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Correlación entre equilibrio estático y autonomía funcional en mujeres de edad avanzada


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Correlación entre equilibrio estático y autonomía funcional en mujeres de edad avanzada

  1. 1. Correlation between static balance and functional autonomy in elderly women Fernanda de Noronha Ribeiro Daniel a, *, Rodrigo Gomes de Souza Vale a , Tania Santos Giani a,b , Silvia Bacellar c , Tatiane Escobar a , Mark Stoutenberg d , Este´lio Henrique Martin Dantas a a Laboratory of Human Motricity Biosciences (LABIMH), Castelo Branco University (UCB), Av. Salvador Allende, n. 6700, Recreio do Bandeirantes, Rio de Janeiro, RJ, CEP 22780-160, Brazil b Esta´cio de Sa´ University (UNESA), Av. prefeito Dulcidio Cardoso, n. 2900, Barra da Tijuca, Rio de Janeiro, RJ, CEP 22631-052, Brazil c Instituto Nacional do Caˆncer (INCA), Rio de Janeiro, Prac¸a da Cruz Vermelha, n. 23, Centro, Rio de Janeiro, RJ, CEP 20230-130, Brazil d Department of Epidemiology and Public Health, University of Miami, Miller School of Medicine, 1425 NW 10th Avenue, Suite 214, Miami, 33136 FL, USA 1. Introduction The rapid increase of elderly populations brings greater attention to the loss of independence in individuals 60 years and older. This loss of independence is related to a decrease in functional capacity in completing activities of daily living (ADL) leading to an increased occurrence of falls which is a leading fear of the elderly due to its serious health consequences (Perracine and Ramos, 2002; Aslan et al., 2008). According to the Brazilian Institute of Geography and Statistics (IBGE, 2004), by 2020 the elderly population will increase by approximately 31.8 million people leaving Brazil with the world’s sixth largest elderly population. By 2050, an estimated 18% of the Brazilian population will consist of elderly people. Biological aging is a multifactorial phenomenon which is associated with profound changes in the activity of cells, tissues and organs, as well as the reduction of effectiveness through a range of physiological processes (Barbosa et al., 2001; Kjaer and Jespersen, 2009; Vale et al., 2009). Due to the aging and deterioration of these different physiological systems, postural control is altered causing gait abnormalities and postural instability (Barau´ na et al., 2004; Tainaka et al., 2009). Postural instability and loss of functional autonomy are public health issues among elderly people when considering the mortality and morbidity rates and the social and economic costs caused by falls (Guimara˜es and Farinatti, 2005). Falls, and subsequent fractures are the most serious consequences of postural imbalances and gait abnormalities and are responsible for 70% of accidental deaths in people 75 years old and older (Ruwer et al., 2005). Postural balance is considered the ability to maintain the body’s center of mass over its base of support, moving the body weight quickly and precisely in different directions from its center, and walking in a safe, fast and coordinated way while adjusting to external disturbances (Ragnarsdo´ttir, 1996; Gazzola et al., 2004; Rugelj, 2009). Thus, in order to control balance, various physical systems have to be integrated through the central command, with this coordinated performance reflecting ones ability to accomplish ADLs (Salminen et al., 2009; Wiacek et al., 2009). Maintenance of Archives of Gerontology and Geriatrics 52 (2011) 111–114 A R T I C L E I N F O Article history: Received 25 August 2009 Received in revised form 6 February 2010 Accepted 9 February 2010 Keywords: Balance Activities of daily living (ADL) Postural stability of the elderly A B S T R A C T The purpose of the present study was to verify the correlation between static balance and functional autonomy in elderly women. The sample was a random selection of 32 sedentary elderly women (mean age = 67.47 Æ 7.37 years, body mass index = BMI = 27.30 Æ 5.07 kg/m2 ), who live in the city of Teresina in the state of Piauı´, Brazil. Static balance was analyzed by stabilometric assessment using an electronic baropodometer which measured the average of the amplitude of postural oscillations in the right (RLD) and left (LLD) lateral displacements, anterior (AD) and posterior (PD) displacements, and in the elliptical area (EA) formed by the body’s center of gravity. Functional autonomy was evaluated by a battery of tests from the LADEG protocol which is composed of: a 10 m walk (10 mW), getting up from a seated position (GSP), getting up from the prone position (GPP), getting up from a chair and movement around the house (GCMH), and putting on and taking off a shirt (PTS). The Spearman’s correlation coefficient (r) indicated a positive and significant correlation between GPP and LLD (r = 0.382; p = 0.031), GPP and PD (r = 0.398; p = 0.024) and GPP and EA (r = 0.368; p = 0.038). These results show that sedentary elderly women who spent the greatest amount of time performing the GPP test achieved the largest mean amplitude of displacement leading to greater levels of instability. ß 2010 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +55 21 2128 2586; fax: +55 21 2128 2594. E-mail address: (F. de Noronha Ribeiro Daniel). Contents lists available at ScienceDirect Archives of Gerontology and Geriatrics journal homepage: 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.02.011
  2. 2. balance can lead to improved performance of ADLs; however, few studies have investigated the relation between ADLs and balance by analyzing the amplitude of displacement in the frontal and sagittal planes and the elliptical area of the center of the body in elderly individuals. In this context, it appears that decreased levels of balance can accentuate the possibility of elderly people developing physical disabilities and becoming clinically institutionalized. Therefore, the aim of this study was to analyze the correlation levels between static balance and functional autonomy related to the performance of ADLs in elderly people. 2. Subjects and methods 2.1. Sample The study sample was composed of 32 apparently healthy, volunteer, elderly women who had not been enrolled in a physical exercise program the previous 6 months. All volunteers were residents of Pic¸arreira I, from the city of Teresina-PI (Table 1). The group was randomly selected from a larger sample after performing a medical evaluation and being considered eligible to take part in the protocols of assessment. Women with the following exclusion criteria were ineligible for inclusion in the study: neurologic disorders, disorders of the vestibular system, movement disorders related to cognitive decline and the use of medications that can harm the balance, posture stability and functional autonomy. Volunteers were selected, by drawing, as participants for this study from a sample group of 96 eligible elderly women to ensure a sample size with a a = 0.05 and a b = 0.20. All participants were required to sign a consent form (according to resolution 196/96 of the National Healthy Council and the Declaration of Helsinki of 1975). The study was submitted and approved by the Institutional Ethics Committee and Research in Human Beings of Piaui State University, UESPI, College of Medical Sciences (protocol no. 89/08). 2.2. Data collection procedure 2.2.1. Anthropometric measurements To assess body mass, height and BMI, a mechanical scale, accurate to 100 g, was used with a 150 kg-capacity stadiometer (Filizola, Brazil). 2.2.2. Balance assessment The assessment of the static balance was conducted in the mornings in a calm and quiet environment with the average temperature ranging between 23 and 25 8C Before starting the tests, the participants remained seated and resting for 5 min. Subjects were then assisted into a standing barefoot position on a force platform, with the arms besides their body, heels 2 cm apart, feet angled 308 away from each, and looking at a fixed visual target situated 90 cm from the platform (AM3 Foot Work Pro, electronic baropodometer model with 4096 sensors, polycarbonate covered, dimension 645 mm  520 mm  25 mm, frequency 200 Hz, Italy). Subjects remained in this position for 20 s. The following parameters were measured: the average amplitude of postural oscillations of the center of pressure (COP) in the frontal plane, right (RLD) and left (LLD) lateral displacements, the average amplitude of postural oscillations of the COP in the sagittal plane, anterior (AD) and posterior (PD) displacements, and the elliptical area (EA) formed by the displacement of the body’s center of gravity on the platform. 2.2.3. Functional autonomy assessment The following tests from the Latin-American Development for the Elderly Group (LADEG) protocol of autonomy were used for the functional autonomy assessment: a 10 m walk (10 mW) (Spila˜ et al., 1996), getting up from a seated position (GSP) (Guralnik et al., 1994), getting up from the prone position (GPP) (Alexander et al., 1997), getting up from a chair and movement around the house (GCMH) (Andreotti and Okuma, 1999), and putting on and taking off a shirt (PTS) (Dantas and Vale, 2004; Vale et al., 2006). All tests were individually conducted and repeated two different times with a minimum of 5 min intervals. The lowest time of the two trials was recorded. After the completion of the tests, the LADEG index of autonomy (LI) was calculated (Vale, 2005), with lower score corresponding to a better result. The LI score was calculated by the following formula: LI ¼ ½ð10 mW þ GSP þ GPP þ PTSÞ Â 2Š þ GCMH 4 where 10 mW, GSP, GPP, PTS e GCMH = time in seconds, LI = LADEG index in scores. 2.3. Statistical analysis The data were analyzed using Windows SPSS version 14.0 (Chicago, IL) and presented as mean, standard deviation, and minimum and maximum values. The Shapiro–Wilk and Levene tests were used to analyze normality and homogeneity of variance of the sample data, respectively. The Spearman correlation coefficient was used to analyze the correlations among the variables. Statistical significance was set a priori at p < 0.05 level. 3. Results Table 2 shows the results of descriptive analysis and normality of stabilometric evaluation of the sample. It can be observed that the RLD and the PD exhibited normal distributions. Table 1 Sample characteristics. Variables Mean Æ S.D. Minimum Maximum * p< Age (years) 67.47 Æ 7.37 60.00 86.00 0.206 Height (m) 1.51 Æ 0.07 1.38 1.68 0.349 Body mass (kg) 62.79 Æ 13.81 36.80 103.00 0.497 BMI 27.30 Æ 5.07 18.04 42.53 0.083 * p refers to the Shapiro–Wilk test of normality. Table 3 Descriptive results of the tests from the LADEG protocol of autonomy of the sample. Tests Mean Æ S.D. Minimum Maximum * p< GSP 9.68 Æ 2.51 6.23 16.83 0.006* GCMH 41.15 Æ 6.30 31.08 58.73 0.018* PTS 11.31 Æ 3.36 6.66 19.71 0.010* 10 mW 7.01 Æ 1.24 5.45 11.83 0.000* GPP 3.73 Æ 1.33 1.70 7.00 0.010* LI 26.15 Æ 4.26 19.49 36.36 0.257 * p refers to the Shapiro–Wilk test of normality. Table 2 Descriptive results of the amplitude of postural oscillations in the RLD, LLD, AD and PD displacements, and the EA measured by stabilometric assessment. Variables Mean Æ S.D. Minimum Maximum * p< RLD (cm) 1.15 Æ 0.31 0.60 2.00 0.056 LLD (cm) À1.12 Æ 0.43 À2.10 À0.60 0.006* AD (cm) 1.46 Æ 0.65 0.80 4.00 0.000* PD (cm) À1.25 Æ 0.43 À2.20 À0.60 0.145 EA (cm2 ) 4.53 Æ 2.42 1.30 11.34 0.020* * p refers to the Shapiro–Wilk test of normality. F. de Noronha Ribeiro Daniel et al. / Archives of Gerontology and Geriatrics 52 (2011) 111–114112
  3. 3. Table 3 represents the results of the descriptive analysis and normality of the functional assessment tests. Of the measured variables, only the LI shows a normal distribution pattern. Table 4 depicts the correlation matrix of the analyzed variables in the study. Significant Spearman correlation coefficients (r) were observed between GPP tests and the LLD, PD and EA of the body’s center of gravity. There was no significant correlation among any other variables. 4. Discussion The results of this study present positive and significant correlation between GPP tests and the average amplitude of the LLD, PD, and the EA of the body’s center of gravity. These results indicate that subjects who required the greatest amount of time to perform the GPP tests also had the greatest distances of displacements and, consequently, the greatest levels of imbalance. It may be a result of the study sample being comprised of sedentary individuals and presenting regular functional autonomy levels, as demonstrated by their LI scores (Vale, 2005). Abreu and Caldas (2008) investigated the relationship a general program of therapeutic exercises and improvements in balance in elderly individuals. Although no significant correlation was seen among the examined variables, it was observed that the intervention group displayed greater levels of balance than the ambulatory group, as assessed by Berg and POMA tests. Thus, it may be possible to assume that increases in balance in healthy elderly individuals can be impacted by general exercise intervention programs. Carvalho et al. (2007) compared balance between elderly who performed regular physical activities (n = 28; age = 77.1 Æ 7.2 years) and sedentary elderly individuals (n = 28; age = 79.4 Æ 8.1 years). The result of this study revealed higher and significant scores in POMA test for the physically active group (r = 0.67; p < 0.001), suggesting that physically active elderly individuals have better balance and less fear of falling when compared to sedentary elderly populations. A positive correlation (r = 0.76; p < 0.01) was also detected between fear of falling and balance (POMA scores), allowing to verify that the increase in FES scores, which indicate levels for fear of falling, was accompanied by greater levels of balance. A positive correlation was also identified between fear of falling scores and levels of physical activity (r = 0.47; p < 0.01) and between levels of balance and physical activity (r = 0.67; p < 0.01). Although the test used to assess balance in this study differed from the tests used in the present study, these data suggest that a regular physical activity program can increase not only the balance in elderly individuals, but also levels of self-confidence. However, these considerations are limited due to the fact that the present research did not assess the quantity of falls, fear of falling or self-confidence as in the study of Bastos et al. (2005) in which tests were applied in a Force Platform (AMTI AccuSway Plus, portable) with blindfolded individuals. The results of the present study may also be influenced by the BMI of the sample population. Greve et al. (2007) indicated that higher BMI levels require greater levels of corporal displace- ment in order to maintain postural balance. Forty young men (BMI = 23.3 Æ 3.2) underwent a series of functional tests of corporal stability using Biodex Balance System (evaluation protocol level 2). A significant correlation was identified between their general stability index and BMI (r = 0.723; dominant side, r = 0.705; non-dominant side), and between their anteroposterior and mediolateral stability indexes and BMI (dominant side r = 0.708; and r = 0.728; and non- dominant side r = 0.656; and r = 0.721, anteroposterior and medio- lateral, respectively). These findings support the correlation found in the present study as the current study sample was considered overweight, based on their BMI classification (WHO, 1998). One other possible explanation for the results in the current study is related to the multiple changes in position required by the GPP tests; starting from the initial prone phase to the standing position. These adjustments to sudden changes of movement can provoke a failure in the processing and maintenance of sensory system stability. Inaccurate sensorial information, selection of a sensorial reference or reaction to rough movements, as well as the musculoskeletal inability to provide a good response, can lead to postural oscillations (Isotalo et al., 2004). Therefore, if these movements are performed quickly they can lead to imbalance in elderly individuals who would then be more liable to falls. The results of the present investigation are in opposition to the study of Aikawa et al. (2006) who analyzed postural oscillations through the measurement of degrees rather than amplitudes of displacement. The authors showed that posterior postural oscilla- tions were more pronounced for both the 60–70 (n = 12.15 Æ 12.15) and 71–80 (n = 11.73 Æ 14.42)-year old groups. The present study found that the antero-displacements were more pronounced than the posterior displacements. However, postural oscillations are commonly found among elderly people and are correlated to changes in the base of support or unexpected displacements such as articular instability (Perracine and Ramos, 2002) and muscle weakness (Wiacek et al., 2009). A limitation of the present study was that these correlations were not investigated preventing the potential examination of these correlations. In conclusion, the results of the present study showed a significant correlation only between the GPP functional autonomy test and LLD and PD amplitude displacements and EA among sedentary elderly individuals. Performance of the GPP test requires sudden changes in postural positioning which can lead to greater postural imbalances. It is recommended that future studies compare the variables used in this investigation in active individuals and to assess the quantity of falls, fear of falling, self-confidence related to balance, and their correlation to performance of ADLs at different points along aging curve. Conflict of interest statement None. References Abreu, S.S.E., Caldas, C.P., 2008. Gait speed, balance and age: a correlation study among elderly women with and without participation in a therapeutic exercise program. Rev. Bras. Fisioter. 12, 324–330 (in Portuguese). Aikawa, A.C., Braccialli, L.M.P., Padula, R.S., 2006. Effects of postural alterations and static balance on falls in institutionalized elderly. Rev. Cienc. Med. 15, 189–196 (in Portuguese). Table 4 Correlation levels between the functional autonomy tests, the amplitude of postural oscillations in the RLD, LLD, AD and PD displacements and the EA. Variables RLD LLD AD PD EA GSP r 0.093 0.114 À0.246 0.153 0.116 p< 0.611 0.536 0.175 0.402 0.527 GCMH r À0.093 0.312 À0.091 0.134 0.213 p< 0.614 0.082 0.621 0.465 0.241 PTS r 0.113 0.070 0.132 0.209 0.251 p< 0.539 0.705 0.472 0.251 0.166 10 mW r À0.019 0.237 À0.174 0.025 0.134 p< 0.917 0.192 0.342 0.891 0.465 GPP r 0.158 0.382* À0.011 0.398* 0.368* p< 0.389 0.031 0.954 0.024 0.038 LI r À0.008 0.193 À0.117 0.234 0.217 p< 0.964 0.290 0.524 0.198 0.233 * Indicates significant differences. F. de Noronha Ribeiro Daniel et al. / Archives of Gerontology and Geriatrics 52 (2011) 111–114 113
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