RGUHS Arunima S et al.

, RJPT 2024;4(3):21-28

Journal of Physiotherapy
ORIGINAL ARTICLE

Effect of Attention Based Exercises in Balance Control and Fall Risk in

Elderly Females - An Interventional Study
Arunima Sasidharan1*, L Gladson Jose2
1
Narayana Hrudayalaya Institute of Physiotherapy, Banglore, Karnataka, India
2
Dr. MV Shetty College of Physiotherapy, Kavoor, Mangalore, Karnataka, India
*Corresponding author:
Ms. Arunima Sasidharan, Narayana Hrudayalaya Institute of Physiotherapy, Banglore, Karnataka, India. E-mail:
nimaaru2@gmail.com
Received date: December 07, 2022; Accepted date: September, 05, 2024; Published date: December 31, 2024

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0.

Abstract
Background / Aim: Fall related injuries in elderly population are one of the most disabling
predicaments, particularly in the age group of 60-70 years. Postural restoration, therefore, is one of
the major concerns demanding attention in elderly individuals with balance impairments. This study
aimed to determine the effect of attention focussed balance interventions in improving balance and
reducing the risk of falling in female elderly population.
Methods: In this experimental interventional study, 54 subjects in the age range of
60-70 years, with age related balance impairments were recruited from an old age home using
purposive sampling technique with the set inclusion and exclusion criteria. Group A (n=27)
(Experimental group) received attention-based balance exercise intervention for five days/week,
for a total duration of 12 weeks and Group B (n=27) (Control group) received normal mobility
training for five days / week for 12 weeks. Outcome measures included Berg balance scale and John
Hopkins Fall Risk Assessment Tool.
Results: Results after statistical analysis within and between groups indicated that Group A subjects
highly benefitted from the attention focussed intervention provided to them for 12 weeks duration
(36.37-47.26). In Group B, though a significant difference was noted in the balance of individuals,
changes were less compared to the experimental group with a t value of -16.480 and a P value of
0.000.
Conclusion: Application of a component of cognition i.e., attention along with balance exercises can
rectify the balance impairments and reduce the risk of falls in this population.
Keywords: Focused attention training, Postural stability, Risk factors for falls, Aging population,
Health outcomes in aging

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Introduction lead to significant improvements in balance and gait.

Aging is a complex, intra-individual process defined Attention-based exercises require participants to focus
as the time independent, progressive decline in an on a task while maintaining balance, which can help
individual’s physiological integrity, which eventually strengthen the neural pathways involved in these dual
leads to deteriorated physical and mental function.1 processes. This is particularly important for elderly
A person spends 75 percent of his/her entire females, who may experience both cognitive decline
lifespan undergoing the process of decline.2 With and decreased physical stability. Hence the study aimed
global population aging trends, many countries are to determine the effect of attention based exercises in
implementing healthy aging policies to minimize balance control and fall risk in elderly population.
disability and increase quality in the extended years
Materials and Methods
of life.3 A significant aspect in the promotion of health
Source of data
among aging is the prevention of falls and fall related
injuries which can cause substantial disability and have Subjects with early and moderate stage balance
great impact on functional independence and quality impairments, with or without a recent history of fall in
of life of older people. Falls place a significant strain the past six months at St Anne’s old age home, Capitanio
on families and are an independent predictor of Dakshin Kannada district, were selected for the study.
admission to nursing homes. This causes massive Method of data collection
stress and burden for individuals, while also leading The data for this study were collected from normal older
to enormous societal costs and indirect expenses for adults in the age group of 60-70 years. The method of
families. data collection was based on the following steps:
Balance is a fundamental skill important for the safe Study design: Experimental interventional study.
performance of many activities that acquiesce older
Sampling method: Purposive sampling method.
people to remain independent in their community.4 As
the individual ages, there is deterioration in balance Sampling size: 54 subjects fulfilling the inclusion and
control system, exerting negative impact on the exclusion criteria.
multitasking abilities in both indoor and outdoor Sampling technique: Purposive sampling with set
environments. This is further accentuated in elderly inclusion and exclusion criteria.
population when they are needed to perform any task
requiring divided attention, making them prone to falls. Sample size estimation: Zα=1.96 zβ=0.842 S=2.88
An inability to restore balance due to competition for d=2.22. Thus, the sample size (n) = (1.96+0.842)2 *
attentional resources between postural system and a (2.88)2 (2.2)2 =7.85*2*8.29 (2.2)2 = 26.90 ≈ 27.
second task, is one of the major reasons for falls in older Inclusion criteria
adults with balance impairments. • Elderly female population aged 60-70 years.
Several studies have indicated that aspects of cognition, • Subjects who could walk 15 ft without any assistive
particularly the declining executive function are device.
predictive of fall risks in older adults without dementia
• Physically and mentally stable subjects (even met
or overt cognitive impairments.5 Since deficits in
with a fall, once or more in the last six months).
executive functions increase with age, this may impair
the ability of the older individuals to compensate for Exclusion criteria
age related changes in balance. However, very few • Neurological and psychosomatic disorders affecting
studies assessed the role of cognitive impairments in the physical function of the patient.
balance control among the aging population.
• Subjects with neurological, musculoskeletal and
The functional benefits of components of cognition, cardiovascular impairments.
specifically attention in the balance control and fall
The standard statistical analysis were applied to the
risk of aging population plays a major role. Research
collected data and the study outcome measures were
suggests that cognitive and motor systems are
compared between two groups for statistical significance
interconnected, and engaging both simultaneously can
using independent sample t-test.

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Duration of study: Approximately 12 weeks. 7. Back leg rises with and without support
Follow up: Subjects were assessed for study outcome 8. Walking on heels
measures i.e. Berg Balance Scale and FRAT (fall Risk
9. Walking on toes
Assessment Tool).
10. Walking heel to toe
Materials: Demographic data sheet, stopwatch, two
standard chairs (with reasonable height), one with 11. Forward stepping
armrest and one without, aerobic stepper or a stool (with The exercise prescription was formulated following
average step height), air filled ball, chalk 32, 15 ft walk- the ACSM (American College of Sports Medicine)
way with markers, and an informed consent form. guidelines, adhering to the FITT (Frequency, Intensity,
Methods Time, and Type) protocol. The program included a
frequency of five days per week, an intensity level of
Phase 1 - Ethical clearance: The synopsis was
5–6 on a 0–10 scale, and a duration of 30 to 60 minutes
submitted to the Institutional research committee
per session. The prescribed type of exercise comprised
(IRC) and permission was obtained. Following this, 54
aerobic activities designed to minimize excessive
subjects were selected following the set inclusion and
cardiological or orthopedic stress. Each session
exclusion criteria from an old age home in Dakshin
concluded with a 10-minute cool-down period.
Kannada district.
Group B (Control group)
With purposive sampling method, subjects for the study
were selected and allocated into two arms (Group A and Twenty seven subjects included in Group B were
Group B). In the initial phase of the study, all subjects provided with flexible goal oriented therapy, conforming
were assessed using the Berg Balance Scale and John to existing practices of treatment for elderly with
Hopkins Fall risk assessment tool for their baseline scores mobility problems.
and then detailed information about the procedure was Treatment consisted of assisted walking within parallel
explained. Written and signed consent was taken from bars, stair practices, and transfers. Treatment schedule
all the participants recruited for the study. Subjects were concentrated on augmenting balance with emphasis on
explained about the warm up and cool down sessions, a safe gait pattern.
and the practice before and after each session.
The intervention was structured to ensure that participants
Group A (Experimental group) in this group performed aerobic exercises twice a week.
The warm up session included three exercises: The exercises were set at an intensity level of 3–4 on
a scale of 0–10, with each session lasting 20 minutes.
1. Marching in place (2 minutes)
The selected aerobic activities were carefully chosen to
2. Active static stretching of major muscles: 30 sec hold minimize stress on the cardiovascular system.
(3 rep)
After 12 weeks of intervention, all subjects were assessed
3. Active range of motion exercises for each joint using Berg Balance Scale (BBS) and John Hopkins Fall
(5 rep) Risk Assessment Tool (JHFRAT) for post-test values.
Subjects allotted to Group 1 were made to perform a set Study outcome measures
of 11 exercises targeting the static and dynamic aspects 1. Balance by Berg Balance Scale
of balance. These involved exercises that strengthen the
core and back to keep the subject upright with major 2. Fall risk by Modified Johns Hopkins FRAT (Fall Risk
focus on cognitive input. Assessment Tool)

1. One leg stance with and without support Results

In the present study, 54 subjects were recruited, with 27
2. Marching in place
in each group by simple randomization. Participants of
3. Ball exercise (Bouncing the ball off a wall) Group A were examined for the effectiveness of attention
4. Dribbling a football based balance training in elderly and subjects in Group
B were observed as controls, performing mobility
5. Wall push-ups
exercises to reduce the inactivity in this population.
6. Clock reach

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Before the intervention, the recruited participants were that participants of both the groups had a homogeneous
subjected to the balance and mobility evaluation with range of mobility or risk of fall before intervention.
intended standardized outcome measures, Berg Balance
Analysis of Parameters Within Group A after
Scale and Modified John Hopkins fall risk assessment
Intervention
tool (JHFRAT).
Analysis of pre and post balance scores (BBS)
The data collected before and after intervention were
The mean value of balance scores with BBS in Group
subjected to various statistical tests in terms of analysis
A subjects before intervention was 36.37±1.471, and
of age and study parameters. Data were also analyzed to
this increased to a value of 47.26±1.196 after the
test the hypothesis of the study.
intervention. By using paired “t” test, comparison of
This study involved a convenience sample of older above parameters resulted in a t value of 23.661 and a
women residing in an old age home in Dakshin Kannada P value of 0.000 representing a very high significance
district. Both Group A and Group B included 27 subjects in analysis. This indicated that Group A subjects highly
each, in the age group of 60-70 years. The mean age of benefitted from the attention focussed intervention
the study participants was 64 years. The mean age of provided to them for a 12 week duration.
female subjects recruited in this study was 64 years.
Analysis of pre and post fall risk scores (JHFRAT)
Group A had 27 female subjects. With the randomness in Group A (Paired sample statistics)
sample allocation, majority of the subjects (18) included
Mean value of mobility score (fall risk) for subjects
were in the age range of 60-61 years.11 subjects (i.e.,
in Group A before the intervention was 3.78±1.601,
20%) included in this group were found to be have major
and this dropped to 1.48±1.312 after the intervention.
fall risk due to aging.
Comparison of this parameter with above values using
The mean value of mobility scores assessed by JHFRAT paired t test resulted in a t value of 16.480 and a P value
in Group A participants was 3.78±1.601, while the mean of 0.000, which represented a very high significance in
value of scores in Group B participants was 1.48±1.312. analysis. This indicated that subjects in Group A trained
The comparison of above using student “t” test showed with the attention based intervention showed a positive
a P value of 0.868 which is non-significant, implying reduction in the fall risk and improvement in their
mobility skills from the 12 weeks intervention.

Table 1: Group A balance scores (Paired sample statistics)

Group A Mean N Standard deviation Standard error mean t value Degrees of freedom P value

Pre 36.37 27 1.471 0.283

23.661 52 0.000*
Post 47.26 27 1.196 0.230

*Highly significant (P ≤0.05)

Table 2: Analysis of pre and post fall risk scores (JHFRAT)

Pairs Mean N Standard deviation Standard error mean t value Degrees of freedom P value

Pre-JHF 3.85 27 1.657 0.319

4.567 26 0.000
Post-JHF 2.96 27 2.103 0.405

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Analysis of Parameters Within Group B after Analysis of Balance Scores and Fall Risk Scores
Intervention Analysis of pre and post fall risk scores (JHFRAT)
Analysis of pre and post balance scores (BBS) Mean value of fall risk scores prior to intervention in
Group B (Paired sample statistics) subjects of Group B was 3.85±1.657 which dropped to a
Mean value of balance scores prior to intervention for mean of 2.96±2.103 following intervention. Comparison
subjects in Group B was 36.59±1.279, which increased of values with paired t test yielded a t value of 4.567
to 38.89±1.396 following intervention. Comparison of and a P value of 0.000 representing high significance
values with paired t test resulted in a t value of -16.480 according to analysis, even though with fewer subjects
and a P value of 0.000 representing high significance compared to Group A, indicating a positive effect of
according to analysis, even though with fewer subjects intervention
compared to Group A, indicating a positive effect of the
intervention.

Table 3: Analysis of balance scores among subjects of Group A and Group B

Group Mean N Standard deviation Standard error mean
1 (Post-BBS) 47.26 27 1.196 0.230

2 (Post-BBS) 38.89 27 1.396 0.269

Levene’s test for

t-test for equality of means
equality of variances
Standard 95% confidence interval of
Mean
F Sig t df Sig (2 -tailed) error the difference
difference
difference lower upper

Post BBS
equal variances 0.008 0.928 23.661 52 0.000 8.370 0.354 7.661 9.080
assumed

On analysis using the Student’s t test, a high statistical significant difference was observed in post balance scores between the groups with a P
value of 0.000 (P <0.001), indicating a positive influence on the balance of participants recruited in this 12 week study.

Table 4: Analysis of post intervention fall risk scores between Group A and Group B
Group A N Mean Standard deviation Standard error mean
1 (Post-JHF) 27 1.48 1.312 0.252
2 (Post-JHF) 27 2.96 2.103 0.405

Table 5: Independent sample t test

Levene’s test for
t-test for equality of means
equality of variances
Standard 95% confidence interval of
Mean
F Sig t df Sig (2 -tailed) error the difference
difference
difference lower upper
Post JHF
Equal variances -3.106
assumed.
9.238 0.004 52 0.000 8.370 0.354 7.661 9.080

Equal variance -3.106

not assumed
Using Student’s t test, high statistically significant difference was observed in post JHF between the groups (P <0.010), indicating that this
intervention can be administered in elderly population for better outcomes in balance and mobility.

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Discussion Post-Intervention Outcomes in Group A

With the proportion of older adults increasing in The intervention's impact on Group A was marked by
many industrialized nations, much research is being significant improvements in both balance and fall risk.
dedicated to understanding the changes that occur Post-intervention, the mean BBS score in Group A
with aging. Although it is well established that sensory rose to 47.26, indicating a substantial improvement in
feedback plays a critical role in postural control, the less balance (P=0.000). This result suggests that attention-
appreciated fact is that the delay in the transmission based balance training can effectively enhance postural
and processing of sensory feedback can disrupt stability among elderly females. The improvement is
standing balance.6,7 The accumulated behavioural, likely due to the dual-task nature of the training, engaging
neuropsychological and neuroimaging evidence shows both cognitive and motor systems. Previous research
that slow gait, postural instability and fall risk in elderly supports the notion that such dual-task exercises can
are associated with cognitive capacities.8,9 strengthen neural pathways involved in balance control
It has been hypothesized that an inability to produce and coordination, leading to better functional outcomes.
an appropriate postural response due to competition for Additionally, the JHFRAT scores for Group A decreased
attentional resources between the demands of postural from 3.78 to 1.48, reflecting a significant reduction in
system and the cognitive task contributes to falls in fall risk (P=0.000). This finding aligns with the literature
older adults with poor balance.10 One factor that has suggesting that targeted balance training can mitigate
consistently been shown to enhance the performance fall risk factors, including poor postural control and
and learning of motor skills, including balance skills, muscle weakness. The substantial reduction in JHFRAT
is the performer’s focus of attention.11,12 This finding scores indicates that attention-based exercises not only
directed the master idea to determine the effect of improve balance, but also contribute to overall safety
including an attention component to a selected set of and functional independence in this population.
balance exercises in the elderly population.
Comparative Analysis Between Groups
Age and Gender Distribution The comparison of post-intervention outcomes between
The study's demographic analysis showed a mean age of the two groups revealed a statistically significant
64 years among the participants. The age distribution was difference in both BBS and JHFRAT scores. The mean
relatively balanced between the two groups, ensuring that difference in BBS scores between Group A and Group
age-related variability did not confound the results. The B was 8.37 (P=0.000), indicating a significantly greater
majority of participants (33.3%) were in the 60-61 age improvement in balance in the intervention group. This
range, followed by a significant portion (22.2%) aged result strongly suggests that attention-based balance
68 years and above. This age distribution is crucial as it training is more effective than general mobility exercises
reflects a population likely to experience significant age- in enhancing postural control.
related decline in balance and mobility, thus providing a
Similarly, the difference in post-intervention JHFRAT
relevant sample for the study's objectives.
scores between the groups was also significant, with
Baseline Measures of Balance and Fall Risk Group A showing a more substantial reduction in fall
Initial assessments revealed that the two groups were risk compared to Group B (mean difference = -1.481,
homogeneous in terms of baseline balance and fall P =0.003). The greater improvement in fall risk in
risk. The mean BBS score was 36.37 in Group A and Group A can be attributed to the specific focus on balance
36.59 in Group B, with no statistically significant and attention in the intervention, which is critical in
difference (P=0.556). Similarly, JHFRAT scores addressing the multifactorial nature of falls in the elderly
indicated comparable fall risk levels, with Group A population.
having a mean score of 3.78 and Group B a score of 3.85 The differential outcomes between the two groups
(P=0.868). These findings underscore the importance can be attributed to the nature of the interventions.
of randomization in creating equivalent groups, thereby Attention-based balance exercises require participants
ensuring that any observed post-intervention differences to simultaneously engage in cognitive and motor tasks,
can be attributed to the interventions themselves rather potentially enhancing neuroplasticity and improving
than pre-existing disparities. the coordination between cognitive and motor systems.

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This dual engagement may be particularly beneficial for mobility exercises contribute to improved physical
elderly females, who often experience both cognitive function, they may not be as effective as attention-based
and physical declines with aging. The study results are training in enhancing balance and reducing fall risk.
consistent with the existing literature underscoring the
Conclusion
interconnectedness of cognitive and motor systems and
Poor health, pain, fear of falling and the risk of injury
suggests that dual-task training can lead to superior
are the most frequently mentioned factors by elderly
improvements in functional abilities.
individuals as limiting their physical activity. In
Furthermore, the statistically significant differences women, this pattern generally reflects the time pressures
observed between the groups in post-intervention BBS associated with their multiple roles at this stage of life
and JHFRAT scores underscore the efficacy of attention- and earlier. Lack of self-compassion associated with
based training. The study's use of standardized outcome age also attributes to the cause. This study concludes
measures and rigorous statistical analysis, including the that simple attention-based balance training, in early
Student’s t-test, bolsters the reliability of these findings. and moderate stage balance impairments, is fruitful
The significant P values (0.000) for both balance and and feasible among the comparatively inactive, 60-70
fall risk outcomes in Group A confirm the effectiveness year old female population. Further, this intervention
of the intervention. was found to alleviate their fear of fall to a great extent,
contributing to self-confidence, enabling them to adopt
Overall, these findings advocate the inclusion of
a physically active lifestyle during the final years of
attention-based balance training in fall prevention and
their life.
rehabilitation programs for the elderly, particularly for
women who are at a higher risk of falls. The study also Conflict of Interests
highlights the need for further research to explore the The author do not have any conflict of interest to declare.
underlying mechanisms contributing to the observed
improvements and to optimize the design of dual-task Acknowledgement
training protocols for maximum benefit. I express my heartfelt indebtness and owe a deep sense
of gratitude to my teacher and my faculty guide Prof.
The findings from this study highlight the significant L. Gladson Jose Principal, Dr M.V. Shetty College of
benefits of attention-based balance training in improving Physiotherapy and for the regular advice, magnitude
balance and reducing fall risk among elderly females. of dynamic and untiresome guidance, suggestion
The intervention group (Group A), which received and encouragement throughout the course of present
specific attention-focused exercises, showed remarkable research.
improvements in balance, as indicated by the increase
I would like to express my sincere thanks to all the
in Berg Balance Scale (BBS) scores from 36.37 to
respectable staff members of Dr M.V. Shetty College
47.26 post-intervention. Similarly, the Modified John
of Physiotherapy, without their co-operation this study
Hopkins Fall Risk Assessment Tool (JHFRAT) scores
wouldn’t have been successful. I acknowledge my
demonstrated a substantial reduction in fall risk, with
sincere gratitude towards the Narayana Hrudayalaya
scores decreasing from 3.78 to 1.48. These results
Institute of Physiotherapy for providing me the time and
suggest that attention-based balance training effectively
opportunity for publishing this study.
enhances postural stability and reduces fall risk,
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