Multisensory training to improve balance to prevent falls

MULTISENSORY TRAINING TO IMPROVE
BALANCE TO PREVENT FALLS IN ELDERLY
POPULATIONS
BY DR.POOJA MAHASETH PT
MPT (NEUROLOGY)
poojamahaseth1993@gmail.com

MULTISENSORY TRAINING
Multisensory training (MST) has impact on more than one sense at a time. Multisensory training doesn’t
require any specific instruments like ergo metric bicycle, trade mill, and swimming pool. So it is easy to
apply.
multisensory training involves several bodily senses that is combines three learning senses auditory, visual
and kinesthetic. In multisensory training exercise are taught using two or more of these modalities
simultaneously to receive or express information.
The senses usually employed in multisensory learning are visual, auditory, kinesthetic and tactile – VAKT
(i.e. seeing, hearing, doing, and touching). Some studies conclude that the benefits of multisensory learning
are greatest if the senses are engaged concurrently and the instruction is direct and systematic.

Why multisensory training?
Elderly peoples started experience manifestations of imbalance and body instability, they develop impairments in
tactile sensitivity, vibration sense, lower limb proprioception and kinesthesia associated to impaired balance, altered
gait patterns and increased risk of falling, therefore, simple activities like stair climbing, rising up from chair and
standing up may become limited because they are dependent on gait and balance, so to improve the balance and gait
multisensory training is given.
Also multisensory training are effective in Improving Balance in elderly populations and reduce falls rate (by 23%)
and may reduce the risk of fractures (by 27%)
MST exercise programme consist of mainly balance and functional exercises. MST reduce the rate of falls and the
number of people experiencing falls in older people living in the community (high-certainty evidence). Exercise
programmes that reduce falls primarily involve balance and functional exercises, while programmes that probably
reduce falls include multiple exercise categories and also helps to preserve and build muscle, thus reducing the risk of
falling.

FALL
A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or
other lower level.
Falls and fall-related injuries are a common & serious problem for older people. Fall potentially life-
threatening events and may be simply the first signs of single problem.
It lead to hospitalization and increase cost and burden on society and even lead to death
Each year, one out of three adults age 65 and older falls, according to the CDC.
Falls are equally common between men and women, but were more likely to result in injury in women.

CAUSES
Medical Risk factors, Side effects of medications, impaired musculoskeletal function, gait abnormality
and osteoporosis, Arthritis, hip weakness and imbalance, Cardiac arrhythmias (irregular heartbeat), blood
pressure fluctuation, Neurologic conditions, stroke, Parkinson's disease, multiple sclerosis, AND
Depression, Alzheimer's disease and senility and Vision or hearing loss
Personal Risk Factors :
• Age: The risk for a fall increases with age. Normal aging affects our eyesight, balance, strength, ability to
quickly react to our environments.
• Activity: Lack of exercise leads to decreased balance, coordination, bone and muscle strength.
• Habits: Excessive alcohol intake and smoking decrease bone strength. Alcohol use can also cause
unsteadiness and slow reaction times.
• Diet: A poor diet and not getting enough water will deplete strength and energy, and can make it hard to
move and do everyday activities.
Risk Factors at Home (e.g. Slippery floors)

PREVENTION
Falls in older persons occur commonly and are a major factor threatening the independence of older
individuals. Falls often go without clinical attention for a variety of reasons:
1. The patient never mentions the event to a health care provider
2. There is no injury at the time of the fall
3. The provider fails to ask the patient about a history of falls; or either provider or patient erroneously
believes that falls are an inevitable part of the aging process
Control Environmental Hazards: At least one-third of all falls in the elderly involve environmental
hazards in the home. The most common hazard for falls is tripping over objects on the floor.
Other factors include poor lighting, loose rugs, lack of grab bars or poorly located/mounted grab bars,
furniture.
It is useful to conduct a walk-through of the home to identify possible problems that may lead to falling. A
home visit by occupational therapist might also be useful to identify risk factors and recommend
appropriate actions

Exercise: Multiple meta-analyses of randomized trials conducted in various populations find that
general exercise reduces the risk of falls, and that exercise programs that include balance components
are most effective. Exercise interventions can be grouped into six categories:
1. Gait and balance training
2. strength training
3. Flexibility
4. Movement
5. General physical activity
6. Endurance
Exercise classes incorporating multiple categories of exercise reduced the risk of falling . Home-based
exercises that included more than one type of exercise also decreased the fall rate and fall risk.
In one trial, a program that integrated balance and strength training into everyday home activities
resulted in a 31 percent decrease in the rate of falls (RaR 0.69, 95% CI 0.480.99) and was more
effective than a structured exercise program done three times a week.

EXERCISE PROGRAM
A warm-up exercise for 5minutes before the activity are included like short walks with normal speed
and games with medicine balls, using hands and feet.
First with eyes open and then with closed, Participants were asked to walk forwards, backwards, and
sideways at different speeds and for various distances. Also different types of ground surfaces were
included like mattresses and foam rubber, apart from the regular floor. With that participants were also
faced challenges from obstacles such as ropes, cones and sticks.
Again with eyes open and then eyes closed, the participants were asked to remain standing on unipedal
or bipedal support, according to individual ability. As part of the multisensory training, they performed
exercises under the following conditions: (1) Eyes open - firm surface & soft surface (2) Eyes
closed- firm surface & soft surface
The exercises included: performing double-legged stance for 10 seconds, performing tandem stance
for 10 seconds and rising from a chair without the use of arms; walking forwards and backwards with a
tandem walking pattern and performing single legged stance for 10 seconds.

First patients were asked to do warm up for 5minutes like short walking and playing games by throwing
and catching medicine ball.
Than two surfaces was taken firm and soft surface for exercises protocol with obstacles kept during task
like ropes, cones and sticks.
In firm surface: patients was asked for walking forward and backward, then tandem walking, lastly pivot
turning first with eyes open by crossing all obstacles then eyes closed.
In soft surface: same was done as done in firm surface
Lastly patients were asked to take rest and do deep breathing exercises for 15 to 20 times.
First week:

Second week:
Warm up same as first week
Exercise on firm and soft surface was same only distance and speed were increased.
Games were given at last like sitting in Swiss ball passing medicine ball to each other’s by trying to maintain their
balance.
Lastly patients were asked to take rest and do deep breathing exercises 15-20 times.
Third and fourth week:
All previous exercise were repeated.
After that patients were asked first for double-legged stance for 15 sec and then single legged stand for 10 sec
first with eyes open and then eyes closed and these were done first in firm surface and then in soft surface.
Again then patients was asked to walk in foam pad which is kept in straight line with help of therapist.
Games was given lastly with addition to previous week like sitting on Swiss ball and pushing each other’s by trying
to maintain balance. Then patients was asked to stand and try to hold medicine ball doing half squatting with
therapist support.
Lastly patients were asked to cool down and take deep breath 15-20times.

Fifth and sixth week:
Warm up was done as previous.
All previous exercises were repeated at different speeds and for various distances with additional.
While patients was walking in foam pad in straight line therapist was only supervised and obstacles such as
cones were kept in way, which patients should trying crossing it maintain their balance and during playing
games also new challenges were given with previous one.
Lastly patients were asked to take rest and do deep breathing exercises for 15-20 times.

OUTCOME MEASURES: BERG BALANCE SCALE
TIMED UPAND GO TEST
BERG BALANCE TESTS AND RATING SCALE
Patient Name ___________________Date____________ Location _____________
ITEM DESCRIPTION SCORE (0-4)
Sitting to standing _____
Standing unsupported _____
Sitting unsupported _____
Standing to sitting _____
Transfers _____
Standing with eyes closed _____

Standing with feet together _____
Reaching forward with outstretched arm _____
Retrieving object from floor _____
Turning to look behind _____
Turning 360 degrees _____
Placing alternate foot on stool _____
Standing with one foot in front _____
Standing on one foot _____
TOTAL _____

Equipment: arm chair, tape measure, tape, stop watch.
Begin the test with the subject sitting correctly (hips all of the way to the back of the seat) in a chair with arm rests. The
chair should be stable and positioned such that it will not move when the subject moves from sit to stand. The subject is
allowed to use the arm rests during the sit – stand and stand – sit movements.
Place a piece of tape or other marker on the floor 3 meters away from the chair so that it is easily seen by the subject.
Instructions: “On the word GO you will stand up, walk to the line on the floor, turn around and walk back to the chair
and sit down. Walk at your regular pace. Start timing on the word “GO” and stop timing when the subject is seated again
correctly in the chair with their back resting on the back of the chair.
The subject wears their regular footwear, may use any gait aid that they normally use during ambulation, but may not be
assisted by another person. There is no time limit. They may stop and rest (but not sit down) if they need to.
Normal healthy elderly usually complete the task in ten seconds or less. Very frail or weak elderly with poor mobility
may take 2 minutes or more. The subject should be given a practice trial that is not timed before testing. Results
correlate with gait speed, balance, functional level, the ability to go out, and can follow change over time.
Timed Up and Go (TUG) Test

DISCUSSION
According to a study done by Nizar Abdul Majeedkutty, Nishad Abdul Latheefmajida (2013): “effect of
multisensory training on balance and gait in persons with type 2 diabetes” concluded that the multisensory training
can improve the balance of diabetic peripheral neuropathy patients. However, there was no statistically significant
difference in gait speed for those in the experimental group who were given multisensory exercise training.
Further, multisensory exercise is low-cost and can be practiced both indoors and outdoors. The results obtained by
statistical analysis using independent ‘t-test’ to compare the descriptive characteristics (age, height, weight) and no
statistically significant difference was found. The significance level was set at 0.05. The results of unpaired t-test’
with mean showed the homogeneity of two groups. There was no statistically significant difference in the TUG
scores of the control group. The scores obtained from the ‘six- minute walk’ test were analyzed using paired and
unpaired tests wherever necessary. The comparisons of pre- and post-values of 6MWT in the multisensory exercise
group were found to be statistically not significant.

REFERENCES:
1. NICE guideline of falls in elderly, assessment and prevention. July 2013
2. Alfieri FM, Riberto M, Gatz LS, Ribeiro CP, Lopes JA, Santarém JM, Battistella LR. Functional mobility and
balance in community-dwelling elderly submitted to multisensory versus strength exercises. Clinical interventions in
aging. 2010;5:181
3. Rosenberg L. The effects of multisensory, explicit, and systematic instructional practices on elementary school
students with learning impairments in encoding and oral reading.
4. Allet L, Armand S, De Bie RA, Golay A, Monnin D, Aminian K, Staal JB, de Bruin ED. The gait and balance of
patients with diabetes can be improved: a randomised controlled trial. Diabetologia. 2010 Mar 1;53(3):458-66.
5. Chartered society of Physiotherapy Falls prevention exercises - Older People's Day Available
at: https://www.youtube.com/watch?v=n8s-8KtfgFM&t=36s (last accessed 27.11.2019)
6. Hamed A, Bohm S, Mersmann F, Arampatzis A. Follow-up efficacy of physical exercise interventions on fall
incidence and fall risk in healthy older adults: a systematic review and meta-analysis. Sports medicine-open. 2018
Dec;4(1):56.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292834/ (last accessed 11.1.2020)

Multisensory training to improve balance to prevent falls

Multisensory training to improve balance to prevent falls

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