Examining the Effect of Exercise Interventions on Balance and Fall Prevention in the Elderly: A Systematic Review
الموضوعات : Exercise Physiology and Performance
Zeynab Amini Valashani
1
,
Hasan Daneshmandi
2
,
Reza Khazaei
3
1 - Department of corrective exercise and sport injuries, Faculty of Physical Education & Sport Sciences, University of Tehran, Tehran, Iran.
2 - Department of sport injuries and corrective exercise, Faculty of Physical Education & Sport Sciences, University of Guilan, Rasht, Iran.
3 - Department of corrective exercise and sport injuries, Faculty of Physical Education & Sport Sciences, Shahid Bahonar University of Kerman, Kerman, Iran.
الکلمات المفتاحية: Balance, Falls Accidental, , Aged, Exercise Interventions, Prevention,
ملخص المقالة :
Background and purpose: With the growing elderly population worldwide, their associated problems are also increasing. Falls and their consequent outcomes are considered major health issues for the elderly, and imbalance is undoubtedly recognized as the primary cause of falls among the elderly.
Materials and methods: The aim of this study was to search for articles published in scientific and research journals from 2000 to 2020 and to review studies related to physical and exercise interventions aimed at improving balance and reducing the risk of falls in the elderly. Keywords such as elderly, older adults, aging, exercise, and falling were used to review the literature in electronic databases such as PubMed, Embase, Medline, SID, Scopus, and Google Scholar.
Results: A total of 190 articles were identified through the preliminary database search. One hundred studies were selected through title screening, and 90 of these records were excluded after abstract analysis. Of the remaining 50 articles, whose full texts were analyzed, 40 were excluded due to non-compliance with the inclusion criteria. Finally, 7 studies were identified as potentially relevant and met all the considered criteria.
Conclusion: It appears that the use of various exercise methods specifically designed for the elderly, such as home-based protocols like Otago, vestibular exercises such as Cawthorne and Cooksey, fall-proof exercises, and other similar exercises mentioned in the present study, which specifically challenge balance in the elderly, can enhance their abilities and consequently reduce the risk of falls.
1- Laessoe U, Hoeck HC, Simonsen O, Sinkjaer T, Voigt M. Fall risk in an active elderly population–can it be assessed?. Journal of negative results in biomedicine. 2007 Dec;6:1-1. doi:10.1186/1477-5751-6-2
2- Chodzko-Zajko W, Schwingel A, Hee C. Successful Aging: The Role of Physical Activity. American Journal of Lifestyle Medicine. 2009;3(1):20-28. doi:10.1177/1559827608325456
3- Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Bmj. 2004 Mar 18;328(7441):680. doi:/10.1136/bmj.328.7441.680
4- Safavi Bayat Z, Zorriasatain F. Determining risk factors associated with falling among elderly at residential care facilities in Tehran. Journal of Inflammatory Diseases. 2008 Feb 10;11(4):66-70. ID: emr-143440.[in persian]
5- Kamrani AA, Azadi F, Foroughan M, Siadat S, Kaldi A. Characteristics of falls in elderly residents of nursing homes. Iranian Journal of Ageing. 2007;1(2):101-5. URL: http://salmandj.uswr.ac.ir/article-1-19-en.html.[in persian]
6- Nejc S, Loefler S, Cvecka J, Sedliak M, Kern H. Strength training in elderly people improves static balance: a randomized controlled trial. European Journal of Translational Myology. 2013 Jul 25;23(3):85-9. doi.org/10.4081/ejtm.2013.1777
7- Granata KP, Lockhart TE. Dynamic stability differences in fall-prone and healthy adults. Journal of Electromyography and Kinesiology. 2008 Apr 1;18(2):172-8. doi:/10.1016/j.jelekin.2007.06.008
8- Pizzigalli L, Filippini A, Ahmaidi S, Jullien H, Rainoldi A. Prevention of falling risk in elderly people: the relevance of muscular strength and symmetry of lower limbs in postural stability. The Journal of Strength & Conditioning Research. 2011 Feb 1;25(2):567-74. doi: 10.1519/JSC.0b013e3181d32213
9- Ungar A, Rafanelli M, Iacomelli I, Brunetti MA, Ceccofiglio A, Tesi F, Marchionni N. Fall prevention in the elderly. Clinical Cases in mineral and bone metabolism. 2013 May;10(2):91. PMID: 24133524
10- de Almeida ST, Soldera CL, de Carli GA, Gomes I, de Lima Resende T. Analysis of extrinsic and intrinsic factors that predispose elderly individuals to fall. Revista da Associação Médica Brasileira (English Edition). 2012 Jul 1;58(4):427-33. doi:10.1016/S2255-4823(12)70224-2
11- Marschollek M, Rehwald A, Wolf KH, Gietzelt M, Nemitz G, zu Schwabedissen HM, Schulze M. Sensors vs. experts-a performance comparison of sensor-based fall risk assessment vs. conventional assessment in a sample of geriatric patients. BMC medical informatics and decision making. 2011 Dec;11:1-7. doi:10.1186/1472-6947-11-48
12- Howcroft J, Kofman J, Lemaire ED. Review of fall risk assessment in geriatric populations using inertial sensors. Journal of neuroengineering and rehabilitation. 2013 Dec;10:1-2. doi:10.1186/1743-0003-10-91
13- Yoshida-Intern S. A global report on falls prevention epidemiology of falls. Geneva: WHO. 2007 Apr 21.
14- Campbell AJ, Robertson MC. Rethinking individual and community fall prevention strategies: a meta-regression comparing single and multifactorial interventions. Age and ageing. 2007 Nov 1;36(6):656-62. doi:10.1093/ageing/afm122
15- Hartholt KA, van Beeck EF, Polinder S, van der Velde N, van Lieshout EM, Panneman MJ, van der Cammen TJ, Patka P. Societal consequences of falls in the older population: injuries, healthcare costs, and long-term reduced quality of life. Journal of Trauma and Acute Care Surgery. 2011 Sep 1;71(3):748-53. doi: 10.1097/TA.0b013e3181f6f5e5
16- Lopes KT, Costa DF, Santos LF, Castro DP, Bastone AC. Prevalence of fear of falling among a population of older adults and its correlation with mobility, dynamic balance, risk and history of falls. Brazilian Journal of Physical Therapy. 2009;13:223-9. doi: 10.1590/S1413-35552009005000026
17- Resende SM, Rassi CM. Effects of hydrotherapy in balance and prevention of falls among elderly women. Brazilian Journal of Physical Therapy. 2008;12:57-63. doi:10.1590/S1413-35552008000100011
18- Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW, Kelly-Hayes M, Wolf PA, Kreger BE, Kannel WB. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. American journal of public health. 1994 Mar;84(3):351-8. doi:10.2105/AJPH.84.3.351
19- Hosseini L, Kargozar E, Sharifi F, Negarandeh R, Memari AH, Navab E. Tai Chi Chuan can improve balance and reduce fear of falling in community dwelling older adults: a randomized control trial. Journal of exercise rehabilitation. 2018 Dec;14(6):1024. doi: 10.12965/jer.1836488.244.[in persian]
20- Shahbazian M ,Daneshmandi H., the effect of 6 weeks of virtual reality exercises on posture control and motor performance of elderly women.2022. https://civilica.com/doc/1599443.[in persian]
21- Shimada H, Suzukawa M, Ishizaki T, Kobayashi K, Kim H, Suzuki T. Relationship between subjective fall risk assessment and falls and fall-related fractures in frail elderly people. BMC geriatrics. 2011 Dec;11:1-8. doi:10.1186/1471-2318-11-40
22- Carter ND, Kannus P, Khan K. Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Sports medicine. 2001 May;31:427-38. doi:10.2165/00007256-200131060-00003
23- Arnold CM, Sran MM, Harrison EL. Exercise for fall risk reduction in community-dwelling older adults: a systematic review. Physiotherapy Canada. 2008 Oct;60(4):358-72. doi.org/10.3138/physio.60.4.358
24- Balzer K, Bremer M, Schramm S, Lühmann D, Raspe H. Falls prevention for the elderly. GMS health technology assessment. 2012;8. doi: 10.3205/hta000099
25- Daneshmandi H. The effect of virtual reality training program on the Functional Fitness of the elderly. Journal of Gerontology. 2021 Apr 10;6(1):32-41. URL: http://joge.ir/article-۱-۴۴۸-fa.html.[in persian]
26- Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, Ory MG, Sattin RW, Tinetti ME, Wolf SL, Schechtman KB. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. Jama. 1995 May 3;273(17):1341-7. doi:10.1001/jama.1995.03520410035023
27- Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH, Cochrane Bone, Joint and Muscle Trauma Group. Interventions for preventing falls in elderly people. Cochrane database of systematic reviews. 1996 Sep 1;2009(1). doi:10.1002/14651858.CD000340
28- Ansai JH, Aurichio TR, Gonçalves R, Rebelatto JR. Effects of two physical exercise protocols on physical performance related to falls in the oldest old: A randomized controlled trial. Geriatrics & gerontology international. 2016 Apr;16(4):492-9. doi:10.1111/ggi.12497
29- Daneshmandi H, hoseinpour M. The role of muscle weakness in balance and postural instability in the elderly with and without falls: A Systematic review. joge 2022; 6 (4) :89-104
URL: http://joge.ir/article-1-532-fa.html.[in persian]
30- Leiros-Rodríguez R, García-Soidan JL. Balance training in elderly women using public parks. Journal of women & aging. 2014 Jul 3;26(3):207-18. doi:10.1080/08952841.2014.888220
31- Zhao Y, Chung PK, Tong TK. Effectiveness of a balance-focused exercise program for enhancing functional fitness of older adults at risk of falling: A randomised controlled trial. Geriatric nursing. 2017 Nov 1;38(6):491-7. doi:10.1016/j.gerinurse.2017.02.011
32- Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013 May 1;75(1):51-61. doi:10.1016/j.maturitas.2013.02.009
33- Sousa N, Mendes R, Silva A, Oliveira J. Combined exercise is more effective than aerobic exercise in the improvement of fall risk factors: a randomized controlled trial in community-dwelling older men. Clinical rehabilitation. 2017 Apr;31(4):478-86. doi:10.1177/02692155166558
34- Keysor JJ. Does late-life physical activity or exercise prevent or minimize disablement?: a critical review of the scientific evidence. American journal of preventive medicine. 2003 Oct 1;25(3):129-36. doi:10.1016/S0749-3797(03)00176-4
35- Sui X, LaMonte MJ, Laditka JN, Hardin JW, Chase N, Hooker SP, Blair SN. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. Jama. 2007 Dec 5;298(21):2507-16. doi:10.1001/jama.298.21.2507
36- Gaught AM, Carneiro KA. Evidence for determining the exercise prescription in patients with osteoarthritis. The Physician and sportsmedicine. 2013 Feb 1;41(1):58-65. doi:10.3810/psm.2013.02.2000
37- Gómez-Cabello A, Ara I, González-Agüero A, Casajús JA, Vicente-Rodriguez G. Effects of training on bone mass in older adults: a systematic review. Sports Medicine. 2012 Apr;42:301-25. doi: 10.2165/11597670-000000000-00000
38- Kouchaki E, Sedaghati P, Daneshmandi H. Comparing the fear of falling and quality of life outcomes following a functional movement protocol among the experimental and control idiopathic Parkinson cases. Feyz Medical Sciences Journal. 2016 Aug 10;20(3):252-9. URL: http://feyz.kaums.ac.ir/article-1-3084-en.html.[in persian]
39- Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC, Kriska A. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Jama. 1995 Feb 1;273(5):402-7. doi:10.1001/jama.1995.03520290054029
40- Leavey VJ. The comparative effects of a six-week balance training program, gluteus medius strength training program, and combined balance training/gluteus medius strength training program on dynamic postural control. West Virginia University ProQuest Dissertations & Theses; 2006.
41- Jung H, Yamasaki M. Association of lower extremity range of motion and muscle strength with physical performance of community-dwelling older women. Journal of physiological anthropology. 2016 Dec;35:1-9. doi:10.1186/s40101-016-0120-8
42- Mittaz Hager AG, Mathieu N, Lenoble-Hoskovec C, Swanenburg J, de Bie R, Hilfiker R. Effects of three home-based exercise programmes regarding falls, quality of life and exercise-adherence in older adults at risk of falling: protocol for a randomized controlled trial. BMC geriatrics. 2019 Dec;19:1-1. doi:10.1186/s12877-018-1021-y
43- Ward K. Effectiveness of FallProof home-based DVD program in improving balance, select functional fitness parameters, and balance-related confidence among community-dwelling older adults who have been identified as moderate to high risk of falls. oai:alma.01CALS_USL:11232444480001671
44- Bjerk M, Brovold T, Skelton DA, Liu-Ambrose T, Bergland A. Effects of a falls prevention exercise programme on health-related quality of life in older home care recipients: a randomised controlled trial. Age and ageing. 2019 Mar 1;48(2):213-9. doi:10.1093/ageing/afy192
45- Wati DN, Sahar J, Rekawati E. Effectiveness of Lafiska exercise on risk of fall, balance, and health status in the elderly. Enfermeria clinica. 2018 Feb 1;28:337-42. doi:10.1016/S1130-8621(18)30181-5
46- Park JH. The effects of eyeball exercise on balance ability and falls efficacy of the elderly who have experienced a fall: A single-blind, randomized controlled trial. Archives of gerontology and geriatrics. 2017 Jan 1;68:181-5. doi:10.1016/j.archger.2016.10.006
47- Khazanin H, Daneshmandi H. Effect of selected fallproof exercise on static and dynamic balance in the elderly. The Scientific Journal of Rehabilitation Medicine. 2020 Sep 22;9(3):16-26. doi:10.22037/JRM.2019.112562.2218.[in persian]
48- Zambare PD, Soni N, Sharma P. Effect of Cawthorne and Cooksey exercise program on balance and likelihood of fall in older women. Ind J Physioth Occupat Therapy-An Inter J. 2015 Jul;9:55. doi: 10.14196/mjiri.32.74
49- Thomas S, Mackintosh S, Halbert J. Does the ‘Otago exercise programme’reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age and ageing. 2010 Nov 1;39(6):681-7. doi:10.1093/ageing/afq102
50- Khazanin H, Daneshmandi H, Fakoor Rashid H. Effect of selected fall-proof exercises on fear of falling and quality of life in the elderly. Iranian Journal of Ageing. 2022 Feb 10;16(4):564-77. URL: http://salmandj.uswr.ac.ir/article--2174-1fa.html.[in persian]
51- Shubert TE, Smith ML, Ory MG, Clarke CB, Bomberger SA, Roberts E, Busby-Whitehead J. Translation of the Otago Exercise Program for adoption and implementation in the United States. Frontiers in public health. 2015 Apr 27;2:152. doi:10.3389/fpubh.2014.00152
52- Rose DJ. Reducing the risk of falls among older adults: the Fallproof Balance and Mobility Program. Current Sports Medicine Reports. 2011 May 1;10(3):151-6. doi: 10.1249/JSR.0b013e31821b1984
53- Macias JD, Massingale S, Gerkin RD. Efficacy of vestibular rehabilitation therapy in reducing falls. Otolaryngology—Head and Neck Surgery. 2005 Sep;133(3):323-5. doi:10.1016/j.otohns.2005.04.024
54- Zanardini FH, Zeigelboim BS, Jurkiewicz AL, Marques JM, Martins-Bassetto J. Vestibular rehabilitation in elderly patients with dizziness. Pró-Fono Revista de Atualização Científica. 2007;19:177-84. doi:10.1590/S0104-56872007000200006
55- Robinovitch SN, Feldman F, Yang Y, Schonnop R, Leung PM, Sarraf T, Sims-Gould J, Loughin M. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. The lancet. 2013 Jan 5;381(9860):47-54. doi:10.1016/S0140-6736(12)61263-X
56- Dashti P, Shabani M, Moazami M. Comparison of the effects of two selected exercises of Theraband and Pilates on the balance and strength of lower limb in elderly women. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2015 Jun 22;18(153):1-9.doi: 10.22038/IJOGI.2015.4698.[in persian]
57- Yaali R, Naeimi Kia M, Gholami A. Effect of weight transfer training on static and dynamic balance of older women. Research in Sport Management and Motor Behavior. 2018 Dec 10;8(16):47-59.doi: 10.29252/JRSM.8.16.47.[in persian]
58- de Bruin ED, Murer K. Effect of additional functional exercises on balance in elderly people. Clinical rehabilitation. 2007 Feb;21(2):112-21. doi:10.1177/0269215506070144
Accepted manuscript (author version)
To appear in Exercise Physiology and Performance (EPP)
Received: 2024/11/14 Revised: 2024/11/30 Accepted: 2024/12/08
DOI:
Examining the Effect of Exercise Interventions on Balance and Fall Prevention in the Elderly: A Systematic Review
Zeynab Amini1, Hasan Daneshmandi2*, Reza Khazaei3
1. Department of corrective exercise and sport injuries, Faculty of Physical Education & Sport Sciences, University of Tehran, Tehran, Iran.
2. Department of sport injuries and corrective exercise, Faculty of Physical Education & Sport Sciences, University of Guilan, Rasht, Iran.
3. Department of corrective exercise and sport injuries, Faculty of Physical Education & Sport Sciences, Shahid Bahonar University of Kerman, Kerman, Iran.
Abstract
Background and purpose: With the growing elderly population worldwide, their associated problems are also increasing. Falls and their consequent outcomes are considered major health issues for the elderly, and imbalance is undoubtedly recognized as the primary cause of falls among the elderly.
Materials and methods: The aim of this study was to search for articles published in scientific and research journals from 2000 to 2020 and to review studies related to physical and exercise interventions aimed at improving balance and reducing the risk of falls in the elderly. Keywords such as elderly, older adults, aging, exercise, and falling were used to review the literature in electronic databases such as PubMed, Embase, Medline, SID, Scopus, and Google Scholar.
Results: A total of 190 articles were identified through the preliminary database search. One hundred studies were selected through title screening, and 90 of these records were excluded after abstract analysis. Of the remaining 50 articles, whose full texts were analyzed, 40 were excluded due to non-compliance with the inclusion criteria. Finally, 7 studies were identified as potentially relevant and met all the considered criteria.
Conclusion: It appears that the use of various exercise methods specifically designed for the elderly, such as home-based protocols like Otago, vestibular exercises such as Cawthorne and Cooksey, fall-proof exercises, and other similar exercises mentioned in the present study, which specifically challenge balance in the elderly, can enhance their abilities and consequently reduce the risk of falls.
Keywords: Balance; Falls Accidental,; Aged; Exercise Interventions; Prevention
Introduction
Aging is likely the most significant demographic phenomenon of the 21st century, with definitions indicating that the onset of aging begins at the age of 65. The aging process is accompanied by a decline in the functioning of various bodily systems, with anatomical and physiological changes in the sensory-motor systems of the elderly leading to increased vulnerability and the occurrence of injuries. Given the growth of the elderly population worldwide, the associated problems are also on the rise, with falls and their consequences being major health issues for older adults. Imbalance is undoubtedly recognized as the primary factor contributing to falls among the elderly.
The most common cause of injuries in individuals over the age of 65 is falls at the same level or ground-level falls. Ground-level falls, defined as sudden events, are a common issue in the elderly population, leading to increased mortality, immobility, reduced functionality, hospitalization, and elevated societal costs. Annually, 28-35% of individuals over 64 years of age experience falls, with the frequency of falls increasing with age and fragility, reaching up to 50% in those over 80 years old. This represents a serious public health issue due to the high demand for healthcare services and the associated costs, significantly impacting each elderly individual. Falls result in consequences such as trauma, pain, functional deficits, and decreased confidence in performing daily activities, leading to reduced independence and even death. Factors associated with falls in the elderly include decreased self-efficacy, increased fear of falling, reduced mobility, and poor balance.
Various factors contribute to falls among the elderly. External factors account for 30% and internal factors for 35.5%. Poor lighting, uneven surfaces, and inappropriate footwear are environmental factors that increase the risk of falling. Additionally, 40-60% of falls among the elderly occur in the absence of a witness. Therefore, if various interventions (pharmaceutical, visual, exercise, etc.) can reverse or mitigate these disorders, the risk of falling and its irreparable consequences can be reduced. Several meta-analyses and review studies have shown that among all available interventions, exercise programs hold the greatest importance in terms of effectiveness and generalizability to larger groups of elderly individuals for fall prevention.
There are various types of exercise interventions, the most commonly used of which include balance exercises, resistance training, yoga, Pilates, sensory-motor exercises, aquatic exercises, and training on various stable and unstable surfaces, each designed and implemented with specific goals in mind. Some researchers have focused on resistance and aerobic exercises to enhance balance and reduce fall risk among the elderly, while others emphasize balance training aimed at engaging various sensory resources, including proprioceptors, the vestibular system, and visual input.
Ambrose et al. (2013) conducted a review study examining the risk factors influencing falls among the elderly. Their findings indicated that falls can result from environmental factors (poor lighting, uneven surfaces, stairs, and inappropriate footwear), physical illnesses, decreased alertness, seizures, sudden strokes, muscular weakness, a history of falls, gait difficulties, lack of balance, visual impairments, movement disorders, fear of falling, and other factors. These factors can also serve as tools for assessing fall risk among the elderly, allowing for the identification of individuals at risk of falling. Furthermore, Ambrose et al. concluded that the most significant risk factor or best tool for identifying elderly individuals at risk of falling is balance tests and kinetic and kinematic parameters of gait. Therefore, examining factors influencing balance and the kinetic and kinematic parameters of walking is of great importance.
Physical activity plays a crucial role not only in preventing age-related physical decline but also in reducing cardiovascular diseases and musculoskeletal degenerative conditions such as osteoporosis and arthritis. Many studies have proposed physical activity as a means to improve fitness and reduce physical fatigue. Some articles have investigated the effects of strength, endurance, aerobic, balance, and flexibility exercises, while others have explored the combined effects of these interventions, noting both their efficacy and ineffectiveness in fall prevention.
Attention to the phenomenon of aging, changes in bodily systems, falls and their consequences, and ultimately finding methods to slow aging and prevent falls have been focal points for researchers. On the other hand, selecting exercises that can be effective for the elderly in a short time with minimal resources has been the ultimate goal of researchers. Therefore, the aim of this review study is to examine the various exercise interventions used to enhance balance and to understand which of these can strengthen the abilities of older adults and support fall prevention.
Materials and Methods
The aim of this study was to explore published articles in scientific and research journals from 2000 to 2020, focusing on studies related to physical and exercise interventions aimed at improving balance and reducing the risk of falls among the elderly. The keywords elderly, older adults, aging, exercise, falling were used to search the literature in electronic databases such as PubMed, Embase, Medline, SID, Scopus, and Google Scholar. In the first stage, the screening of abstracts and titles was conducted, concentrating on various exercise interventions related to balance and fall risk in the elderly population, with publications available in both Persian and English. The researcher independently reviewed the abstracts of the articles, and in the second stage, a full-text screening was performed based on specific publication criteria (focusing on specific exercise programs) and clearly defined target populations. Descriptive information was collected and verified by the researcher. A standard sample table was utilized to extract information regarding the target population, balance measurement tools, fall risk levels, and their outcomes (Table 1). Exclusion criteria for the study included articles that did not pertain to healthy elderly individuals (those examining balance and fall risk in elderly patients with Parkinson's disease, Alzheimer's disease, orthopedic problems, stroke, spinal canal injuries, multiple sclerosis, motor neuron diseases, or peripheral nerve diseases). A total of 190 articles were identified through preliminary searches of the database. One hundred studies were selected through title screening, and 90 of these records were eliminated after abstract analysis. From the remaining 50 articles, which underwent full-text analysis, 40 were excluded due to non-compliance with the inclusion criteria, leaving 7 potential studies that met all the established criteria (Figure 1).
Image number one: Overview of the selection of articles
The articles included in this review study, based on the established inclusion and exclusion criteria, were evaluated using a questionnaire (Table 1) that examines key factors of the studies. This questionnaire comprised 9 questions and was used to score the articles.
· Scoring System:
· Articles scoring 0 to 49% were classified as weak studies.
· Articles scoring 50 to 89% were classified as moderate studies.
· Articles scoring over 90% were classified as good studies.
This scoring system allowed for a systematic assessment of the quality of the included studies, ensuring that only relevant and methodologically sound research contributed to the findings of the review.
Table 1 (Study Quality Assessment)
Study Reference Score
|
How was allocation to the intervention group done? 2 = random 1 = cluster random 0 = historical comparison/volunteer or convenience group
|
Was the assigned intervention concealed before allocation? 2 = adequate 1 = unclear 0 = inadequate/impossible
|
Were the outcomes of participants who withdrew described and included in the analysis (intention to treat/effect of compliance)? 2 = withdrawals well described and accounted for in analysis 1 = withdrawals described and analysis not possible 0 = no mention, inadequate mention, or obvious differences and no adjustment
|
Were the outcome assessors blinded to treatment status? 2 = effective action taken to blind assessors 1 = small or moderate chance of unblinding of assessors 0 = not mentioned or not possible
|
Were the inclusion and exclusion criteria (age, previous injury, sport) clearly defined? 2 = clearly defined 1 = inadequately defined 0 = not defined
|
Were the intervention and control group comparable at entry? 2 = good comparability of groups, or confounding adjusted for in analysis 1 = confounding small; mentioned but not adjusted for 0 = large potential for confounding, or not discussed
|
Were the interventions clearly defined? 2 = clearly defined interventions are applied 1 = clearly defined interventions are applied but the application is not standardised 0 = intervention and/or application are poorly or not defined
|
Were the outcome measures used clearly defined?(injury: selfreported injury/medically confirmed/severity defined) 2 = clearly defined 1 = adequately defined/recorded 0 = not adequately defined/recorded
|
Was the surveillance period active and of clinically appropriate duration? 2 = active surveillance and appropriate duration 1 = active surveillance, but inadequate duration 0 = surveillance not active or not defined
|
Total score (18=%100) |
Results
The participants in the studies included elderly men and women aged 60 years and older. The minimum number of participants was 30, while the maximum reached 405. In most studies, in addition to assessing balance and fall risk, factors such as strength, range of motion, performance, quality of life, and psychological factors like anxiety and depression were addressed over different time periods (40, 41). As indicated by the results of the studies, the duration of the exercise protocol ranged from 8 to 12 weeks.
The variables examined in the current study included balance variables, which comprised static and dynamic balance as well as functional balance. Static balance was assessed through one-leg standing tests (stork test), while dynamic balance was evaluated using the Timed Up and Go (TUG) test, as this test requires not only mobility but also good dynamic ability, making it a simple test with high reliability and validity for assessing dynamic balance (42). Functional balance was measured using the Berg Balance Scale and the Fullerton Advanced Balance Scale (43). A summary of the research process, number of participants, methodology, and results of these studies is presented in Table 1.
Article Title | Study Design and Sample Size | Measured Variables | Evaluation Tools | Score | Main Findings |
Effects of three home-based exercise programmes regarding falls, quality of life and exercise adherence in older adults at risk of falling (Anne-Gabrielle Mittaz Hager et al., 2019) | Clinical trial; 405 participants (aged 65+), divided into three training groups: Otago (162), T&E (162), Helsana (81). | Balance, falls, and quality of life | Timed Up and Go Test (TUG), Functional Sit-to-Stand Test (FTSTS), Functional Reach Test (FR), Six-Meter Walk Test (SMWT), OPQOL-35 Questionnaire | 14 | After six months of follow-up, all three exercise protocols had positive effects on fall prevention in older adults. |
Effects of a falls prevention exercise programme on health-related quality of life in older home care recipients (Bjerk, Maria et al., 2019) | Clinical trial; 150 participants divided into two groups: Otago exercises and control (functional exercises) over 12 weeks | Static balance and risk of falling | 30-Second Sit-to-Stand Test, Berg Balance Scale, Four-Meter Walk Test, SF-36 Questionnaire | 13 | Otago fall prevention exercises significantly improved balance and quality of life in older adults receiving home care. |
Effectiveness of Lafiska exercise on risk of fall, balance, and health status in the elderly (Dwi Nurviyandari et al., 2018) | Prospective study; 80 older adults in two groups: control (40) and Lafiska exercises (40) for 10 weeks | Risk of falling, balance, and health status | Berg Balance Scale, SF-12 Questionnaire | 15 | Lafiska exercises significantly reduced fall risk and improved balance and health status in older adults. |
The effects of eyeball exercise on balance ability and falls efficacy of the elderly who have experienced a fall (Park, Jh et al., 2017) | Clinical trial; 61 participants divided into eyeball exercise group (30) and functional exercise group (31) for 10 weeks | Static balance, dynamic balance, and risk of falling | TUG Test, Modified Falls Efficacy Scale (MFES) Questionnaire | 13 | Eyeball exercises were more effective than functional exercises in improving balance and reducing falls in older adults. |
The effect of selected FallProof exercises on static and dynamic balance in older adults (Hossein Khazanin Hassan Daneshmandi, 2019) | Semi-experimental study; 24 older adults (60-74 years), divided into experimental and control groups for 8 weeks | Static and dynamic balance | Sharpened Romberg Test (eyes open and closed), TUG Test | 14 | Selected FallProof exercises significantly improved static balance (eyes open and closed) and dynamic balance in the experimental group compared to controls. |
Effect of Cawthorne and Cooksey Exercise Program on Balance and Likelihood of fall in Older Women (Prajakta D. Zambare et al., 2015) | Clinical trial; 60 older women (60-69 years), divided into two groups of 30, for 9 weeks (3 days/week, 60 minutes/session) | Balance and risk of falling | Dynamic Gait Index (DGI), Berg Balance Scale, Fall Efficacy Scale | 13 | Significant improvement in Berg Balance Scale and Fall Efficacy Scale results in the Cawthorne and Cooksey group compared to the control group. |
Effectiveness of FallProof home-based DVD program in improving balance, select functional fitness parameters, and balance-related confidence among community-dwelling older adults at moderate to high risk of falls (Kelly Ward et al., 2011) | 38 participants divided into FallProof home-based exercise group (23) and non-exercise control group (15) for 12 weeks | Balance in older adults at high risk of falling | Fullerton Advanced Balance Scale, Balance Efficacy Scale | 13 | Significant improvements in the exercise group, while the control group showed no improvements. |
Conclusion
In this study, seven international case research articles published between 2011 and 2019, along with one domestic article published in (2019), were utilized. Each of these studies holds a high level of credibility in the field of balance and fall prevention among the elderly. Two of the articles employed Otago exercises, which are specialized balance exercises aimed at preventing falls in older adults (42, 44). The Otago exercise program includes muscle strengthening and balance recovery activities conducted at home by a trained instructor (50, 49). The rationale behind this exercise program is that muscular strength, flexibility, balance, and reaction time are critical risk factors for falls among the elderly (49). This program is unique due to its clearly defined protocol and its feasibility for implementation within the elderly community; consequently, it is widely used in New Zealand and other parts of the world (49, 51).
Another exercise program that has gained attention among the elderly is the Fall Proof exercise protocol, developed by Rose and colleagues in 2011. The primary goal of this balance and movement program is to enhance functional independence and improve risk factors that contribute to falls among older adults. This is achieved through four program components: voluntary and involuntary center of gravity control, sensory perception and skill integration, selection and scaling of postural strategies, and development of walking pattern flexibility. Overall, the structure of the Fall Proof program follows the principles and theories of the Woollacott & Shumway-Cook motor control system. This theory posits that multiple systems collaborate to control orientation and movement. According to their framework, in addition to the sensory-motor systems that form the basis of postural control, musculoskeletal and cognitive systems enable an individual to achieve specific actions. Thus, it can be stated that the components integrated into the Fall Proof program—including sensory, vestibular, and strength components, as well as center of gravity maintenance and control strategies—can impact the movement control system (52). Therefore, a possible reason for the association between Rose's program and this theory may be the presence of such components in the Fall Proof fall prevention program. In the study by Khazinin and Daneshmandi, an exercise program based on postural control systems and related factors affecting balance in the elderly was selected (47).
According to Makias and colleagues, vestibular rehabilitation is one of the most crucial exercises for improving balance disorders (53). The Cawthorne and Cooksey exercises are part of vestibular rehabilitation that engages balance control centers such as vision, proprioception, and the vestibular system (54). Visual impairment is considered the primary cause of balance deficits and increased fall risk among the elderly, and the aforementioned exercises can enhance their balance. Based on the available articles and the conducted reviews, it can be concluded that Cawthorne and Cooksey exercises likely improve balance in older adults (48).
Duy and colleagues (2018) examined the effects of Lafisca exercises on fall risk, balance, and health status among the elderly. The results indicated that Lafisca exercises had a significant impact on reducing fall risk and enhancing balance and health in older adults (45).
Discussion
The aim of this study was to review the scientific literature to identify exercise programs capable of enhancing balance in older adults. It appears that focusing on the development of specific aspects of movement control in intervention programs may contribute to their effectiveness. As mentioned, the decline in neuromuscular, musculoskeletal, and sensory systems with aging leads to difficulties for older adults in maintaining postural control.
Muscle strength is a key component of balance and walking ability, which, along with other degenerative changes in bodily systems, tends to decrease with age. The reduction in muscle mass and the weakening of sensory systems (visual, proprioceptive, and vestibular) contribute to decreased balance and instability during walking and daily activities. Recent research has also indicated that improper weight transfer is a primary cause of falls in older adults. Stable standing is achieved when the center of mass is within the base of support. The location of the center of mass is determined by changes in the center of pressure. To maintain balance during daily activities, individuals must control the position of their center of mass through weight transfer. Typically, older adults require more movement adjustments to achieve the target point during voluntary weight transfer and often fail to reach it. This is likely due to their reduced ability to perform proper weight transfer movements necessary for maintaining balance. Given that balance is a variable and adaptable factor, it seems that exercise interventions for older adults should focus on multiple training components (55, 56, 57, 58).
Final Conclusion
It appears that the use of various specialized exercise methods for older adults, such as home-based protocols like Otago, vestibular exercises such as Cawthorne and Cooksey, the Fall Proof program, and similar exercises mentioned in this study, can enhance the capabilities of older adults and reduce the risk of falls.
Acknowledgment
The authors of the article extend their deepest gratitude to those who collaborated in conducting this study.
References
1- Laessoe U, Hoeck HC, Simonsen O, Sinkjaer T, Voigt M. Fall risk in an active elderly population–can it be assessed?. Journal of negative results in biomedicine. 2007 Dec;6:1-1. doi:10.1186/1477-5751-6-2
2- Chodzko-Zajko W, Schwingel A, Hee C. Successful Aging: The Role of Physical Activity. American Journal of Lifestyle Medicine. 2009;3(1):20-28. doi:10.1177/1559827608325456
3- Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Bmj. 2004 Mar 18;328(7441):680. doi:/10.1136/bmj.328.7441.680
4- Safavi Bayat Z, Zorriasatain F. Determining risk factors associated with falling among elderly at residential care facilities in Tehran. Journal of Inflammatory Diseases. 2008 Feb 10;11(4):66-70. ID: emr-143440.[in persian]
5- Kamrani AA, Azadi F, Foroughan M, Siadat S, Kaldi A. Characteristics of falls in elderly residents of nursing homes. Iranian Journal of Ageing. 2007;1(2):101-5. URL: http://salmandj.uswr.ac.ir/article-1-19-en.html.[in persian]
6- Nejc S, Loefler S, Cvecka J, Sedliak M, Kern H. Strength training in elderly people improves static balance: a randomized controlled trial. European Journal of Translational Myology. 2013 Jul 25;23(3):85-9. doi.org/10.4081/ejtm.2013.1777
7- Granata KP, Lockhart TE. Dynamic stability differences in fall-prone and healthy adults. Journal of Electromyography and Kinesiology. 2008 Apr 1;18(2):172-8. doi:/10.1016/j.jelekin.2007.06.008
8- Pizzigalli L, Filippini A, Ahmaidi S, Jullien H, Rainoldi A. Prevention of falling risk in elderly people: the relevance of muscular strength and symmetry of lower limbs in postural stability. The Journal of Strength & Conditioning Research. 2011 Feb 1;25(2):567-74. doi: 10.1519/JSC.0b013e3181d32213
9- Ungar A, Rafanelli M, Iacomelli I, Brunetti MA, Ceccofiglio A, Tesi F, Marchionni N. Fall prevention in the elderly. Clinical Cases in mineral and bone metabolism. 2013 May;10(2):91. PMID: 24133524
10- de Almeida ST, Soldera CL, de Carli GA, Gomes I, de Lima Resende T. Analysis of extrinsic and intrinsic factors that predispose elderly individuals to fall. Revista da Associação Médica Brasileira (English Edition). 2012 Jul 1;58(4):427-33. doi:10.1016/S2255-4823(12)70224-2
11- Marschollek M, Rehwald A, Wolf KH, Gietzelt M, Nemitz G, zu Schwabedissen HM, Schulze M. Sensors vs. experts-a performance comparison of sensor-based fall risk assessment vs. conventional assessment in a sample of geriatric patients. BMC medical informatics and decision making. 2011 Dec;11:1-7. doi:10.1186/1472-6947-11-48
12- Howcroft J, Kofman J, Lemaire ED. Review of fall risk assessment in geriatric populations using inertial sensors. Journal of neuroengineering and rehabilitation. 2013 Dec;10:1-2. doi:10.1186/1743-0003-10-91
13- Yoshida-Intern S. A global report on falls prevention epidemiology of falls. Geneva: WHO. 2007 Apr 21.
14- Campbell AJ, Robertson MC. Rethinking individual and community fall prevention strategies: a meta-regression comparing single and multifactorial interventions. Age and ageing. 2007 Nov 1;36(6):656-62. doi:10.1093/ageing/afm122
15- Hartholt KA, van Beeck EF, Polinder S, van der Velde N, van Lieshout EM, Panneman MJ, van der Cammen TJ, Patka P. Societal consequences of falls in the older population: injuries, healthcare costs, and long-term reduced quality of life. Journal of Trauma and Acute Care Surgery. 2011 Sep 1;71(3):748-53. doi: 10.1097/TA.0b013e3181f6f5e5
16- Lopes KT, Costa DF, Santos LF, Castro DP, Bastone AC. Prevalence of fear of falling among a population of older adults and its correlation with mobility, dynamic balance, risk and history of falls. Brazilian Journal of Physical Therapy. 2009;13:223-9. doi: 10.1590/S1413-35552009005000026
17- Resende SM, Rassi CM. Effects of hydrotherapy in balance and prevention of falls among elderly women. Brazilian Journal of Physical Therapy. 2008;12:57-63. doi:10.1590/S1413-35552008000100011
18- Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW, Kelly-Hayes M, Wolf PA, Kreger BE, Kannel WB. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. American journal of public health. 1994 Mar;84(3):351-8. doi:10.2105/AJPH.84.3.351
19- Hosseini L, Kargozar E, Sharifi F, Negarandeh R, Memari AH, Navab E. Tai Chi Chuan can improve balance and reduce fear of falling in community dwelling older adults: a randomized control trial. Journal of exercise rehabilitation. 2018 Dec;14(6):1024. doi: 10.12965/jer.1836488.244.[in persian]
20- Shahbazian M ,Daneshmandi H., the effect of 6 weeks of virtual reality exercises on posture control and motor performance of elderly women.2022. https://civilica.com/doc/1599443.[in persian]
21- Shimada H, Suzukawa M, Ishizaki T, Kobayashi K, Kim H, Suzuki T. Relationship between subjective fall risk assessment and falls and fall-related fractures in frail elderly people. BMC geriatrics. 2011 Dec;11:1-8. doi:10.1186/1471-2318-11-40
22- Carter ND, Kannus P, Khan K. Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Sports medicine. 2001 May;31:427-38. doi:10.2165/00007256-200131060-00003
23- Arnold CM, Sran MM, Harrison EL. Exercise for fall risk reduction in community-dwelling older adults: a systematic review. Physiotherapy Canada. 2008 Oct;60(4):358-72. doi.org/10.3138/physio.60.4.358
24- Balzer K, Bremer M, Schramm S, Lühmann D, Raspe H. Falls prevention for the elderly. GMS health technology assessment. 2012;8. doi: 10.3205/hta000099
25- Daneshmandi H. The effect of virtual reality training program on the Functional Fitness of the elderly. Journal of Gerontology. 2021 Apr 10;6(1):32-41. URL: http://joge.ir/article-۱-۴۴۸-fa.html.[in persian]
26- Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, Ory MG, Sattin RW, Tinetti ME, Wolf SL, Schechtman KB. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. Jama. 1995 May 3;273(17):1341-7. doi:10.1001/jama.1995.03520410035023
27- Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH, Cochrane Bone, Joint and Muscle Trauma Group. Interventions for preventing falls in elderly people. Cochrane database of systematic reviews. 1996 Sep 1;2009(1). doi:10.1002/14651858.CD000340
28- Ansai JH, Aurichio TR, Gonçalves R, Rebelatto JR. Effects of two physical exercise protocols on physical performance related to falls in the oldest old: A randomized controlled trial. Geriatrics & gerontology international. 2016 Apr;16(4):492-9. doi:10.1111/ggi.12497
29- Daneshmandi H, hoseinpour M. The role of muscle weakness in balance and postural instability in the elderly with and without falls: A Systematic review. joge 2022; 6 (4) :89-104
URL: http://joge.ir/article-1-532-fa.html.[in persian]
30- Leiros-Rodríguez R, García-Soidan JL. Balance training in elderly women using public parks. Journal of women & aging. 2014 Jul 3;26(3):207-18. doi:10.1080/08952841.2014.888220
31- Zhao Y, Chung PK, Tong TK. Effectiveness of a balance-focused exercise program for enhancing functional fitness of older adults at risk of falling: A randomised controlled trial. Geriatric nursing. 2017 Nov 1;38(6):491-7. doi:10.1016/j.gerinurse.2017.02.011
32- Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013 May 1;75(1):51-61. doi:10.1016/j.maturitas.2013.02.009
33- Sousa N, Mendes R, Silva A, Oliveira J. Combined exercise is more effective than aerobic exercise in the improvement of fall risk factors: a randomized controlled trial in community-dwelling older men. Clinical rehabilitation. 2017 Apr;31(4):478-86. doi:10.1177/02692155166558
34- Keysor JJ. Does late-life physical activity or exercise prevent or minimize disablement?: a critical review of the scientific evidence. American journal of preventive medicine. 2003 Oct 1;25(3):129-36. doi:10.1016/S0749-3797(03)00176-4
35- Sui X, LaMonte MJ, Laditka JN, Hardin JW, Chase N, Hooker SP, Blair SN. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. Jama. 2007 Dec 5;298(21):2507-16. doi:10.1001/jama.298.21.2507
36- Gaught AM, Carneiro KA. Evidence for determining the exercise prescription in patients with osteoarthritis. The Physician and sportsmedicine. 2013 Feb 1;41(1):58-65. doi:10.3810/psm.2013.02.2000
37- Gómez-Cabello A, Ara I, González-Agüero A, Casajús JA, Vicente-Rodriguez G. Effects of training on bone mass in older adults: a systematic review. Sports Medicine. 2012 Apr;42:301-25. doi: 10.2165/11597670-000000000-00000
38- Kouchaki E, Sedaghati P, Daneshmandi H. Comparing the fear of falling and quality of life outcomes following a functional movement protocol among the experimental and control idiopathic Parkinson cases. Feyz Medical Sciences Journal. 2016 Aug 10;20(3):252-9. URL: http://feyz.kaums.ac.ir/article-1-3084-en.html.[in persian]
39- Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC, Kriska A. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Jama. 1995 Feb 1;273(5):402-7. doi:10.1001/jama.1995.03520290054029
40- Leavey VJ. The comparative effects of a six-week balance training program, gluteus medius strength training program, and combined balance training/gluteus medius strength training program on dynamic postural control. West Virginia University ProQuest Dissertations & Theses; 2006.
41- Jung H, Yamasaki M. Association of lower extremity range of motion and muscle strength with physical performance of community-dwelling older women. Journal of physiological anthropology. 2016 Dec;35:1-9. doi:10.1186/s40101-016-0120-8
42- Mittaz Hager AG, Mathieu N, Lenoble-Hoskovec C, Swanenburg J, de Bie R, Hilfiker R. Effects of three home-based exercise programmes regarding falls, quality of life and exercise-adherence in older adults at risk of falling: protocol for a randomized controlled trial. BMC geriatrics. 2019 Dec;19:1-1. doi:10.1186/s12877-018-1021-y
43- Ward K. Effectiveness of FallProof home-based DVD program in improving balance, select functional fitness parameters, and balance-related confidence among community-dwelling older adults who have been identified as moderate to high risk of falls. oai:alma.01CALS_USL:11232444480001671
44- Bjerk M, Brovold T, Skelton DA, Liu-Ambrose T, Bergland A. Effects of a falls prevention exercise programme on health-related quality of life in older home care recipients: a randomised controlled trial. Age and ageing. 2019 Mar 1;48(2):213-9. doi:10.1093/ageing/afy192
45- Wati DN, Sahar J, Rekawati E. Effectiveness of Lafiska exercise on risk of fall, balance, and health status in the elderly. Enfermeria clinica. 2018 Feb 1;28:337-42. doi:10.1016/S1130-8621(18)30181-5
46- Park JH. The effects of eyeball exercise on balance ability and falls efficacy of the elderly who have experienced a fall: A single-blind, randomized controlled trial. Archives of gerontology and geriatrics. 2017 Jan 1;68:181-5. doi:10.1016/j.archger.2016.10.006
47- Khazanin H, Daneshmandi H. Effect of selected fallproof exercise on static and dynamic balance in the elderly. The Scientific Journal of Rehabilitation Medicine. 2020 Sep 22;9(3):16-26. doi:10.22037/JRM.2019.112562.2218.[in persian]
48- Zambare PD, Soni N, Sharma P. Effect of Cawthorne and Cooksey exercise program on balance and likelihood of fall in older women. Ind J Physioth Occupat Therapy-An Inter J. 2015 Jul;9:55. doi: 10.14196/mjiri.32.74
49- Thomas S, Mackintosh S, Halbert J. Does the ‘Otago exercise programme’reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age and ageing. 2010 Nov 1;39(6):681-7. doi:10.1093/ageing/afq102
50- Khazanin H, Daneshmandi H, Fakoor Rashid H. Effect of selected fall-proof exercises on fear of falling and quality of life in the elderly. Iranian Journal of Ageing. 2022 Feb 10;16(4):564-77. URL: http://salmandj.uswr.ac.ir/article--2174-1fa.html.[in persian]
51- Shubert TE, Smith ML, Ory MG, Clarke CB, Bomberger SA, Roberts E, Busby-Whitehead J. Translation of the Otago Exercise Program for adoption and implementation in the United States. Frontiers in public health. 2015 Apr 27;2:152. doi:10.3389/fpubh.2014.00152
52- Rose DJ. Reducing the risk of falls among older adults: the Fallproof Balance and Mobility Program. Current Sports Medicine Reports. 2011 May 1;10(3):151-6. doi: 10.1249/JSR.0b013e31821b1984
53- Macias JD, Massingale S, Gerkin RD. Efficacy of vestibular rehabilitation therapy in reducing falls. Otolaryngology—Head and Neck Surgery. 2005 Sep;133(3):323-5. doi:10.1016/j.otohns.2005.04.024
54- Zanardini FH, Zeigelboim BS, Jurkiewicz AL, Marques JM, Martins-Bassetto J. Vestibular rehabilitation in elderly patients with dizziness. Pró-Fono Revista de Atualização Científica. 2007;19:177-84. doi:10.1590/S0104-56872007000200006
55- Robinovitch SN, Feldman F, Yang Y, Schonnop R, Leung PM, Sarraf T, Sims-Gould J, Loughin M. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. The lancet. 2013 Jan 5;381(9860):47-54. doi:10.1016/S0140-6736(12)61263-X
56- Dashti P, Shabani M, Moazami M. Comparison of the effects of two selected exercises of Theraband and Pilates on the balance and strength of lower limb in elderly women. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2015 Jun 22;18(153):1-9.doi: 10.22038/IJOGI.2015.4698.[in persian]
57- Yaali R, Naeimi Kia M, Gholami A. Effect of weight transfer training on static and dynamic balance of older women. Research in Sport Management and Motor Behavior. 2018 Dec 10;8(16):47-59.doi: 10.29252/JRSM.8.16.47.[in persian]
58- de Bruin ED, Murer K. Effect of additional functional exercises on balance in elderly people. Clinical rehabilitation. 2007 Feb;21(2):112-21. doi:10.1177/0269215506070144
