy or nephropathy; (4) systolic blood pressure
> 180 mmHg or diastolic blood pressure > 110 mmHg at rest; and
(5) diagnosis of heart disease, an acute orthopedic problem, or
dementia diagnosed by a medical doctor and a recommendation by
this doctor that the participants be excluded. The study was
approved by the ethical clearance committee on human rights
related to researches involving human individuals, Walailak Uni-
versity (068/2009). The study was described in detail to each
participant before the intervention began, and informed consent
was obtained prior to their participation in this study.
2.2. Measurements
The balance functions which represent an ability to control their
body mass stably were evaluated by the timed up-and-go test, and
the functional reach test. In the timed up-and-go test, the partici-
pant was instructed to sit back in a firm, upright chair and then rise
from it without using his or her arms for support. It uses the time
that a person takes to rise from a chair, walk 3 m, turn around, walk
back to the chair, and sit down. A score of
14 seconds indicates
that the person may be at risk for falls17. In the functional reach test,
participants stood next to a wall, unsupported, with their feet a
comfortable distance apart and their dominant arm raised to 90
shoulder flexion. They were asked to reach as far forward as
L. Thiamwong, J. Suwanno
possible without overbalancing. Overbalancing was defined as
needing to take a step, requiring hands-on assistance to maintain
balance, or needing to lean against the wall. The distance of addi-
tional reach was recorded (meters)18.
Fear of falling was evaluated using the Thai version of Falls Ef-
ficacy Scale-International (Thai FES-I). It comprises 16 items and is
used to assess concerns relating to basic and more complex physical
and social activities. It has good reliability and validity in older Thai
adults. Cronbach's alpha overall for the Thai FES-I was 0.95 and
mean inter-items correlation of the 16 items in FES-I was 0.6719.
2.3. Intervention
The intervention or training protocol consisted of a set of
balancing exercises that progressed in difficulty. This training
protocol was constructed according to the American College of
Sports Medicine guidelines (2011)20 and other researches14,15,21,22.
The simple home-based balance training program included: (1)
emphasizing hip abductors and extensors strengthening exercise;
(2) marching; (3) stepping over a bench; (4) closed kinetic chain
quadriceps exercise; (5) standing up from a chair with arms folded;
and (6) a tandem walk (walking heel-to-toe in a straight line).
Participants were shown how to perform and asked to perform 20
repetitions of each balancing exercise, which took about 30 mi-
nutes/session. They practiced the exercises until they could
perform them correctly. All received brochures and a DVD
reminding them how to exercise daily at home15,20e22. The target
and intensity of training was individually set. The implementation
of the exercise program was conducted and run by two trained
nurses. The nurses, who had no previous experience in prescribing
exercise, attended a 1 week training course run by a physiothera-
pist. The trained nurses delivered the exercise program in
conjunction with their work as district nurses. A series of site visits
and regular telephone calls were made by the supervising physio-
therapist to assess and ensure quality control.
2.4. Statistical analyses
SPSS version 15 (SPSS Inc., Chicago, IL, USA) was used for statis-
tical analysis. The significance level was set at p < 0.05. Baseline
demographic data, balance performance, and fear of falling were
compared using the Chi-square test for categorical variables and
analysis of covariance for continuous variables. In addition, measures
of balance and fear of falling across the active intervention phase
were evaluated with repeated measures of analysis of variance.
3. Results
A total of 110 rural community-dwelling older adults completed
the initial assessment. Six participants were excluded because they
did not meet the inclusion criteria. At the end of the 12-week
intervention period of the trial, no participant withdrew from the
study because of inability to commit to the exercises. Thus, 104
participants could be completely followed up for 1 year. The mean
age of the 104 study participants was 71.36 ± 8.49 years (range,
60e96 years), and 64 were women. Table 1 presents the de-
mographic data and medical comorbidities of the exercise and
control groups. The exercise and control groups did not differ in
demographic data and comorbidities that may influence balance in
older adults. In addition, the exercise and control groups did not
differ in age, balance performance, and Thai FES-I scores at the
initial assessment (Table 2). The results showed that the exercise
group performed significantly better than the controls in both the
functional reach test and timed up-and-go test. The distance of
additional reach of the exercise group was increased significantly
Falling in Rural Older Adults 145

Table 1
Comparison of demographic data and medical comorbidities (n ¼ 104).

Variables Exercise group Control group p

(n ¼ 52) (n ¼ 52)

n % n %

Sex
Female 36 70.6 28 52.8 0.720
Male 15 29.4 25 47.2
Literacy
Illiterate 13 25.0 7 13.5 0.213
Literate 39 75.0 45 86.5
Marital status
Married 28 53.8 18 34.6 0.075
Single/divorced/separated 24 46.2 34 65.4
Living alone
Yes 3 5.8 0 0 0.243 Fig. 1. Comparison of the functional reach test between the exercise and control
No 49 94.2 52 100 groups. Significantly different compared to baseline in the exercise group at p < 0.001.
Have financial problem Not significantly different compared to baseline in the control group at p < 0.05.
Yes 37 71.2 41 78.8 0.497
No 15 28.8 11 21.2
Have stroke history Additionally, 40% of the older adults who were involved in home-
Yes 6 11.5 1 1.9 0.112
No 46 88.5 51 98.1
based exercise programs had a reduction in falls8.
Use hypertensive drugs The simple home-based balance training, as undertaken in this
Yes 22 42.3 13 25.0 0.096 study, tries to meet these criteria. To obtain benefits from balance
No 30 57.7 39 75.0 exercises, it is concluded that exercises should challenge balance
Use sedative or psychotic drugs
reactions, be dynamic in nature, involve weight shift, be performed
Yes 4 7.7 1 1.9 0.363
No 48 92.3 51 98.1 without upper limb support, be of moderate intensity, and be
progressive23. Improving balance and fear of falling may have im-
No significant difference between the exercise and control groups at p < 0.05.
plications for function and activity for older adults. These physical
and psychological changes may also be associated with increased
when compared with baseline, after 3, 6, 9, and 12 months activity levels, which were also evident in previous studies22e24. An
(p < 0.001). There was no statistically significant difference in the individualized balance training home exercise program led by
control group after 3, 6, 9, and 12 months (p < 0.05) when trained nurses is feasible for the community-dwelling older adults
compared with baseline, as shown in Fig. 1. The time for per- and may improve stability during walking and other functional
formed timed up-and-go test of the exercise group was decreased activities. These improvements are consistent with previous
significantly when compared with baseline, after 3, 6, 9, and 12 studies, which have shown that among relatively healthy older
months (p < 0.001). There was no statistically significant adults, home-based exercise programs have greater adherence
difference in the control group when compared with baseline, rates than groups-based community programs and are effective in
after 3, 6, 9, and 12 months (p < 0.05), as shown in Fig. 2. In improving functional performance and balance in functionally
addition, the Thai FES-I scores of the exercise group decreased impaired older adults25. In addition, supervision by a healthcare
significantly when compared with baseline, after 3, 6, 9, and 12 professional in home-based exercise demonstrated more positive
months (p < 0.001). The Thai FES-I scores indicated no significant health outcomes than in a comparable unsupervised program25.
difference in the control group when comparing their baseline data All participants completed the program. When asked whether
with additional data after 3, 6, 9, and 12 months (p < 0.05), as they were satisfied with the exercise, none of these reported dif-
shown in Fig. 3. ficulty in completing the program. It is likely that the feasibility of
the program is compromised by the response from these partici-
4. Discussion pants; however, issues on motivation to undertake exercise may
require more focus. It is acknowledged that the study has two
The results of this study demonstrated that a simple home- limitations. Firstly, the sample size is small because of difficulty
based balance training program is feasible for Thai rural older
adults, providing preliminary support to improve outcomes on a
number of balance performance measures and fear of falling. These
improvements are consistent with previous studies that have
shown benefits from the simple home-based balance training22,23.

Table 2
Comparison of age, balance performances, and fear of falling (baseline) (n ¼ 104).

Variables Exercise group Control group t p

(n ¼ 52) (n ¼ 52)

M SD M SD

Age 74.35 8.59 68.37 7.33 1.09 0.297

Balance performances
Functional reach test 5.63 0.68 5.54 0.89 1.03 0.312
Timed up-and-go test 15.45 0.45 14.85 0.34 0.94 0.631
Fig. 2. Comparison of the timed up-and-go test between the exercise and control
Thai FES-I scores 31.46 9.28 29.69 7.25 3.15 0.790
groups. Significantly different compared to baseline in the exercise group at
No significant difference between the exercise and control groups at p < 0.05. p < 0.001. Not significantly different compared to baseline in the control group at
FES-I ¼ Falls Efficacy Scale-International; M ¼ mean; SD ¼ standard deviation. p < 0.05.
146
Fig. 3. Comparison of the fear of falling scores between the exercise and control
groups. Significantly different compared to baseline in the exercise group at p < 0.001.
Not significantly different compared to baseline in the control group at p < 0.05.
recruiting participants within the study period. This problem was
magnified on measures, because of missing data. There is potential
bias in excluding participants with missing data from a specific
analysis, but when the mean substitution approach to manage
missing data was performed, results remained unchanged. Sec-
ondly, it is possible that factors other than balance training may
have played a role in the lower fear of falling scores observed in the
exercise group. The control group did not take part in an equivalent
non-balance training activity, so there is the potential that the
educational component of the program may have contributed to
behavioral changes and subsequent lower fear of falling scores re-
ported in the exercise group.
In summary, an individualized balance training home exercise
program led by trained nurses is feasible for rural older adults and
may improve stability during walking and other functional activ-
ities; however, these outcomes need to be evaluated within a cost-
effectiveness analysis. This simple home-based balancing training
was safe, effective, and acceptable to older adults and healthcare
providers. It is likely that nurses are at the forefront of providing
community health services and play an essential role in the pre-
vention of falls. Therefore, nurses must concentrate on assessing
the fall-prone older adults to identify the potential causes of a fall,
especially balance impairment, and provide this effective strategy
for improving balance performance and fear of falling.
Acknowledgments
This project was funded by a grant from the National Grant and
Institute of Research and Development, Walailak University
(WU53110). We are grateful for the older adults, caregivers and
healthcare providers who made this study possible.
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