Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial

Abstract

During challenging tasks, such as dual-tasks, there is an increased risk of falls in the elderly, so it is essential besides to seek for an effective balance training, also to study the effect of different therapeutic strategies in order to prevent falls.
Objective
The aim of this study was to evaluate the effects of balance training, supervised and home-based, on gait with and without dual-task in elderly.
Method
Older adults were randomly assigned to: supervised group (n= 15); home-based group (n= 15) or control group (n= 15). The gait was assessed in three situations: normal walking, functional dual-task and cognitive dual-task. The balance training protocol asted 10 weeks for both, supervised and home-based group, including warm up, stretching, semi-static and dynamic balance and cool down. Data were treated by intention-to-treat method. For parametric variables ANOVA two-way and post hoc Bonferroni
were applied. For non-parametric variables, Friedman analysis was applied. The level of statistical significance was set at p ≤ 0.05.
Results
The balance training, regardless of whether supervised or home-based, did not improve any gait variable after 10 weeks of exercise. In the control group, it was observed a decrease of cadence in cognitive dual-task and an increase of percentage of double support in functional and cognitive dual-task, after 10 weeks.
Conclusion
The protocol predominantly based on balance training was not efficient to improve gait parameters with and without dual-task, in the young-old dwelling adults.

Full text

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Jacobs Journal of Physiotherapy and Exercise
Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly:
Randomized Clinical Trial
Paulo Ferreira dos Santos1, Paola Errera Magnani1, Erika Harumi Tanaka1, Natalia Camargo
Rodrigues1, Patrícia Silva2, Paulo Roberto Pereira Santiago2, Renato de Moraes2, Daniela Cristina Carvalho de Abreu3*
1Post-Graduation Program in Rehabilitation and Functional Performance, School of Medicine of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, SP, Brazil
2Physical Education Course, School of Physical Education and Sport of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP,
Brazil
3Physiotherapy Course, Department of Biomechanics, Medicine and Rehabilitation of Locomotor System, School of Medicine of Ribeirão
Preto, University of São Paulo, Ribeirão,Brazil
*Corresponding author: Dr. Daniela Cristina Carvalho de Abreu, 3900, Bandeirantes ave, Ribeirao Preto/SP, Brazil-14049-900,
Tel: +55 16 3315-4413; Email: dabreu@fmrp.usp.br
Received: 10-05-2016
Accepted: 11-17-2016
Published: 12-14-2016
Copyright: © 2016 Daniela Cristina Carvalho de Abreu
Research Article
Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Abstract
During challenging tasks, such as dual-tasks, there is an increased risk of falls in the elderly, so it is essential besides to seek for
an effective balance training, also to study the effect of different therapeutic strategies in order to prevent falls.
Objective
The aim of this study was to evaluate the effects of balance training, supervised and home-based, on gait with and without
dual-task in elderly.
Method
Older adults were randomly assigned to: supervised group (n= 15); home-based group (n= 15) or control group (n= 15). The
gait was assessed in three situations: normal walking, functional dual-task and cognitive dual-task. The balance training protocol
lasted 10 weeks for both, supervised and home-based group, including warm up, stretching, semi-static and dynamic balance
and cool down. Data were treated by intention-to-treat method. For parametric variables ANOVA two-way and post hoc Bonfer-


Results
The balance training, regardless of whether supervised or home-based, did not improve any gait variable after 10 weeks of exer-
cise. In the control group, it was observed a decrease of cadence in cognitive dual-task and an increase of percentage of double
support in functional and cognitive dual-task, after 10 weeks.
JACOBS
PUBLISHERS

Conclusion
The protocol predominantly based on balance training was
-
al-task, in the young-old dwelling adults.
Keywords: Aging; Balance Exercise; Kinematic; Variability;
Walking
Introduction
Aging is considered a heterogeneous process that affects each
individual differently, and the decrease of balance control
makes gait, a dynamic task, more complex [1]. Multiple factors
are responsible for these impairments, including sensory, mo-
tor and cognitive processing reductions and muscle function
impairment [2]. These factors explain the gait instability and
may increase risk of falling in older adults [3,4].
Falls are strongly associated with attention ability reduction,
instability in standing position and during dynamic daily ac-
 
32% of falls occur due to balance impairments and only 13%
occur due to extrinsic factors related to environmental barri-
ers, such as the presence of a step [6].
Regarding gait alterations, older persons tend to reduce gait
speed and increase their base of support in order to attain
greater postural stability during walking [6,7]. The gait speed,
the base of support and other gait parameters change sharply
during dual-tasks conditions, when older adults need to divide
their attention to keep their balance [8]. Moreover, age-related
-
utive function in community-elderly [9], which demonstrate

dual-task has been largely used to evaluate interaction be-
tween cognition, gait and risk of falls [9-11].
Intervention protocols have been performed to improve gait
parameters during dual-tasks and consequently to avoid risk
of falls in older adults. According to Hiyamizu et al [12], studies
using motor dual-task in the balance training reported positive
results. However, few studies have been done to clarify clini-
cal evidence about the effect of balance training on dual-task
ability.
Exercise protocols including muscle strength, balance and tai-
chi-chuan exercises are effective to prevent falls, highlighting

  
balance training in order to investigate if balance improve-
         
faster resoluteness for balance in older adults. The faster res-
oluteness can be an important strategy to keep the elderly ad-
herence and to prevent dropouts, a relevant aspect in health
promotion approaches. In addition, a home-based training can
be a good alternative to perform an exercise program for those
Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Jacobs Publishers 2
-
bilitation center.
The hypothesis of this study was that a training including pre-
dominant balance exercises could improve functional balance,
spatio-temporal gait parameters and gait variability. In addi-
tional, if training protocol has been appropriately instructed
to perform at home (e.g., available booklet and DVD of the ex-
ercises), supervised and home-based modalities could induce
similar effects on gait variables of older adults.
Therefore, the purpose of the present study was to evaluate: I)
the effect of a balance training protocol on gait, with and with-
out dual-tasks (functional and cognitive) regarding the gait
spatio-temporal parameters and the intra-individual gait vari-
ability; II) whether there is a better therapeutic strategy to ap-
ply the training protocol, considering the exercise performed
through supervised group or at home individually.
Methods
This randomized clinical trial, blind to evaluators, followed
recommendations of the Consolidated Standards of Reporting
Trials (CONSORT) [14] and participants signed a consent term
that was approved by the local Human Research Ethics Com-
mittee.
Participants
      -
pendent to walking and without cognitive impairment were
recruited at random from the local community (Ribeirão Preto,
SP, Brazil) to participate voluntarily in the study.
Study sample was made up from 179 elderly contacted; 134
elderly were excluded because did not attend evaluation or did
not meet the inclusion and exclusion criteria of the study (Fig-
ure 1). Therefore, 45 subjects were evaluated. Simple random-
ization was performed using opaque envelopes from which
three groups of options: Supervised group (n=15), Home-
based group (n=15) and Control group (n=15). Researcher
who performed randomization did not participate in the eval-
uations and in the protocol training, keeping the blind design
of the study.
Inclusion criteria comprised: elderly aged 60 to 80, indepen-
dent to walking (without assistive devices), able to understand
and to execute commands, independent to perform activities
of daily living and instrumental life (subjects with mild or no
-
ly, elderly that reside in the local community.
Exclusion criteria comprised: cognitive impairment traced
by the Mini-Mental State Examination (MMSE), taking into
consideration each subject’s level of education (Unlettered:
20 points, 1-4 years: 25 points, 5-8 years: 26,5 points, 9-11
years: 28 points, Above 11 years: 29 points) [16], decreased

Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Jacobs Publishers 3
   
presence of cardiovascular disease, neurological or musculo-
skeletal that would compromise the static or dynamic balance,
recent episodes of dizziness or chronic dizziness [18], lack of
visual or auditory acuity, previous surgery in the last 6 months,
pain in lower limbs that interfere in gait, medication that com-
promises balance or cognitive abilities, and medical restric-
tions to any of performed procedures in this study.
Initially, personal contact information and history of falls in
the last 6 months were collected. Also, anthropometric data
(body mass and height) and gait analysis were performed.
Gait Analysis
Gait analysis was performed at the Motion Analysis Laboratory
of the Rehabilitation Center of the Clinical Hospital, School of
Medicine of Ribeirão Preto, University of São Paulo, Brazil
(FMRP-USP).
The tridimensional kinematic analysis of gait was performed
  -
       
placed approximately 2.5 meters above the ground, supported
-

Track Manager program. Data were registered at 120Hz and
acquisition time corresponded to an average of two gait cycles.
The collected data were interpolated, when needed, for a max-
  -
terworth low-pass, at the cutoff frequency of 6Hz [19] to re-
duce noise produced by the markers. Subsequently, data were
         
       
analysis.
Figure 1. Flowchart of randomized study design (supervised group, home-based group and control group).

Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Jacobs Publishers 4
The four passive spherical markers that were used for gait

each participant on the back of the heel bone (calcaneus) and
on the dorsum of the foot between the 2nd and 3rd metatarsal
axes, bilaterally, following Helen Hayes model [20]. Prior to
kinematic analysis, we gathered static data, needed for gener-
 
For this procedure, subjects were placed in stationary position,
previously delimited on a carpet rubber used to gait.
For dynamic tasks, subjects were barefoot and instructed to
execute normal gait and two dual-task situations on carpet
rubber.
Three gait conditions were randomly assessed: I) Normal
gait – the participant was instructed to walk at a self-select-
ed speed; II) Functional dual-task – walking at a self-selected
speed while transferring a coin from one pocket to another in
a bag that measured 19 x 20 cm, attached in a belt, in front of
the belly of each subject [21]; III) Cognitive dual-task – walking
while say the days of the week aloud and backwards, begin-
ning with Saturday [22]. Each task was repeated three times

gait were disregarded, in order to exclude the acceleration and
deceleration phases.
Table 1. Balance Training Protocol performed for supervised group and home-based group during twenty sessions, two times a week.

Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Jacobs Publishers 5
For each gait conditions above cited the follow spatio-tempo-
ral gait variables were analyzed: gait speed, step length, step
width, stride length, double support time and single support
time in percentage of the gait cycle, cadence and toe clearance
-
ability was also analyzed.
The assessments were performed at baseline and after 10
weeks.
Training Protocol
The balance training protocol was performed at Integrated
Center of Rehabilitation at State Hospital of Ribeirão Preto
(CIR-HE/RP).
The supervised group carried out 20 sessions of supervised
balance training protocol, twice a week. The home-based
group performed the balance training protocol with 2 super-
vised sessions at CIR-HE/RP and 18 sessions conducted at
home, twice a week, following instructions in a booklet and in
a DVD that included the same training protocol of supervised
group (Table 1).
The training of supervised group and the 2 sessions of home-
based group were conducted by physiotherapists, who were
blinded for the baseline assessments. In addition, the home-
based group received phone calls to keep adherence to train-
ing and to clear possible doubts.
We designated other researchers to call weekly the subjects of
home-based group. As soon as the supervised and home-based
  
the volunteers were reassessed.
The control group did not perform exercise protocol or any
other exercise.
Statistical Analysis
The initial sample size calculation was 15 participants per
group, considering gait speed as main variable, power of 0.96,
an alpha level of 0.05, and effect size of 1.16 (data of a pilot
study), using the G*Power Software, version 3.1.92 (Universi-
tat Kiel – Germany).
Analysis of gait variability were conducted with a minimum
    -
tion was applied to the raw data, which consists of dividing the
standard deviation (SD) by the mean (M) and then multiplying
the result by 100 [23].
Missed data were adjusted by intention-to-treat analysis that
is a statistical approach to deal with dropouts, non-compliant
participants and equal groups, like imputation method the Ex-
treme Case Analysis was used [24].
Data were expressed as mean and standard deviation. Shap-
iro-Wilk and Levene test were applied to evaluate the normal-
ity and homogeneity of the results, respectively. For data that
did not present a non-normal distribution, logarithmic trans-
formation was carried out.
For data with non-normal distribution, Kruskal-wallis test was
used to determine possible differences between groups before
and after exercise of each group for single support time, double
support time, stride length and toe clearance. Friedman test
was used to determine possible differences when compared

of intervention in gait parameters for single support time, dou-
ble support time, stride length and toe clearance.
For data with normal distribution, ANOVA two way followed
by Bonferroni post-hoc test were used to determine possible
differences when compared each group before and after ex-
 -
eters for step length, step width, cadence and speed gait for
supervised group; step length, step width, cadence and speed
gait for home-based group; and step length, step width, stride
length, double support time and speed gait for control group.
For variability data with non-normal distribution, Krus-
kal-wallis test was used to determine possible differences be-
tween groups before and after exercise for step length, step
width, stride length, single support time, double support time,
cadence and toe clearance. Friedman test was used to deter-
mine possible differences when compared each group before
   
gait parameters for stride length and cadence for supervised
group; single support time for home-based group; and step
length for control group.
All analyzes were performed using SPSS (SPSS for Windows,


Results
Table 2 presents the characteristics of the studied population.
      
differences (p> 0.05) in sex, age, height, weight and Body Mass
Index (BMI) among the three groups. Descriptive analysis was
       -
tionnaire and number of falls.
Gait Variables
    -
cant differences for any of gait parameters (p> 0.05), consider-
ing the different gait conditions in the baseline versus after 10
weeks (Table 3).
         -
crease in the percentage of double support time (p< 0.05)

during functional dual-task and cognitive dual-task. Also, a sig-
       
cognitive dual-task after 10 weeks (Table 3).
Gait Variability
In gait variability (step length, step width, percentage of sin-
gle support time, percentage of double support time, stride
   
differences (p> 0.05) in any gait parameters (p> 0.05) regard-
ing after 10 weeks for supervised group, home-based group
and control group (Table 4).
      -
cant increase (p= 0.015) during functional dual-task (6.43%
± 6.58) when compared to normal gait (2.19% ± 1.39).
 
during functional dual-task (3.97% ± 2.90) when compared to
normal gait (1.99% ± 1.43).
Besides, at baseline, for home-based group, the percentage of

(p= 0.019) during cognitive dual-task (6.16% ± 3.40) when
compared to functional dual-task (2.78% ± 1.64). For control

Jacobs Publishers 6
Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Variables
Group
Supervised
Home
Control
p
Sex
F=15 / M=0
F=14 / M=1
F=12 / M=3
--
Age (years)
66.40 ± 3.48
64.60 ± 4.14
66.20 ± 4.51
0.32
Height (m)
1.57 ± 0.08
1.56 ± 0.06
1.58 ± 0.11
0.937
Weight (kg)
Pre-intervention
69.05 ± 13.06
66.61 ± 11.39
65.41 ± 11.91
0.833
Post-intervention
68.41 ± 13.49
67.12 ± 11.70
65.24 ± 11.92
0.636
BMI (kg/m²)
Pre-intervention
28.02 ± 4.86
27.36 ± 3.75
26.19 ± 3.48
0.856
Post-intervention
27.75 ± 4.99
27.55 ± 3.76
26.12 ± 3.43
0.599
MMSE
27 ± 2.2
27 ± 2.1
28 ± 2.0
--
Education (No. Subjects, %)
Unlettered
0 (0.0%)
0 (0.0%)
0 (0.0%)
--
1-4 years
3 (20.0%)
3 (20.0%)
1 (6.6%)
--
5-8 years
4 (26.7%)
4 (26.7%)
5 (33.3%)
--
9-11 years
5 (33.3%)
4 (26.7%)
0 (0.0%)
--
Above 11 years
3 (20.0%)
4 (26.7%)
9 (60.0%)
--
BOMFAQ (No. Subjects, %)
No difficult
9 (60.0%)
10 (66.6%)
7 (46.6%)
--
Mild difficult
6 (40.0%)
5 (33.4%)
8 (53.4%)
--
Moderate difficult
0 (0.0%)
0 (0.0%)
0 (0.0%)
--
Several difficult
0 (0.0%)
0 (0.0%)
0 (0.0%)
--
Number of Falls (in past 6 months)
Pre-Intervention
>4
>4
1
--
Post-intervention
3
2
3
--
Table 2. Population’s characteristics of present study.

Jacobs Publishers 7
Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Table 3. Data are expressed as mean ± standard deviation. Spatio-temporal gait variables in supervised, home and control groups during
three gait conditions (normal, functional dual-task and cognitive dual-task), pre- and post-intervention.

Jacobs Publishers 8
Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.
Table 4.-
vised, home-based and control groups during three gait conditions (normal, functional dual-task and cognitive dual-task), pre- and
post-intervention.

(p= 0.047) during functional dual-task (5.74% ± 3.95) when
compared to normal gait (2.88% ± 1.44).
Discussion
         -
cause the training protocol, regardless of supervised or domi-
ciliary strategy, based predominantly in balance exercises did
not improve gait parameters during normal gait and during
dual-task gait conditions.
There are evidences that balance training improves the pos-
tural control during dual-task conditions [25], however, our
         
balance training protocol, which corroborates with Hiyamizu
-
col (strength training and balance training, two times a week,
during 24 session) on dynamic balance associated to cognitive
tasks in older adults.
Studies included in the systematic review conducted by Ag-
mon et al [25] have performed different dual-tasks, different
   -
quency, evaluating different gait variables. Also, those studies
emphasize that the magnitude of changes in the gait variables
after the training protocol variates according to gait parame-

Plummer et al [27] showed a lack of consensus about frequen-
cy training, types of training, type of dual-tasks and variables
analyzed, discussing the need of a minimal standard training to
allow the comparison among studies. This approach is import-
-
prove gait parameters associated to dual-tasks performance.
Speed gait is a variable extensively discussed in the literature,
and studies have shown an interaction between age, speed gait
   
differences in gait speed before and after intervention program
among evaluated groups. However, it is possible to observe
that the mean of the gait speed among the three groups during
Normal gait was higher than during dual-tasks, as observed in
other studies [9-11]. Also, the values of the gait speed during
dual-task conditions are within the recommended gait speed

et al [29].
In the control group, the percentage of double support time in-
creased during dual-task conditions (functional and cognitive
dual-task) and it is known that the older adults remain more
time in double support as a strategy to maintain stability [6].
Also in the control group, the cadence decreased during cogni-
tive dual-task corroborating to the literature that reports that
the gait parameter changes during dual-task in elderly [26].
In addition, the increase in percentage of double support time
and the decrease in the cadence can be a compensatory strat-
egy due to a challenge task. Studies [11,27] have reported that
during cognitive dual-task, elderly change gait parameters, in-
creasing the percentage of double support time, because the
attention is focused on the second task.

factor for falls in the old age and there is evidence that gait
variability further deteriorates in dual-task conditions [23].
The results related to the gait variability have shown differenc-
es only at baseline. In the supervised group, the stride length
variability and cadence were higher during the functional du-
al-task condition. In the home-based group, the percentage
of single support variability was higher during the functional
dual-task condition. In the control group, the step length vari-
ability was higher during the functional dual-task condition.

variability among gait tasks for any group, which can suggest
     -
er, the same effect was observed after 10 weeks in the control
group that did not perform the training program.
The training protocol used in the present study met the re-
     
as mentioned in the review conducted by Lauenroth, Loan-
nidis and Teichmann [30], which include blind design, inten-
       
frequency of 1 to 3 hours weekly. However, our protocol lasted
10 weeks instead of 12 to 16 weeks, which is more likely to
reach detectable improvements. Therefore, the lack of balance
improvement in the present study may be related to the pop-
ulation’s characteristic, which included young old adults [31]
(range 60-72 years) and independent elderly living in the com-
munity.
Conclusion
We conclude that the training with predominantly balance ex-
    
single task and dual-task conditions in young-old dwelling
adults.
Limitation of The Study
The present study has some limitations: the inclusion of young-
old and the restrained exercise progression in balance training
protocol, because the same protocol was performed at home,
without supervision.


Acknowledgement
The authors would like to thank the responsible of Laborato-
Jacobs Publishers 9
Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.

ry of Movement Analysis (LAM) and responsible of Center of
Rehabilitation – CER, Clinical Hospital of RibeirãoPreto HCRP-
          
and Technological Development (CNPq, - Brazil) for their as-
sistance and support provided.
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Cite this article: Paulo Ferreira dos Santos . Effect of Balance Training on Gait With and Without Dual-Tasks in Elderly: Randomized Clinical Trial.
J J Physiother Exercise. 2016, 2(3): 022.