Tinetti balance and gait evaluation pdf

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Invest Clin 61(3): 1330-1337, 2020

Effect of Gait Balance Health Exercise in the Prevention of Falls in the Elderly

Huilei Hou

Shijiazhuang No.1 Hospital, Shijiazhuang 050011, Hebei, China

Abstract With China's gradual entry into an aging society, the fall of the elderly has become a serious public health problem. Many countries in the world have relatively mature clinical practice guidelines to prevent falls. Domestic researchers have also designed action exercises to prevent falls for the elderly. It is found that anti falls exercises can enhance the muscle strength of the upper and lower limbs, improve the coordination and balance of the body, and adhere to exercise can reduce the occurrence of falls for the elderly and improve the quality of life of the elderly. In this study, a set of gait balance health exercise was developed to prevent falls in combination with the Tinetti gait balance test project. The application effect of the gait balance health exercise was evaluated by analyzing the Morse fall risk score, Tinetti gait balance test score, time to stand to walk test score, elderly fall efficacy score and other indicators. The results show that the gait balance health exercise can effectively improve the gait of the elderly, improve their gait stability and balance ability, improve their fear of falling and choose inactivity, and reduce the incidence of falling. In this study, gait balance exercise was used to reduce the incidence of falls, the medical cost and human resource waste caused by falls, and to achieve win-win economic and social effects. Keywords: Gait Balance Exercise, Elderly, Fall

1.Introduction

Fall refers to the uncontrolled or unintentional fall of the human body to the ground or other lower plane. Falls exclude the causes of strong blow, loss of consciousness, sudden paralysis or epilepsy [1]. Fall is an important factor affecting the disability and death of the elderly. According to the relevant statistical data, under the background of the accelerated global aging process, the number of people who fall to death increases by 12.7% every year, and the probability of falls for the elderly over 80 years old is as high as 50%; 5% - 10% of the elderly fall will cause fractures, dislocations, soft tissue damage and brain tissue damage, And the patients will have fear and anxiety after falling, which will seriously affect the normal physical and mental health of the elderly [2] .

In 2015, according to the statistics of the National Working Committee on aging, there are 220 million people over 60 years old in China, accounting for 16.15% of the total population. About 30% - 40% of the elderly have fallen once or many times every year. About 25 million people are hospitalized for falls every year [3]. According to the data statistics of the fifth census of Hebei Province, the growth rate of the elderly population in our province is the fastest from 2000 to 2020, which belongs to the important period of the rapid development of aging. In the process of the total increase of the elderly population, the proportion of the elderly over 80 years old in the elderly population is increasing rapidly. By 2050, it can account for 39% of the elderly population [4]. In addition, according to the fall survey conducted by Shijiazhuang Center for Disease Control and prevention in the elderly over 60 years old, about 11.2% of the elderly fall every year, 14.4% of the elderly who fall need to be hospitalized, and 24.4% need to go to the hospital for emergency treatment. Falls will not only cause disability and threaten the physical and mental health of the elderly, but also bring heavy burden and pressure to the family, resulting in a waste of medical resources [5].

There are many potential factors for falls in the elderly, such as drug factors, disease factors, cognitive factors and so on. Falling is not just an accident, but a behavior that can be prevented and controlled. The United States, the United Kingdom, Australia and other countries have relatively mature clinical practice guidelines to prevent falls, but these guidelines are from the perspective of public health summarized the evidence and experience of the prevention of falls for the elderly at home and abroad, and then put forward the intervention measures and methods. Most of the foreign countries use resistance training and aerobic exercise to improve the balance and physical function of the elderly [6]. In recent years, the research on prevention of falls in China has gradually risen, but there is no real effective prevention and control method and complete institutional services. At present, the research direction of preventing falls in China is mainly for inpatients. The methods mainly

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include fall risk grading nursing, different health education modes, fall process management methods, specialized nurses' fall prevention methods, evidence-based nursing methods, etc. So far, the globally recognized fall prevention effect is significant in health education and exercise [7].

With the help of the core strength training theory and various gait characteristics of the elderly, the gait balance health exercise is to develop a set of health exercise to prevent the elderly from falling. The core strength training theory is the theory of strength ability to study the stability of the core area of the human body, control the movement of the center of gravity, and transfer the strength of the upper and lower limbs. The core area mainly includes the waist, pelvis, hip joint and all muscle groups. Core strength training can improve the stability, balance and conduction of the body's center of gravity [8]. The Tinetti balance and gait analysis consists of balance and gait test. Balance test includes nine items: sitting balance, getting up, trying to get up, immediately standing up balance function, sitting balance, jogging, closing eyes, turning 360 °, sitting. Gait test includes nine items: starting, foot lifting height, step length, gait symmetry, step continuity, walking path, trunk stability, step width [9]. Cheng [10] scholars use cspdca model to design their own fall prevention exercises for the elderly. It is found that the exercise can enhance the muscle strength of the upper and lower limbs, improve the coordination and balance of the body, promote the clear mind, and adhere to the exercise can reduce the occurrence of falls and improve the quality of life of the elderly. Essien [11] research balance and muscle exercise exercise can improve the balance ability and muscle strength of the elderly patients, So as to reduce the fall risk of elderly patients. This study randomly selected 60 elderly people who have no barrier to their ability of self-care in a pension institution to explore the effect of gait balance health exercise on improving their ability of gait balance and reducing the risk of falls. The research has achieved good results. Now the relevant situation is reported as follows.

2. Materials and Methods

2.1 Research Object

60 elderly people with no barrier to self-care ability in a pension institution were randomly selected and divided into experimental group and control group according to the method of random number table, 30 in each group. There were 17 males and 13 females in the experimental group, aged 65-77 years, with an average age of (72.54 ± 1.83) years, including 11 patients with hypertension, 6 with hyperglycemia, 4 with respiratory diseases, and 9 without underlying diseases. In the control group, there were 15 males and 15 females, aged 65-78, with an average age of (71.66 ± 1.35) years, including 8 cases of hypertension, 4 cases of hyperglycemia, 2 cases of respiratory system disease, 3 cases of digestive system disease, 1 case of renal insufficiency, 2 cases of mild Alzheimer's disease, and 10 cases without basic diseases. All the elderly patients met the clinical rational medication standard, and there was no statistical difference in the basic data of the selected elderly, such as name, gender, age, basic diseases, commonly used oral drugs, P > 0.05.

2.2 Inclusion and Exclusion Criteria

Inclusion criteria: age ≥ 65 years old; clear consciousness, no obstacle in daily life, no obvious communication obstacle, able to understand and cooperate with operation; healthy limbs, no obvious discomfort in both legs in the near future; signing informed consent;

Exclusion criteria: nervous system disease with brain dysfunction; serious internal disease, systemic multiple organ failure; previous history of mental disease; total failure to cooperate more than 16 times during 16 weeks of intervention.

2.3 Research Methods and Implementation

The experimental group used gait balance exercise twice a week, 30 minutes each time, for a total of 16 weeks. There was no intervention in the control group. The composition of gait balance and health exercise: there are 8 kinds of gait, including 14 movements, such as standing with eyes open, standing with eyes closed, center of gravity transfer, crouching slightly, starting sideways, standing and heel lifting, standing and walking in place, Among them, the five gait of standing with eyes open, standing with eyes closed, micro squatting with knees bent, turning movement and side starting are divided into left and right directions, and the center of gravity transfer is divided into front, back, left and right and side three movements, each of which is twice for 15 minutes. All movements are designed gently and slowly, fully considering the physiological characteristics of the elderly, so that the elderly feel safe and assured in the practice of gait balance exercise. The implementation of gait balance health exercise: on the basis of routine daily food and daily life, the 30 minute gait balance health exercise is carried out twice a week, four times a week. This study was carried out jointly by three persons who had received unified training. A Japanese doctor of health care and a geriatric expert set up a "safety and quality control" group to patrol and ensure the safety of the elderly during the research process.

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2.4 Evaluation Indicators

The Morse fall risk score, Tinetti gait balance test score, timed up walking test score, fall efficacy score of the elderly and the number of falls of the patients were assessed before, at the eighth and sixteenth weeks of the intervention; ① Morse Fall assessment scale, Morse The scale specially developed in 1989 to assess the fall risk of patients mainly includes fall history, more than one medical diagnosis, walking assistance, intravenous therapy / heparin lock, gait and cognitive status items. See Table 1 for the scoring standard. ② This scale is a fast and quantitative method to evaluate functional walking ability. If the test time is more than 30s, it means there is activity obstacle; if the test time is 20-29s, it means the activity is unstable; if the test time is less than 20s, it means most of the subjects can move independently; if the test time is less than 10s, it means they can move freely. ③ Tinetti gait balance scale, which includes balance and gait. The balance test includes nine items: sitting balance, getting up, trying to get up, immediately standing up balance function, sitting balance, jogging, closing eyes, turning 360 ° and sitting down. The gait test includes eight items: starting, foot lifting height, step length, gait symmetry, step continuity, walking path, trunk stability and step width. The total score is 28 points. If the test result is less than 15 points, it means there is a risk of falling. If the score is less than 24 points, it means there is balance dysfunction. ④ Fall effect energy scale for the elderly, which includes 14 items, including changing clothes, preparing simple meals, bathing, rising and falling from chairs, going to bed and getting out of bed, answering the door or answering the phone, walking around in the room, reaching for things in the box or drawer, doing light physical housework, simple shopping, taking public transportation, crossing the road, doing light physical gardening or drying clothes, going up and down stairs 。 A total of 140 points. The lower the score, the lower the confidence of the subjects, and the more likely they are to fall.

Table 1. Mores Fall Assessment scale

History of falls Yes=25 Points No=0 Points More than one medical

diagnosis Yes=25 Points No=0 Points

Walking Assisted Bed rest is taken care of by nurses or not needed = 0 point; Walking with walking sticks, walking aids, crutches = 15

points; Walking with supporting furniture = 30 points

intravenous treatment/ heparin lock

Yes=25 Points No=0 Points

Gait

For normal gait, no activity in bed rest = 0 point For weakness and weakness of both legs = 10 points For disability or dysfunction = 20 points

cognitive state Walking according to strength = 0 point Overestimate yourself or forget to limit yourself = 15 points

2.5 Statistical Method

Use epidata3.1 to input the data, spss21.0 to analyze the data. The measurement data of Morse fall risk score, Tinetti gait balance test score, time rising walking test score and elderly fall efficacy score before and

after the intervention were expressed as " sx  " and t test was used. P < 0.05 was statistically significant.

3. Results

3.1 Comparison of Morse Fall Assessment Scores Between The Two Groups Before Intervention, 8 Weeks After Intervention and 16 Weeks After Intervention

The Morse score of the elderly in the experimental group decreased gradually, which was statistically significant before and after the intervention. There was no statistical difference in the scores of the control group. There was no statistical difference in Morse score between the two groups before intervention (P > 0.05); after 8 weeks of intervention, the difference between the two groups was statistically significant (P < 0.05); after 16 weeks of intervention, the scores of the two groups were statistically significant (P < 0.01).See Table 2 for details.

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Table 2. Comparison Morse Fall score Groups n after the

intervention after 8 weeks of

intervention after 16 weeks of

intervention experimental

group 30 62.74±11.37 43.62±8.24 31.70±6.43

control group 30 60.86±10.43 61.32±10.26 61.32±10.26 t 1.863 8.354 11.655 P >0.05 <0,05 <0.01

3.2 Comparison of the Scores of Time up and go test and ROC Curve analysis Between the Two Groups

The results showed that the completion time of tugt was 11.85s in the experimental group and 14.62 in the control group. There was statistical significance between the two groups (P < 0.05).

ROC curve was used to analyze the fall prediction efficacy of tugt in two groups of elderly. The best critical value of tugt in the control group was 12.54s, at this time AUC was 0.685, sensitivity was 76.8%, specificity was 68.3%; the best critical value of tugt in the experimental group was 11.07s, AUC was 0.694, sensitivity was 75.6%, specificity was 69.6%; see Figure 1 and Figure 2 for details.

Figure1. The control group Figure 2. The experimental group

3.3 Comparison of the Scores of Tinetti Gait Balance Experiment Between the Two Groups Before Intervention, 8 Weeks After Intervention and 16 Weeks After Intervention

The gait and balance scores of the elderly in the experimental group showed a gradual upward trend, which was statistically significant before and after the intervention. There was no statistical difference in the scores of the control group. There was no statistical difference between the two groups in the scores of Tinetti gait and balance experiment before intervention (P > 0.05); after eight weeks of intervention, the scores of balance and gait gradually increased, and the difference between the two groups increased, the difference was statistically significant (P < 0.05); after 16 weeks of intervention, the scores of gait and balance of the two groups were statistically significant (P < 0.01).See Table 3 for details.

Table 3. Comparison Tinetti Gait and Balance Scores Groups n balance scores

gait scores

after the intervention

after 8 weeks of

intervention

after 16 weeks of

intervention

after the interventio

n

after 8 weeks of

interventio n

after 16 weeks of interventi

on experimental

group 30 10.36±3.17 11.26±3.63 12.54±3.63 6.74±2.18 7.45±3.02 8.16±4.07

control group 30 10.14±3.08 10.29±3.14 10.14±3.08 6.53±2.60 6.47±2.48 6.38±2.92 t 0.443 5.825 13.965 0.138 4.975 14.873 P >0.05 <0.05 <0.01 >0.05 <0.05 <0.01

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3.4 Comparison of Fall Efficacy Scores of the Elderly in the Two Groups Before, 8 Weeks and 16 Weeks After Intervention

The fall efficacy score of the elderly in the experimental group increased gradually, and there was statistical significance before and after the intervention. There was no statistical difference in the scores of the control group. There was no statistical difference between the two groups in the score of fall efficacy before intervention (P > 0.05); after 8 weeks of intervention, the difference between the two groups was statistically significant (P < 0.05); after 16 weeks of intervention, the difference between the two groups was significantly increased (P < 0.01).See Table 4 for details.

Table 4. Comparison of Fall Efficacy Scores of the Elderly Groups n after the

intervention after 8 weeks of

intervention after 16 weeks of

intervention experimental

group 30 46.34±9.36 57.40±10.53 73.89±12.86

control group 30 47.41±8.75 48.62±9.45 47.94±8.66 t 0.861 6.722 15.482 P >0.05 <0.05 <0.01

3.5 Comparison of the Falls of the Elderly in the Two Groups Before, 8 Weeks and 16 Weeks

The falls of the elderly in the experimental group were statistically different before and after the intervention, and the falls of the elderly were less and less. There was no significant difference in the number of falls in the control group. Before the intervention, the number of falls ≤ 1 in the experimental group and the control group was 20%, 23.3%; the number of falls ≤ 2 was 20%, 16.7%; there was no significant statistical difference between the two groups, P > 0.05; after 8 weeks, the number of falls ≤ 1 in the experimental group and the control group was 13.4%, 20%; the number of falls ≤ 2 was 16.7%, 16.7%; the difference between the two groups was statistically significant, P < 0.05; after 16 weeks of intervention, falls ≤ 1 in the experimental group and the control group were 10%, 23.3%; falls ≤ 2 times were 6.7%, 20%; there was a significant statistical difference between the two groups, P < 0.01.See Table 5 for details.

Table 5. Comparison of the Falls of the Elderly

Groups n after the intervention after 8 weeks of intervention

after 16 weeks of intervention

falls≤1 falls≤2 falls≤1 falls≤2 falls≤1 falls≤2 experi mental group

30 6（20%） 6（20%） 4（13.4%） 5（16.7%） 3（10%） 2（6.7%）

control group

30 7（23.3%） 5（16.7%） 6（20%） 5（16.7%） 7（23.3%） 6（20%）

t 2.343 1.975 4.803 0.000 17.326 14.753 P >0.05 >0.05 <0.05 >0.05 <0.01 <0.01

4.Discussion

4.1 Influencing Factors of Falls in the Elderly

Fall is the primary cause of injury and death in the elderly over 65 years old. The causes of falls can be divided into internal causes and external causes. The internal causes mainly include age, gender, fall history, nutritional status, physical disease, psychological factors, balance and gait, living alone, etc. The external causes are environmental factors, such as smooth ground, obstruction, too dark light and so on. Studies have shown that older women are twice as likely to fall as older men, and older people with a history of falls are more likely to fall a second time [12] . From the psychological point of view, the elderly will have a psychological shadow of "fear of falling" when they reach a certain age. Under this psychological effect, the scope and ability of the elderly's activities will gradually shrink and decrease, which will lead to the defect of the elderly's activity function and increase the risk of falling. The main cause of falls is the decline of gait ability and balance ability. From the perspective of biomechanics, the lower limb muscle contraction function of the elderly is decreased, the heel landing, ankle and plantar flexion and knee joint extension and flexion are slow, the degree of leg elevation is reduced, and the gait is unstable. Therefore, the elderly falls easily[13] .

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4.2 Fall and Gait Balance Health Exercise for the Elderly

Resistance training and aerobic training are widely used in foreign countries to strengthen the muscle strength of the lower limbs to prevent the elderly from falling, but some of the movements and training methods are not suitable for the physical characteristics of the elderly in China [14] . The health exercise of gait balance fully considers the physiological characteristics of the elderly in China, so that the elderly feel safe and assured in the training of gait balance exercise. The gait balance health care exercise is divided into 8 kinds of gait, including 14 movements such as open eye standing, closed eye standing, center of gravity transfer, curving knee micro squatting, side starting, standing heel lifting, standing on the spot and so on. Among them, open eye standing, closed eye standing, curving knee micro squatting, turning movement, side starting 5 gait are divided into left and right directions, center of gravity transfer is divided into front, back, left and right and side three movements. The movement of gait balance health care exercise combines science and feasibility, is easy to learn and safe. It mainly exercises the gait balance of the elderly, and plays a certain role in enhancing the activity ability, self-confidence and self-esteem of the elderly.

4.3 Innovation and Application of Gait Balance Health Exercise

Based on the core strength theory and the gait characteristics of the elderly, combined with the measurement project of Tinetti's gait balance, we consulted many elderly care experts, geriatric medicine experts, rehabilitation medicine experts, etc. to develop a gait balance health exercise suitable for the elderly in China. In this study, the elderly who have no barrier to self-care ability of the elderly care institutions are selected, which is more extensive and representative than the elderly patients in hospital. In the study, the experimental group carried out a total of 16 weeks of gait balance health exercise training, and twice a week. During the training process, a professional safety and quality team was equipped to patrol to ensure the safety of the elderly. In the study, Morse fall risk score, Tinetti gait balance test score, timed rise walk test score and fall efficacy score were selected for the fall risk assessment of the elderly.

Morse fall risk score has high sensitivity and specificity. When the diagnostic value is 50, the specificity of Morse Fall scale is 55.8%, the sensitivity is 78.9%, and the positive and negative predictive values can reach 30.8% and 91.4%[15] . Tinetti gait balance scale is widely used in foreign countries to evaluate the balance gait. In the fall risk prediction of the elderly in China, the internal consistency Cronbach a coefficient of the scale is 0.887, the balance subscale is 0.872, and the gait subscale is 0.718, which shows that it has good stability and reliability, and the reliability and validity of the scale are better[16]. The time "up and go" test (tugt) can effectively evaluate the ability of balance, walking and other functional movements needed by the elderly in daily life. In previous studies, it has good reliability and validity. Cronbach a coefficient is 0.983. In the reliability and validity analysis, the reliability of the elderly's fall efficacy score was 0.977, and the correlation coefficient was 0.637-0.92617. The results are scientific and reliable [17].

4.4 Effect of Gait Balance Exercise on Falls of the Elderly

After falling down, the elderly will have limited daily activities, decreased quality of life, and may cause a lot of economic costs and social human resources tension caused by the use of human care. The purpose of this study is to improve the gait stability and balance ability of the elderly, to improve their fear of falling and choose inactivity, to reduce the incidence of falls and the medical cost and human resource waste caused by falls [18]. In the course of this study, it was found that the Morse score of the elderly in the experimental group who had the gait balance health exercise training was gradually decreasing, which indicated that the risk of falls of the elderly in this group was gradually decreasing. After 8 weeks and 16 weeks of intervention, the difference of Morse score between the two groups is more and more big, t value is 11.655, there is significant statistical difference between the two groups, indicating that the gait balance health exercise has a good effect on improving the gait balance. The results of Tinetti gait balance scale showed that the balance score and gait score of the elderly in the experimental group were higher and higher as time went on, which indicated that the elderly in the experimental group had stronger and stronger gait balance ability.

The fall effect energy scale for the elderly is an important scale to evaluate the confidence of the subjects, which can indicate the possibility of falls. The lower the score, the lower the confidence of the subjects, and the more likely they are to fall. After the training of gait balance and health exercise, the performance score of the elderly in the experimental group is higher and higher, which indicates that the confidence of the elderly in the experimental group is also higher and higher, suggesting that the possibility of falling is becoming smaller and smaller. Tugt is a scale with good reliability and validity to measure falls. In this study, it was found that the predicted time of falls in the elderly in the experimental group was longer than that in the control group, suggesting that the elderly in the control group were more likely to fall. There was statistical difference between the two groups. ROC curve showed that the optimal critical value of tugt in the control group was 12.54s, AUC was 0.685, sensitivity was 76.8%, specificity was 68.3%; the optimal critical value of tugt in the experimental

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group was 11.07s, AUC was 0.694, sensitivity was 75.6%, specificity was 69.6%. After 16 weeks of intervention, the number of falls in the experimental group and the control group was 10%, 23.3%, 6.7% and 20% respectively, and there was significant statistical difference between the two groups (P < 0.01).

5.Conclusions

With the aging society becoming more and more serious, falls of the elderly have become one of the focuses in the medical field. In addition to the death of the elderly, falls can also lead to a large number of disabilities, which seriously threaten the physical and mental health, daily activities and the ability to live independently of the elderly, increase the economic and mental burden of caregivers and family members, and also cause the waste of medical resources and social human resources. At present, both at home and abroad are actively carrying out the work of preventing falls of the elderly, and many interdisciplinary fall prevention measures, such as health education and sports training, are adopted abroad. The prevention of falls in China is mainly aimed at the evidence-based nursing of inpatients and the prevention of falls by specialized nurses[19] . This study mainly developed a set of health exercise for the elderly with self-care ability in the nursing home. It drew lessons from the core strength theory and the gait characteristics of the elderly, combined with the measurement project of Tinetti gait balance, consulted many elderly care experts, geriatricians, rehabilitation medicine experts and other development of gait balance health exercise for the elderly in China. The health care exercises include the combination of scientific and feasible actions, simple and easy to learn, high safety, mainly exercise the gait balance of the elderly, and play a certain role in enhancing the activity ability, self-confidence and self-esteem of the elderly.

In conclusion, gait balance health exercise can effectively improve the gait stability and balance ability of the elderly, improve their fear of falling and choose inactivity, reduce the incidence of falls and the medical cost and human resource waste caused by falls, and achieve a win-win economic and social effect. Acknowledgement

The research and application of gait balance exercise in preventing falling among seniors (20181031).

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