The Effectiveness of the Exercise Education

Hong Kong Journal of Occupational Therapy (2011) 21, 56e63 Available online at www.sciencedirect.com journal homepage: www.hkjot-online.com ORIGINAL ARTICLE The Effectiveness of the Exercise Education Programme on Fall Prevention of the Community- dwelling Elderly: A Preliminary Study Moonyoung Chang a,*, Yan-hua Huang b, Heyyoung Jung c a Department of Occupational Therapy, College of Biomedical Science and Engineering, Inje University, Gimhae, South Korea b Department of Occupational Therapy, School of Health and Human Services, College of Professional Studies, California State University, Dominguez Hills, California, USA c Department of Occupational Therapy, Suncheon First College, Suncheon, South Korea Received 15 March 2011; received in revised form 29 June 2011; accepted 13 October 2011 KEYWORDS Abstract Objective: The purpose is to identify the effects of the exercise education pro- community-dwelling; gramme on fall prevention of community-dwelling elderly. elderly; Methods: A single blind preliminary randomized control trial was conducted. Participants exercise; (N Z 10) in the experimental group was assigned to an exercise education programme which fall prevention; consisted of 28 sessions, 30w40 minutes per day for 4 weeks and a self-management telephone self-management; monitoring programme once every two days. Participants (N Z 8) in the control group received telephone monitoring no intervention. The effectiveness of exercise education programme was measured by fall index, balance confidence scale, and balance scale. Results: The fall risks decreased from moderate to minimum in the experimental group (p < .001). Balance confidence scores increased, especially 6 items measured statistically significant increases (p < .05). However, balance scores did not show statistically significant improvement. Conclusion: The exercise education programme might be effective for fall prevention of commu- nity-dwelling elderly. Copyright ª 2011, Elsevier (Singapore) Pte. Ltd. All rights reserved. Introduction * Corresponding author. Department of Occupational Therapy, Due to the recent population ageing, rises in diseases in the College of Biomedical Science and Engineering, Inje University, 607 elderly population and in medical expenses are coming to Obang-dong, Gimhae-si, Gyeongsangnam-do 621-749, South Korea. the forefront as important social problems (Lee et al., 2009). In Korea, 15% of total deaths of the elderly are due E-mail address: [email protected] (M. Chang). 1569-1861/$36 Copyright ª 2011, Elsevier (Singapore) Pte. Ltd. All rights reserved. doi:10.1016/j.hkjot.2011.10.002

Exercise education programme on fall prevention 57 to accidents; of these accidental deaths, 70% are due to presented exercise programmes that included balance falls (H.K. Kim, 2009). The medical expenses for those aged training as recommendations for preventing falls in elderly 65 years or older are about 30% of the total medical costs in persons. Also, the Centers for Disease Control and Korea. The treatment costs related to fractures in the Prevention (2007) determined that improving strength and elderly due to falls is known to be the highest (Kim, Bae, balance exercise may reduce falls among the elderly. Park, Gu, & Hong, 2003). Falls due to ageing is ranked as However, most of the exercise education programmes on the fifth cause of death among the elderly population fall prevention are limited to aerobic exercises performed (Hansen, Morild, Engesaeter, & Viste, 2004). Although falls in groups such as eurhythmics or dance programmes. There may occur at any time across a person’s lifespan, they is a lack of exercise education programmes that individuals occur more frequently in persons 60 years or older (Kannus, can practice on their own during their daily living activities Sievanen, Palvanen, Jarvinen, & Parkkari, 2005). Around (S.H. Kim, 2009). one-third of community-dwelling elderly individuals expe- rience falls every year (Fong, Siu, Au Yeung, Cheung, & Self-management refers to the individual’s ability to Chan, 2011), and one of every 40 elderly persons who manage his physical and psychosocial functions and to experience a fall is hospitalised. In Korea, 50% of elderly develop preventive strategies (Barlow, Wright, Sheasby, patients hospitalised due to falls survived less than 1 year Turner, & Hainsworth, 2002). Self-management is a form (Ryeom, Kim, So, Park, & Lee, 2001). of health promotion. In self-management, patients solve their health problems as an active participant (Sohng, Kim, Falls may occur without any external cause while per- & Cho, 2001). Self-management programmes in the elderly forming activities of daily living; individuals may uninten- have been studied in people who have diabetes mellitus, tionally lose balance or stability resulting with part of the hypertension, and osteoarthritis, and it has been proven body coming in contact with the ground (Lord, Clark, & to improve self-efficacy (Chodosh et al., 2005). However, Webster, 1991). When elderly people experience falls, the the development of self-management programmes for physical damage causes a reduction in their physical ability; fall prevention in the healthy community-dwelling elderly however, even if their physical abilities are restored, the population is currently insufficient. fear of falling again may reduce general physical activity and increase their dependency on others (Jeon, Jeong, & In this respect, the purpose of this study was to determine Choe, 2001). This decreases their skills for activities of the effectiveness of an exercise education programme on daily living and eventually lowers their quality of life (Hill & fall prevention for this elderly population. The hypothesis Schwarz, 2004). Occupational therapy expertise is valued was that there would be statistically significant differences for its fall prevention interventions such as assertiveness between the experimental group and the control group in training, exercise programmes, home evaluations and fall risk, sense of balance, and sense of efficacy. modification, functional assessments, assistive device training, and risk-reduction education (Caldeira & Reitz, Methods 2009). In addition, exercise and home visits performed by occupational therapists will facilitate self-reflection and Research design improve awareness of the risk factors of the environment surrounding the patient in order to prevent future falls The study was a single-blind, preliminary randomised (Caldeira & Reitz, 2009; Cumming et al., 1999). control trial aimed at examining the effects of fall prevention exercise programmes on the elderly populations The prevention of falls in elderly patients includes risk of falls, sense of balance, and sense of efficacy against monitoring factors that may contribute to fall prevention falls. such as age, sex, marital status, amount of medication taken, a history of previous disease, previous fall experi- Patients ences, and physical strength (Chu, Chi, & Chiu, 2005; Fong et al., 2011; Whooley et al., 1999). Physical strength is one Patients were community-dwelling elderly persons who variable that can be controlled (Gu, Jeon, & Eun, 2006), were using a social welfare centre facility located in G City and, if physical factors such as muscular strength, agility, in Gyeongsangnam-do, South Korea. Convenience sampling balance, flexibility, endurance, or athletic abilities was used. The inclusion criteria included: (a) persons aged decrease, they may cause falls (Judge, Linsay, Underwood, 65 or older who were using the social welfare centre & Winsemius, 1993). facility, (b) no serious foot problems (Tinetti, Speechley, & Ginter, 1988), (c) no deficiencies in cognition, and those The most common fall prevention method for elderly who scored at least 24 points in a Mini-Mental State individuals is exercise. Exercise education programmes in ExaminationeKorean version (MMSE-K) (Kwon & Park, fall prevention will affect physiologic variables such as 1989), (d) elderly persons with no experience in falls in flexibility, balance, endurance, coordination, gaits, and the past 12 months, and (e) elderly persons who understood reaction time, as well as psychological variables such as the purpose of this study and agreed to participate. anxiety, depression, life satisfaction, self-esteem, and a sense of efficacy against falls (Calderia & Reitz, 2009; Twenty patients were randomly divided into an experi- Sung, 2007). Robertson, Devlin, Gardner and Campbell mental group of 10 patients and a control group of 10 (2001) used muscle-strengthening exercises and balance patients by a social worker of an institution who did not training programmes on elderly persons to measure their know the contents of the experiment. During the con- fall preventing effects. The American Geriatrics Society, ducting evaluation, two patients in the control group did the British Geriatrics Society, and the American Academy not participate in a re-evaluation; thus, the final number of of Orthopedic Surgeons Panel on Falls Prevention (2001)

58 M. Chang et al. Figure 1 Research procedures. using the Berg Balance Scale, and (3) “senses of efficacy against fall” was measured using the Activity-specific enrolees was 18 in total including 10 in the experimental Balance Confidence Scale (ABC). group and 8 in the control group (Fig. 1). All of the patients enrolled in the experimental group (N Z 10) were women. Fall risk All of the 18 patients had an education level higher than We used the Tetrax Interactive Balance System to measure elementary school. Based on the results of the cognitive fall risk, and the system’s testeretest reliability was good function evaluation using the MMSE-K, the majority of the (r Z .89) (Schwesig & Mueller, 2003). The Tetrax Interac- patients scored 28e30 points in both groups (Table 1). This tive Balance System used in the study objectively evaluated study was conducted for a total of 4 weeks (28 days) from balancing abilities in eight different postures and showed July 26, 2009, through August 20, 2009. fall indexes in numerical outcomes so that fall risk could be predicted in relation to various situations that may occur Outcome measures while the patients performed activities of daily living skills. The tool is composed of a safety bar, a force plate, The outcome measures were evaluated in three domains: a monitor, and a balance test programme. The fall indexes (1) “fall risk” was measured using the Tetrax Interactive are obtained through the weight ratios, weight distribution Balance System, (2) “senses of balance” was measured indexes, and pressure patterns entered into each footplate that reflected the degrees of coordination and efficiency. Table 1 Demographic Characteristics The fall indexes are divided into 0e35 points as minimum fall risks, 36e57 points as moderate fall risks, and 58e100 Characteristics Experimental Control points as maximum risks. The eight postures measured are (N Z 10) (N Z 8) a method used in previous studies and the reliability and N (%) reproducibility of the method has been proven (Kohen-Raz, N (%) 1 (12.5) 1991; Kohen-Raz & Hiriatborde, 1979). The eight postures 7 (87.5) measured are a normal position, with eyes open (NO); Sex (n) Man 0 (0) a normal position, with eyes closed (NC); eyes open, on Woman 10 (100.0) 3 (37.5) pillows (PO); eyes closed, on pillows (PC); head turned right 4 (50.0) and eyes closed (HR); head turned left and eyes closed Age (y) 65e70 5 (50.0) 0 (0) (HL); head bent backward about 30 degrees and eyes closed 70e75 3 (30.0) 1 (12.5) (HB); and head leaning forward about 30 degrees and eyes 75e80 0 (0) closed (HF). 80e85 2 (20.0) 0 (0) 8 (100.0) Sense of balance Education (y) 0 0 (0) The Berg Balance Scale has been developed to measure an Elementary 10 (100.0) 2 (25.0) elderly person’s static and dynamic balancing abilities, and school 6 (75.0) the scale is divided into three areas including sitting, standing, and posture changes. It is composed of a total of MMSE (score) 24e27 3 (30.0) 8 (100.0) 14 items (Berg, Maki, Williams, Holiday, & Wood- 28e30 7 (70.0) 0 (0) Dauphinee, 1992). This is a five-point scale to be scored minimum 0 through maximum 4 and its full score is 56 Marital status Married 10 (100.0) 4 (50.0) points (Shumway-Cook, Baldwin, Polissar, & Gruber, 1997). Single 0 (0) 4 (50.0) The time required is around 15 minutes and higher scores mean better degrees of balance. It has been reported that Caregiver Yes 8 (80.0) if the total score of a person is 0e20 points, the person No 2 (20.0) must use a wheelchair; if 21e40 points, the person can walk using aiding tools; and if 41 points or higher, the person can y Z Year. walk completely independently. Persons with scores of 40 points or higher are not likely to fall (Berg et al., 1992). The Berg Balance Scale’s reliability values within measurers and between measures are r Z .97 and r Z .99 respectively (Berg, Wood-Dauphinee, & Williams, 1995). Sense of efficacy against falls In order to measure the psychological effects of the fall preventing exercises, we measured senses of efficacy against falls using the ABC. This scale was developed by Powell and Myers (1995) to measure an elderly person’s fear of falls. The questions are composed of a total of 16 items regarding not only indoor activities but also outdoor activities (Jang, Cho, Ou, Lee, & Baik, 2003). The patients are asked how confident they are to do individual works without falling or losing balance, and the answers can be given by checking anywhere

Exercise education programme on fall prevention 59 between 0% (not at all confident) and 100% (completely participant to perform and manage exercises by themselves confident). The average of the scores to the 16 questions continuously every day. Telephone monitoring was con- becomes the final total score. During the study, the validated ducted once every 2 days by the researcher, and that call Korean language version of the ABC was used and its Cron- took about 5 minutes. The telephone appointments were bach’s a Z .99 (Jang et al., 2003). We also tested the reli- scheduled based on each participant’s availability after he ability of the Korean language version of the ABC in our study or she completed the first exercise programme. The and the results showed high internal consistency of Cron- researcher called the patients in the experimental group to bach’s a Z .949.Therefore, the measurement outcome of check if they were implementing the exercise programme this version of the ABC is adequate for this study. and also encouraged them to continuously implement the programme. Intervention programme Procedures Exercise programme The programme used in this study was composed by On Day 1 of the study, a preintervention baseline evaluation a professor of the Department of Occupational Therapy of the entire study population was conducted. The 10 who specialises in elderly rehabilitation and an occupa- patients in the experimental group were educated by an tional therapist. Together they reviewed previous studies of occupational therapist on the exercise educational pro- exercise education programmes on fall prevention. The gramme on fall prevention for 1.5 hours. During this session, exercises were configured so that they can improve self- the occupational therapies gave the patients manuals with perception of risk factors based on the belief that exercise explanations and pictures of the exercises for them to intervention, balancing exercises, and muscular strength practice by themselves at home. On the last day of the exercises are effective at preventing falls (Barnett, Smith, study, a postintervention evaluation was conducted (Fig. 1). Lord, Williams, & Baumand, 2003; Gu et al., 2006). Data analysis method The American College of Sports Medicine (1995) advised that, although an elderly person’s frequency of exercise Data were analysed using the SPSS/WIN 12.0 programme may vary with the levels of physical strength, each interval (SPSS Inc.). Amounts of changes in the senses of balance between exercises should not exceed 48 hours and exer- and the senses of efficacy against falls in the experimental cises should be performed at least three times a week to be and the control group were analysed using Mann-Whitney effective. It was also advised that for the desired effects of tests. Changes in the risks of falls in the experimental group exercises, exercises should be continued for at least 20e30 and the control group between before and after the minutes, warming-up exercises and cooling-down exercises intervention were compared and analysed using the fall for around 5e10 minutes, and main exercises for around indexes presented in the static balance tester. The statis- 20e30 minutes were appropriate. Based on this guidance, tical significance level was a Z .05. the time for one session of the exercise education pro- gramme on fall prevention in this study was composed of Results approximately 30e40 minutes, which included warming-up exercises, cooling-down exercises for around 5e10 There were no statistically significant differences in age, minutes, respectively, and main exercises for around 20e30 cognitive function, baseline scores of the fall index, minutes (Table 2). The warming-up and cooling-down balance scores, or sense of efficacy scores between the two exercises were composed of stretching, and the main groups by independent t test (p > .05). Therefore, the exercises were composed of upper and lower extremity baselines between the two groups were equal. After muscle strength and balancing exercises. treatment, we found a statistically significant result in fall risk (p < .001), but there were insignificant results in sense Self-management telephone monitoring of balance and sense of efficacy between the two groups. We used a manual with explanations and drawing of the However, six out of the 16 items within the sense of efficacy exercise programme, a self-checklist, and stickers. Partic- measurement showed a statistically significant difference. ipants were asked to attach a sticker to the self-checklist every time they finished exercises in order to enable the Table 2 The Components of Exercise Education Programme on Fall Prevention Warming-up exercises Shoulder rotating, neck stretching, arm stretching, moving two arms laterally, arm rotating, back bending, enfolding, wrist rotating and extending, making Main exercises Upper extremity muscular circles strength exercises Lifting the body from a chair, ball grabbing, ball side pressing, ball rolling and Lower extremity muscular pressing, vertically pressing a ball strength exercises Lower extremity flexion, lower extremity extension, ankle rotating and lifting, Balancing exercises standing on the toes and the heel, knee lifting Three-stage gaits, standing on one foot, fixing one foot and moving the other Cooling down exercises foot laterally, walking along one line, writing letters with a foot The same as the warming-up exercises

60 M. Chang et al. Table 3 Group Comparison of Pre-post Test of Fall Index and Fall Risk Score Patient Pre Post Difference (PostePre) Fall risk score difference (PreePost) Experimental 1 36 23 e13 Moderate-Minimum Moderate-Minimum 2 46 22 e24 Minimum-Minimum Moderate-Minimum 3 16 16 0 Moderate-Moderate Minimum-Minimum 4 46 24 e22 Maximum-Maximus Maximum-Moderate 5 48 41 e7 Maximum-Moderate Maximum-Maximum 6 28 20 e8 Moderate-Minimum 7 80 62 e18 Minimum-Moderate Minimum-Minimum 8 65 51 e14 Minimum-Minimum Moderate-Moderate 9 58 40 e18 Minimum-Moderate Maximum-Maximum 10 68 59 e9 Moderate-Moderate Maximum-Maximum Mean (SD) 49.1 35.5 e13.30 (7.44)** Moderate-Moderate Control 1 34 42 8 2 16 24 8 3 10 20 10 4 38 46 8 5 22 50 28 6 80 84 4 7 42 40 e2 8 60 68 8 Mean (SD) 37.75 46.75 9.00 (8.55)** * Statistically significant result as p < .05. ** Statistically significant result as p < .001. Physical effects Sense of balance The Berg Balance Scale values of the two groups did not Fall risks show any statistically significant differences (Table 4). The mean score of the fall index as evaluated by the Tetrax Interactive Balance System conducted before and after the Psychological effects treatment for both the experimental and control groups (Table 3). The fall risks decreased from moderate to Sense of efficacy against falls minimum in the experimental group. There was a statisti- Senses of efficacy against falls were evaluated using the cally significant difference (p < .001) between the two ABC. There were statistically significant results found in six groups. The experimental group has decreased fall risks of the 16 items. In the remaining 10 items, senses of effi- when compared with the control group. cacy against falls increased in the experimental group that Table 4 Comparison of Mean Differences of Berg Balance Scale Between Two Groups After Training Experimental (N Z 10) Control (N Z 8) P value Mean (SD) Mean (SD) 1.000 .765 1 Sitting to standing 4.00 (0.000) 4.00 (0.000) 1.000 2 Standing unsupported 4.00 (0.000) 3.94 (0.250) .937 3 Sitting unsupported 4.00 (0.000) 4.00 (0.000) .671 4 Standing to sitting 3.75 (0.786) 3.75 (0.683) .962 5 Transfers 3.80 (0.616) 3.63 (0.806) 1.000 6 Standing with eyes closed 3.95 (0.224) 3.94 (0.250) 1.000 7 Standing with feet together 4.00 (0.000) 4.00 (0.000) 1.000 8 Reaching forward with outstretched arm 4.00 (0.000) 4.00 (0.000) 1.000 9 Retrieving object from floor 4.00 (0.000) 4.00 (0.000) .290 10 Turning to look behind 4.00 (0.000) 4.00 (0.000) 1.000 11 Turning 360 degrees 3.80 (0.616) 3.38 (0.957) .814 12 Placing alternate foot on stool 4.00 (0.000) 4.00 (0.000) .912 13 Standing with one foot in front 3.85 (0.671) 4.00 (0.000) .539 14 Standing on one foot 3.70 (0.923) 3.81 (0.544) Total score 57.85 (2.134) 54.44 (2.449) * Statistically significant result as p < .05.

Exercise education programme on fall prevention 61 participated in the exercise educational programme on fall of muscular strength and balancing exercises reduced the prevention compared with the control group, although the risk of falls by 35% (Robertson et al., 2001). Although this differences were not statistically significant (Table 5). exercise programme significantly reduced fall risks, it did not produce any statistically significant differences in any Discussion items of senses of balance measured using the Berg Balance Scale. The Berg Balance Scale is a tool to measure balancing The occupational therapisteled exercise education pro- abilities, which may be used to predict fall risks (An, Lee, gramme on fall prevention in community-dwelling elderly Cho, & Shin, 2007). However, Bogle Thorbahn and Newton patients might be effective according to the results of this (1996) advised that although the Berg Balance Scale is study. Elderly individuals had a decreased fall risk in the very sensitive to patients with high fall risks, it is not very physical factors and an increased sense of efficacy against sensitive to patients with low fall risks. In particular, falls in the psychological factors. The uniqueness of in this persons who scored 41 points or higher could walk study is that telephone monitoring was conducted so that completely independently and persons who scored 40 points the community-dwelling elderly patients could manage or higher were not likely to fall (Berg et al., 1992). The the exercise educational programme on fall prevention on individuals in this study scored at least 40 points when their own. measured using the Berg Balance Scale; thus, they were patients who were not likely to fall. It may be possible that The physical effects of the exercise educational pro- the enrolees showed ceiling effects in this balancing test gramme on fall prevention were tested using the Tetrax and thus did not show any significant results after training. Interactive Balance System. This tool is expensive and cannot be easily used in clinics (Shin, An, & Lee, 2005), but it The psychological effects of the exercise educational is advantageous because it integrates risk factors for falls programme on fall prevention were measured using the and provides objective fall indexes. Based on the results of ABC. Based on the results, senses of efficacy against falls this study, the mean fall index of the experimental group increased in general in the experimental group. In partic- decreased from a moderate falls risk at 49.1 points to ular, statistically significant results were shown in walking a minimum falls risk at 35.5 points. These results indicate up and down stairs, standing on toes in order to grab objects that the exercise educational programme on fall prevention located overhead, walking up and down slopes, walking was effective on patients with moderate or higher falls risks. around in crowd shopping malls, walking around crowded These results are consistent with a report by Hahm and Lee places, and walking along escalators without holding hand- (2009) that indicated that the programme was effective on rails. It has been reported that senses of efficacy against patients with higher falls risks. These results also support falls is a major cause that affects falls (Jung, Lee, & Chung, the results of studies indicating that muscular exercises 2006). As senses of efficacy against falls increase, the performed by elderly persons were effective in preventing quality of life related to physical health is improved (Lim future falls (Kim & Bae, 2002), and that the implementation et al., 2007). Yoo and Choi (2007) advised that the higher the senses of efficacy against falls, the lower the frequency Table 5 Group Comparison of Mean Differences of Activity-Specific Balance Confidence Scale Variables Experimental Control p value (N Z 10) (N Z 8) .262 Mean (SD) Mean (SD) .009* .077 1 .Walk around the house? 96.00 (8.207) 90.00 (13.662) 62.50 (23.523) .168 2 .Walk up or down stairs? 84.00 (20.365) 84.38 (12.633) .028* .062 3 .Bend over and pick up a slipper from the front of a 92.00 (9.515) 88.13 (14.705) .053 78.75 (20.936) .352 closet floor? 75.00 (23.094) .539 75.00 (23.094) .262 4 .Reach for a small can off a shelf at eye level? 95.00 (10.000) 82.50 (19.833) .001* 83.75 (19.279) .033* 5 .Stand on your tiptoes and reach for something above your head? 93.50 (14.609) 85.00 (17.889) .012* 65.63 (16.317) .140 6 .Stand on a chair and reach for something? 88.00 (10.563) 80.00 (15.492) 75.00 (18.619) .009* 7 .Sweep the floor? 89.00 (16.827) 83.13 (19.906) .422 8 .Walk outside the house to a car parked in the driveway? 90.00 (11.239) 70.63 (18.428) 9 .Get into or out of a car? 89.50 (11.910) 53.75 (30.523) 10 .Walk across a parking lot to the mall? 93.00 (9.234) 11 .Walk up or down a ramp? 86.50 (16.311) 12 .Walk in a crowded mall where people rapidly walk past you? 91.00 (13.727) 13 .Are bumped into by people as you walk through the mall? 91.00 (14.105) 14 .Step onto or off an escalator while you are holding onto a 93.50 (8.751) railing? 15 .Step onto or off an escalator while holding onto parcels such that you 86.50 (14.965) cannot hold onto the railing? 16 .Walk outside on icy sidewalks? 62.50 (14.096) *p < .05.

62 M. Chang et al. of falls. Therefore, in this study, the statistically significant effective for the prevention of falls in the community- increase in senses of efficacy against falls proved that the dwelling elderly population. Elderly patients who partici- intervention of an exercise programme might be useful. pated in this programme had a decreased fall risk and an increased sense of efficacy against falls. The uniqueness of Effective programmes for preventing the risk of falls this study is not only the use for the exercise education pro- aimed to enable elderly persons to live independently and gramme but also the use of the telephone monitoring method reduce their risk of falls should include educational factors to follow-up the study participants. This exercise education for promoting behavioural changes (Desai, Zhang, & programme with self-management telephone monitoring is Hennessy, 1999). In the research of Clemson et al. (2004), recommended for future fall prevention programmes and they used a small-group educational programme to promote studies for the community-dwelling elderly population. personal control and problem solving. In this study, education was provided so that elderly persons could Acknowledgements implement the exercise programme for preventing falls continuously by themselves and they were encouraged to This work was supported in 2010 by the Inje Research and maintain the programme through telephone monitoring. Scholarship Foundation. Recently, as attention is paid to cost effectiveness and patient-oriented service environments, programmes References implemented at home are being emphasised (Song, 2005). One of the approaches to fall prevention programmes American College of Sports Medicine. (1995). ACSM’s guidelines implemented in home settings is telephone monitoring. for exercise testing and prescription. Baltimore: Williams & This method is the most convenient method to easily access Wilkins. patients in their home settings and is effective in providing opportunities to have continuous contact with these elderly American Geriatrics Society, British Geriatrics Society, & American patients (Muller, Vuckovic, Knox, & Williams, 2002). Riegel Academy of Orthopedic Surgeons Panel on Falls Prevention et al. (2002) stated that telephone monitoring should be (AGS, BGS, AAOS). (2001). Guidelines for the prevention of falls done at least once a week to be effective. In this study, in older persons. Journal of the American Geriatrics Society, telephone monitoring was conducted by an occupational 49, 664e681. therapist once every 2 days to check that the patients were implementing the exercise programme, to discuss any An, S. H., Lee, H. S., Cho, B. M., & Shin, Y. I. (2007). Application and difficulties in implementing the programme, and to correlation between functional performance measures in older encourage the patients to continue to follow the exercise people. International Journal of Coaching Science, 9, 15e168. programme in order to prevent future falls. The exercise education programme and the telephone monitoring Barnett, A., Smith, B., Lord, S. R., Williams, M., & Baumand, A. method guided by an occupational therapist for this (2003). Community-based group exercise improves balance and community-dwelling elderly population were unique reduces falls in at-risk older people: a randomized controlled because, to our knowledge, it might be the first study in trial. Age Ageing, 32, 407e414. occupational therapy to combine exercise and follow-up self-management through telephone monitoring. Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002). Self-management approaches for people with chronic Limitations conditions: a review. Patient Education and Counseling, 48, 177e187. This study has four limitations. First, the number of the participants in this study is 18 in total. This study may not be Berg, K. O., Maki, B. E., Williams, J. I., Holiday, P. J., & Wood- generalised due to the small sample size. Second, although Dauphinee, S. L. (1992). Clinical and laboratory measures of the Berg Balance Scale is widely used in clinics to measure postural balance in an elderly population. Archives of Physical the effects of fall prevention intervention (Berg et al., 1992), Medicine Rehabilitation, 73, 1073e1080. it is not a sensitive tool when evaluating community-dwelling elderly patients with good functions. Therefore, more Berg, K., Wood-Dauphinee, S., & Williams, J. I. (1995). The balance sensitive tools should be used in future studies to test the scale: reliability assessment with elderly residents and patients effectiveness of fall prevention programmes. Third, the with and acute stroke. Scandinavian Journal of Rehabilitation exercise education programme was only 4 weeks. Future Medicine, 27, 27e36. longitudinal studies should follow-up these healthy elderly individuals. Fourth, the method of telephone monitoring had Bogle Thorbahn, L. D., & Newton, R. A. (1996). Use of the berg not been standardised because its time intensities have not balance test to predict falls in elderly persons. Physical been clearly defined (Song, 2003). Future studies may Therapy, 76, 576e583. further formalise implementation methods and the required time of the telephone monitoring method. Calderia, K. M., & Reitz, M. (2009). Preventing falls among community-dwelling older adults. In M. E. Scaffa, S. M. Reitz, & Conclusion M. A. Pizzi (Eds.), Occupational therapy in the promotion of health and wellness (pp. 470e492). Philadelphia: Davis The 4-week exercise education programme with self- Company. management telephone monitoring method might be Centers for Disease Control and Prevention. 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