A home-based exercise program focused on proprioception to reduce falls in frail and pre-frail community-dwelling older adults

Fea u e A icle
A home-based exe cise p og am ocused on p op iocep ion o educe alls
in ail and p e- ail communi y-dwelling olde adul s
Pila P
e ez-Ros, RN, PhD
a,b,
*
,1
, Ra ael Vila-Candel, RNM, PhD
a,c,d,1
,
F ancisco Miguel Ma ínez-A nau, PT, PhD
a,b,e
a
Depa men o Nu sing, Uni e sidad Ca 
olica de Valencia San Vicen e M
a i , 46007 Valencia, Spain
b
F ail y and Cogni i e Impai men Resea ch G oup (FROG), Uni e si y o Valencia, 46010 Valencia, Spain
c
Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, FISABIO. C a. Co be a km 1, 46600 Valencia, Spain
d
Depa men o Nu sing, Facul y o Nu sing and Podia y, Uni e si a de Val
encia, Jaume Roig, s/n, 46010 Valencia, Spain
e
Depa men o Physio he apy, Uni e si a de Val
encia, 46010 Valencia, Spain
ARTICLE INFO
A icle his o y:
Recei ed 10 Oc obe 2019
Recei ed in e ised o m 14 Janua y 2020
Accep ed 20 Janua y 2020
A ailable online 18 Ma ch 2020
ABSTRACT
F ail y and alls a e closely associa ed wi h each o he as well as wi h disabili y, hospi aliza ion, and dea h. Exe cise
can educe hese isks in bo h obus and ail olde people. This be o e-a e , non- andomized in e en ion s udy
assessed a one-yea p op iocep ion aining p og am wi h indi idual daily home exe cises in 564 communi y-
dwelling people aged 70 yea s and o e , wi h di e en ail y pheno ypes. A e he exe cise p og am, we
obse ed a mode a e educ ion in he mean numbe o alls, ea o alls, body mass index and body a pe cen age
in ail and p e- ail pa icipan s. These esul s sugges ha a home p op iocep ion p og am may be a iable al e -
na i e o complex mul icomponen exe cise p og ams in se ings whe e hese a e no easible, since home p op i-
ocep ion can each a la ge popula ion a a lowe cos , and i a o ds clea benefi s.
© 2020 Else ie Inc. All igh s ese ed.
Keywo ds:
F ail
Falls
Olde people
Communi y dwelling
P op iocep ion exe cises
INTRODUCTION
Falls cons i u e an impo an public heal h p oblem in adul s aged
o e 65 yea s due o hei medical, psychological and economic con-
sequences.
1
Mo e han 30% o all olde adul s all a leas once a yea ,
and his is he second leading cause o dea h due o acciden al o
unin en ional inju y wo ldwide.
2
F ail y and p e- ail y a e closely associa ed wi h alls, ac u es
and o he os eoa icula p oblems
3
as well as disabili y, hospi aliza-
ion and dea h.
4
Al hough he p ecise cha ac e is ics o his clinical
synd ome ha e been desc ibed in di e en ways (mainly ela ing o
weakness, al e ed balance, and gai p oblems—all o which can p e-
dispose olde people o alls),
5
F ied’s
6
defini ion is he mos com-
monly ci ed. This au ho conside s ail y o be cha ac e ized by a
leas h ee o he ollowing fi e ac o s: weakness ( educed g ip
s eng h), slowness (gai speed), weigh loss, low physical ac i i y,
and exhaus ion. People wi h one o wo o hese cha ac e is ics a e
classified as p e- ail, while obus people ha e none. The p e alence
o ail y among communi y-dwelling indi iduals aged 65 yea s o
o e anges om 4% o 59.1%.
7
The Ame ican College o Spo s Medicine holds ha pa icipa ion
in egula physical ac i i y elici s a numbe o a o able esponses
ha con ibu e o heal hy aging.
8
Exe cise is ecommended in bo h
obus and ail olde people, as well as in hose wi h ch onic diseases
and disabili ies.
9,10
Demons a ed benefi s include inc eased mobili y
and bone mine al densi y, imp o ed pe o mance o ac i i ies o daily
li ing and walking, ewe alls, and a g ea e o e all sense o well-
being.
1113
E idence shows ha mul icomponen p og ams can
educe ail y by inc easing s eng h and balance.
14
In p e- ail olde
people, he use o new echnologies such as Kinec ha e also yielded
posi i e esul s.
15
Howe e , he e is no clea consensus as o which
s a egy is he mos sui able o each ype o ail y pheno ype.
16
In ela ion o all p e en ion, he e is likewise a lack o ag eemen
abou he mos app op ia e ype o exe cise o olde people, as ac o s
such as como bidi y; unc ion; and he communi y, hospi al o social-
heal h en i onmen can all modi y he e ec s.
17
In communi y-dwelling
olde people, in e en ions ha e included nu i ional p og ams, s eng h
and balance exe cises, ai chi, p op iocep ion, and mul icomponen
physical ac i i y egimens.
18
In ail popula ions, all p e en ion s a e-
gies aim o imp o e s eng h, inc ease muscle mass,
19,20
and p omo e
pa icipa ion in mul icomponen p og ams, since hese also imp o e
socializa ion and cogni ion.
21
Howe e , implemen ing la ge-scale p og ams ha combine di -
e en ypes o exe cise emains challenging. T aining is complica ed,
*Co esponding au ho : Pila P
e ez-Ros, Espa e o 7, 46010 Valencia (Spain).
E-mail add ess: [email p o ec ed] (P. P
e ez-Ros).
1
These au ho s con ibu ed equally o he p esen s udy.
h ps://doi.o g/10.1016/j.ge inu se.2020.01.017
0197-4572/$ see on ma e © 2020 Else ie Inc. All igh s ese ed.
Ge ia ic Nu sing 41 (2020) 436444
Con en s lis s a ailable a ScienceDi ec
Ge ia ic Nu sing
jou nal homepage: www.gnjou nal.com
as he p o essionals managing complex exe cise p og ams mus
in es subs an ial ime in ins uc ing pa icipan s, ensu ing hei
comp ehension, and moni o ing and co ec ing hei pe o mance.
Some s udies poin o a sho age in ained nu ses, physio he apis s,
and p o essional ins uc o s who can wo k ull- ime on ace- o- ace
physical ac i i y p og ams. Home-based exe cise p og ams may help
o amelio a e his gap in capaci y, op imizing he use o esou ces o
p o essional aining and ollowing up olde people while a e ing
he need o p o essionals o di ec ly moni o daily pe o mance.
22,23
P op iocep ion— he awa eness o body pos u e wi h espec o he
su ounding en i onmen — ep esen s one in e en ion a ea ha
could educe he isk o alls in olde people. Exe cises o imp o ing
p op iocep ion seek o imp o e he body's abili y o de ec mo emen
and he posi ion o i s join s, bo h a es and in mo ion. P op iocep ion
influences balance and he pe cep ion o one’s pos u e, and i is also
ela ed o he coo dina ion and esponsi eness o he ne ous sys-
em.
24
In his espec , i s a ge di e s om s eng h and mul icompo-
nen exe cise in e en ions, which ha e no been ound o imp o e
pos u al con ol.
25
I p ope ly ca ied ou , p op iocep ion exe cises
could be beneficial o imp o ing ou comes in olde communi y mem-
be s wi h ega d o ail y, unc ion, and he incidence o alls.
This s udy aimed o assess he e ec s o a one-yea home-based
p op iocep ion exe cise p og am on he incidence o alls in obus ,
p e- ail and ail communi y-dwelling olde people.
METHODS
S udy design and pa icipan s
This be o e-a e non- andomized in e en ion s udy included
pa icipan s in h ee g oups acco ding o hei ail y pheno ype:
obus , p e- ail, and ail. Inclusion c i e ia we e: aged 70 yea s o
olde ; independen o walking (wi h possible echnical aids, bu no
assis ed by ano he pe son); and li ing wi hin he ca chmen a ea o
La Ribe a Heal h Depa men (Valencia, Spain). Exclusion c i e ia
we e e usal o pa icipa e in he s udy, he exis ence o associa ed
diseases esul ing in a li e expec ancy o unde 6 mon hs, blindness
and dea ness, se ious psychia ic p oblems (se e e dep ession sub-
jec ed o ea men , o acu e psychosis), and mode a e o se e e cog-
ni i e impai men (diagnosed p e iously by a physician o a sco e o
less han 25 on he Mini-Men al S a e Examina ion (MMSE
26
wi h
C onbach’s alpha 0.90
27
).
Pa icipan s we e ec ui ed om Decembe 2014 o May 2015,
and he in e en ion was ca ied ou in p ima y ca e and in social
cen e s o olde adul s ( he la e a e egula ed by he own hall and
o e ec ea ional and cul u al ac i i ies o use s). To encou age pa -
icipa ion, pos e s we e hung and flye s dis ibu ed; open in o ma-
ion sessions we e also held o olde indi iduals in e es ed in
pa icipa ing in he s udy.
La Ribe a Heal h Depa men uses elec onic medical eco ds,
wi h pa ien da a om p ima y, seconda y and e ia y ca e le els.
We used hese his o ies o collec da a on age, gende , como bidi ies
(a e ial hype ension, diabe es melli us, and hype lipidemia), and
he numbe o alls in he 12 mon hs p io o s udy inclusion, as
epo ed o ally by pa ien s o eco ded by heal h p o essionals ol-
lowing isi s o he eme gency depa men a e a all. A single all
o e he 12-mon h pe iod was conside ed an isola ed all, while wo
o mo e alls we e defined as ecu en alls.
P ima y ca e nu ses pe o med a comp ehensi e ge ia ic assess-
men o ca ego ize pa ien s acco ding o he F ied F ail y Pheno-
ypes
6
(3/5 cha ac e is ics = ail; 12 cha ac e is ics = p e- ail; 0
cha ac e is ics = obus ). Weakness was assessed ollowing s anda d-
ized p ocedu es, using a 100 kg dynamome e (Smedley S, TTM,
Tokyo, Japan). G ip s eng h cu o s deno ing weakness we e s a i-
fied o gende and body mass index (BMI) and we e, o men:
BMI 24 kg/m
2
:GS29 kg; BMI 24.128 kg/m
2
:GS30 kg;
BMI >28 kg/m
2
:GS32 kg; and o women: BMI 23 kg/m
2
:
GS 17 kg; BMI 23.129 kg/m
2
:GS18 kg; BMI >29 kg/m
2
:
GS 21 kg. Slowness was dicho omized based on he ime aken o
walk 4.5 m, wi h a cu o alue o <0.8 m/s. Unin en ional weigh
loss was defined as a loss o 4.5 kg o 5% o body weigh in he las
yea (de e mined by di ec measu emen o weigh ). Pa icipan s
we e conside ed o ha e low physical ac i i y acco ding o
he weigh ed sco e o kilocalo ies expended pe week (men,
383 kcal/week and women, 270 kcal/week). Las ly, poo endu ance
and ene gy we e defined by sel - epo ed exhaus ion: (a) “I el ha
e e y hing I did was an e o ”; (b) “I could no ge going”.
Func ional and an h opome ic a iables we e also eco ded. Func-
ional pa ame e s we e assessed based on he Ba hel index wi h C on-
bach's alpha 0.70,
28
he Law on index wi h C onbach's alpha 0.94,
29
and
he Tine i index wi h C onbach's alpha 0.95.
30
An h opome ic da a
comp ised BMI; hand g ip s eng h, de e mined using a Ke nMap-40 kg
dynamome e ; body a pe cen age, de e mined by bioelec ical imped-
ance analysis (Tani a BC-601); and he Mini-Nu i ional Assessmen
Sho Fo m (MNA-SF) wi h C onbach's alpha 0.670.
31
In addi ion, we
collec ed da a on ea o alls (modified Falls E ficacy Scale In e na ional,
FES-I, a=0.96)
32
and he weekly hou s o exe cise in he p e ious 12
mon hs acco ding o pa icipan sel - epo .
The Clinical Resea ch E hics Commi ee o Hospi al Uni e si a io
de la Ribe a (Valencia, Spain) app o ed he s udy, and each pa ici-
pan signed in o med consen be o e inclusion in he s udy and s a-
is ical p ocessing o he da a.
In e en ion
The in e en ion consis ed o a one-yea daily p op iocep i e home
exe cise p og am and was ca ied ou by eigh communi y nu ses in p i-
ma y ca e cen e s, who had ou yea s’expe ience in physical ac i i y-
ela ed all p e en ion p og ams. Pa icipan s we e ad ised o pe o m
he exe cises, in he mo ning whene e possible, on 5 days a week.
Each exe cise session las ed app oxima ely 40 min o 50 min and con-
sis ed o a 10-min wa m-up pe iod wi h slow walking, s e ching and
mobili y exe cises; 20 min o 30 min o p op iocep i e exe cises; and a
10-min cool-down wi h s e ching and elaxa ion exe cises. Exe cises
included dynamic and s a ic posi ions, and hei in ensi y and phases
we e ailo ed o pa icipan s’abili ies. Exe cises 1 o 5 we e pe o med
in wo se ies o 10 o 15 epe i ions, while exe cises 6 o 12 we e pe -
o med in wo se ies o 15 s o 30 s; pa icipan s es ed o one minu e
be ween exe cises (Supplemen a y file 1).
33,34
Ou comes we e mea-
su ed a 12 mon hs’ ollow-up.
T ea men fideli y
The indica ions o he NIH Beha io Change Conso ium we e ol-
lowed o enhance ea men fideli y,
35
ha is, o ensu e pa icipan s
ecei ed he same ea men dose wi hin s udy condi ions and an equi -
alen dose ac oss condi ions. Th ee senio esea che s ( wo nu ses and
one physio he apis ) wo ked wi h he eigh p ima y ca e nu ses o mon-
i o implemen a ion and apply co ec i e measu es when necessa y.
Du ing he ini ial 60 min o 80 min isi wi h he pa ien , he
nu ses me wi h pa icipan s o p o ide in o ma ion on he benefi s
o an en i onmen ee o all isks and o explain he p op iocep ion
exe cises ha he pa ien s should pe o m a home. Pa icipan s
we e also gi en a documen speci ying he exe cises o be pe o med
(Supplemen a y file 1), he numbe o epe i ions, and he leng h o
ime, as well as an exe cise eco d shee o eco d hei ac i i ies and
du a ion (Supplemen a y file 2).
The nu ses who we e pe sonally supe ising he pa ien s phoned
hem each mon h o ollow up. They eco ded he numbe o alls,
defined as an e en in which a pe son inad e en ly comes o es on
P. P
e ez-Ros e al. / Ge ia ic Nu sing 41 (2020) 436444 437
he g ound, floo , o some o he lowe le el,
2
occu ing o e he las
30 days. The nu ses specifically asked he ollowing: “Ha e you allen
in he las mon h, inad e en ly coming o es on he g ound o floo
o some o he lowe le el?”The nu ses subsequen ly asked abou
how pa icipan s we e ge ing on wi h he exe cises and whe he
hey had any doub s, and hey eminded he pa ien s o documen
he ac i i ies pe o med on he exe cise eco d shee . I pa icipan s
had doub s ha could no be esol ed by elephone, an appoin men
was a anged o imp o ing and co ec ing pe o mance. In addi ion
o hese mon hly check-ins, e e y h ee mon hs he nu ses isi ed all
pa icipan s o make any necessa y modifica ions o he exe cise eg-
imen, acco ding o pa icipan s’p og ess o changes in hei unc-
ional o como bidi y s a us. The qua e ly isi s las ed 40 min o
60 min, and he ollow-up isi s o esol e pa icipan s’doub s,
20 min o 30 min.
S a egies o moni o ing and imp o ing p o ide aining
included a s anda dized aining p o ocol and exe cise p og am
shee . Fou nu ses om he esea ch eam we e assigned o each p i-
ma y ca e cen e , while he qua e ly isi s we e conduc ed by wo
di e en , andomly selec ed nu ses o minimize p o ide di e ences.
In o de o ensu e p o ide skill acquisi ion, he nu ses e alua ed he
en i e exe cise session o co ec any po en ial e o s in echnique by
he pa icipan s. The esea ch eam me mon hly o minimize “d i ”
in p o ide skills and esol e doub s on how o adap he exe cises
acco ding o pa icipan s’specific pa hologies o capaci ies.
Di e en aspec s we e moni o ed o sa egua d he fideli y o he
in e en ions. Pa icipan s could submi complain s o sugges ions,
which helped o de ec di e ences in he deli e y o ea men , and
adhe ence o ea men p o ocols we e e alua ed acco ding o he exe -
cise shee and aining eco d. Pa icipan s’comp ehension o he exe -
cise egimen was ensu ed, ini ially h ough he s udy exclusion c i e ia
(i.e. indi iduals wi h cogni i e impai men we e ineligible) and hen
h ough ollow-up isi s o moni o pe o mance echnique by means
o a checklis and analysis o di ficul ies encoun e ed in adhe ence ( ime
spen on he exe cise, numbe o isi s needed o esol e doub s).
S a is ical analysis
The sample size was calcula ed based on he 2013 popula ion cen-
sus. The egion o La Ribe a (Valencia, Spain) has a popula ion o
abou 253,330 inhabi an s (15.8% o e 70 yea s o age). Based on an
assumed incidence o alls o 35% and an es ima ed educ ion o 8%
(wi h alpha e o o 5% and s a is ical powe o 95%), a sample o 437
pa icipan s was equi ed. This figu e was inc eased o 525 o con ol
o an es ima ed p opo ion o d opou s o 20%.
The a iables a e epo ed as p opo ions and/o means and
s anda d de ia ions (SD). The Kolmogo o -Smi no es was used
o assess no mali y, and he Le ene es was applied o explo e
homogenei y o a iances o con inuous a iables (age, Ba hel
Index,Law onIndex,Tine iIndex,MNA-SFscale,BMI,body a
pe cen age, handg ip and numbe o alls). The e we e no signifi-
can ou lie s. The da a me he main assump ions o he - es o
independen samples, so pa ame ic es ing (analysis o a iance
[ANOVA]) was used o compa e quan i a i e a iables (age), while
nonpa ame ic es s (chi-squa ed es ) we e used o compa e ca e-
go ical a iables (gende , como bidi y, pe cen age o alle s, ecu -
en alle s, and physical ac i i y). Ou comes we e assessed by
analyzing he numbe o alls, FES-I scale, Ba hel Index, Law on
Index,Tine iIndex,MNA-SFscale,BMI,body a pe cen age,and
handg ip da a, based on wo- ailed mixed-e ec (be ween-wi hin)
ANOVA including h ee g oups ( ail, p e- ail, and obus ) a base-
line and pos -in e en ion, wi h epea ed measu emen o he las
ac o using 95% confidence in e als (95% CI). The da a me he
main assump ions o ANOVA: independence o cases, no mali y,
and equali y. E ec sizes (e a-squa ed) o ANOVA we e also
calcula ed, wi h alues o mo e han 0.01 conside ed small; mo e
han 0.058, mode a e; and mo e han 0.138, la ge.
S udy da a we e en e ed in o MS Excel sp eadshee s, whe e each
quali a i e a iable wi h assigned alues (e.g. man/woman) o quan-
i a i e a iable wi h a ange o alues (e.g. Ba hel om 0 o 100)
was p ocessed wi h d op-down lis s o a oid en e ing e oneous
da a. S a is ical analysis was unde aken using he SPSS e sion 23.0
s a is ical package (IBM SPSS S a is ics).
RESULTS
O he 732 people ini ially e alua ed o pa icipa e, 168 we e excluded
(22.9%), wi h easons: 6 (3.5%) did no mee he selec ion c i e ia, 126
(75.0%) declined o pa icipa e, and 36 (21.5%) ailed o answe he ele-
phone when called o a end he in o ma ion session. The final s udy
sample hus comp ised 564 pa icipan s. Acco ding o he F ied F ail y
Pheno ype c i e ia, 10.99% o he pa icipan s (n= 62) we e ca ego ized
as ail, 72.87% (n= 411) as p e- ail, and 16.13% (n= 91) as obus (Fig. 1).
Table 1 shows pa icipan s’baseline cha ac e is ics by ail y pheno-
ype. F ail y was posi i ely co ela ed wi h age: obus pa icipan s we e
younge han p e- ail and ail indi iduals. The e we e mo e women in
bo h he p e- ail g oup (67.1%, n= 276) and he ail g oup (79.01%;
n= 49). No di e ences we e obse ed in cogni i e unc ion (Table 1).
Jus 9.6% (n= 55) o he pa icipan s we e able o comple e he
p og am wi hou any ollow-up isi s o esol e hei doub s. O e
he one-yea in e en ion, ail pa icipan s eques ed a mean 4.3 e-
isi s o his pu pose, compa ed o 5.35 e- isi s in p e- ail pa ici-
pan s and 5.15 e- isi s in obus pa icipan s; hese di e ences we e
no significan . Mos o hese e- isi s (78.99%, n= 2264) we e in he
fi s semes e o ollow-up. F ail and p e- ail olde adul s we e sig-
nifican ly mo e adhe en o he exe cise egimen han obus pa ici-
pan s (p<0.001; Table 2), wi h significan inc eases in weekly hou s
o physical ac i i y in he ail and p e- ail g oups (Table 3).
The p e alence o alls in he 12 mon hs p io o he s a o he
s udy was 70.03% (n= 395), wi h a highe pe cen age o alle s in he
ail g oup (p<0.01). The e we e no di e ences in ecu en alle s
be ween g oups. Du ing he in e en ion yea , he o e all incidence
o alls dec eased o 38.74% (n= 210) due o educ ions in he ail
and p e- ail g oups (Table 3 and Fig. 2).
Likewise, in he p e-s udy yea ail olde pa icipan s showed a
highe numbe o mean alls (1.46) compa ed o he p e- ail (0.66 alls)
and obus g oups (0.23 alls), and hey had a highe ea o alling (FES-I
sco e 28.16 e sus 18.85 e sus 10.95, espec i ely). By s udy end, mean
alls had mode a ely dec eased in bo h he ail and p e- ail g oups
(h
2
= 0.058), and he di e ences be ween g oups had disappea ed. Simi-
la ly, he di e ences in FES-I sco e disappea ed, wi h a lowe ea o alls
in he ail and p e- ail g oups (Table 4 and Fig. 2; mean di e ences
be ween g oups a e epo ed in Supplemen a y file 3).
Func ional assessmen e ealed high unc ionali y, wi h no di e en-
ces be ween g oups (p= 0.07), hough he ail pa icipan s sco ed
sligh ly lowe on he Ba hel Index, Law on Index, and Tine i Index
(Table 4 and Fig. 2). S a is ically significan a ia ions we e obse ed in
BMI, wi h he p e- ail pa icipan s ob aining he g ea es benefi ollow-
ing he s udy in e en ion (mean di e ence 0.23 kg/m
2
;p<0.01; Sup-
plemen a y file 3). Al hough he e we e no di e ences be ween g oups
in he body a pe cen age a e he in e en ion, in a-g oup (p e-pos )
di e ences we e obse ed in he p e- ail g oup (mean di e ence
1.05%; p<0.01), while non-significan educ ionswe eseenin he ail
(mean di e ence 0.36%) and obus indi iduals (mean di e ence
0.33%). A he end o he s udy, all g oups showed a s onge handg ip,
wi h he la ges imp o emen s in he ail indi iduals (Table 4;Fig. 2).
The ail y pheno ype was e-assessed a he end o he s udy,
e ealing a dec ease in he p opo ion o ail (5.8% o he o al sam-
ple; n= 32) and p e- ail indi iduals (71.5%, n= 391), and an inc ease
in obus indi iduals (22.81%; n= 125).
438 P. P
e ez-Ros e al. / Ge ia ic Nu sing 41 (2020) 436444
E alua ed o selecon (n=732)
Final sample (n=564)
F ail (n=62)
Mon h 1: ollow-up isi s o doub s n=52
Mon h 2: ollow-up isi s o doub s n=44
Mon h 3: ollow-up isi s o doub s n=40
Los o ollow-up a 3 mon hs (n=2)
Mon h 4: ollow-up isi s o doub s n=38
Mon h 5: ollow-up isi s o doub s n=31
Mon h 6: ollow-up isi s o doub s n=22
Los o ollow-up a 6 mon hs (n=2)
Mon h 7: ollow-up isi s o doub s n=17
Mon h 8: ollow-up isi s o doub s n=13
Mon h 9: ollow-up isi s o doub s n=7
Los o ollow-up a 9 mon hs (n=2)
Mon h 10: ollow-up isi s o doub s n=2
Mon h 11: ollow-up isi s o doub s n=1
Mon h 12: ollow-up isi s o doub s n=0
Los o ollow-up a 12 mon hs (n=2)
Analysed (n=60)
- Excluded om anaysis (n=2)
P e- ail (n=411)
Mon h 1: ollow-up isi s o doub s n=368
Mon h 2: ollow-up isi s o doub s n=329
Mon h 3: ollow-up isi s o doub s n=292
Los o ollow-up a 3 mon hs (n=6)
Mon h 4: ollow-up isi s o doub s n=261
Mon h 5: ollow-up isi s o doub s n=222
Mon h 6: ollow-up isi s o doub s n=195
Los o ollow-up a 6 mon hs (n=9)
Mon h 7: ollow-up isi s o doub s n=159
Mon h 8: ollow-up isi s o doub s n=123
Mon h 9: ollow-up isi s o doub s n=89
Los o ollow-up a 9 mon hs (n=11)
Mon h 10: ollow-up isi s o doub s n=61
Mon h 11: ollow-up isi s o doub s n=27
Mon h 12: ollow-up isi s o doub s n=4
Los o ollow-up a 12 mon hs (n=12)
Analysed (n=399)
- Excluded om anaysis (n=12)
Robus (n=91)
Mon h 1: ollow-up isi s o doub s n=80
Mon h 2: ollow-up isi s o doub s n=74
Mon h 3: ollow-up isi s o doub s n=67
Los o ollow-up a 3 mon hs (n=0)
Mon h 4: ollow-up isi s o doub s n=59
Mon h 5: ollow-up isi s o doub s n=51
Mon h 6: ollow-up isi s o doub s n=39
Los o ollow-up a 6 mon hs (n=1)
Mon h 7: ollow-up isi s o doub s n=33
Mon h 8: ollow-up isi s o doub s n=26
Mon h 9: ollow-up isi s o doub s n=17
Los o ollow-up a 9 mon hs (n=1)
Mon h 10: ollow-up isi s o doub s n=13
Mon h 11: ollow-up isi s o doub s n=5
Mon h 12: ollow-up isi s o doub s n=5
Los o ollow-up a 12 mon hs (n=1)
Analysed (n=90)
- Excluded om anaysis (n=1)
Excluded (n=168)
- Do no mee selecon c i e ia (n=6)
- Declines o pa cipa e (n=126)
- Did no answe elephone (n=36)
Sample a s udy end (n=549)
Fig. 1. S udy flowcha .
P. P
e ez-Ros e al. / Ge ia ic Nu sing 41 (2020) 436444 439
DISCUSSION
In his one-yea home-based p op iocep ion exe cise p og am,
ail and p e- ail olde adul s li ing in hei communi y achie ed a
mode a e dec ease in he incidence o alls and inc eased he weekly
hou s dedica ed o physical ac i i y. We also obse ed a lessened ea
o alls and imp o ed an h opome ic pa ame e s, along wi h a
dec ease in he numbe o olde adul s ca ego ized as ail and p e-
ail; indeed, pa icipan s wi h hese pheno ypes a baseline expe i-
enced he g ea es benefi s.
Table 1
Baseline pa icipan cha ac e is ics, acco ding o ail y pheno ype.
F ail (n= 62) P e- ail (n= 411) Robus (n= 91) To al (n= 564) p- alue
a
n(%) n(%) n(%) n(%)
Women 49 (79.01) 276 (67.1) 31 (34.1) 356 (63.1) <0.01
A e ial hype ension 48 (77.42) 262 (63.74) 60 (65.93) 370 (65.6)
0.11
Diabe es melli us 31 (50) 111 (27) 20 (21.98) 162 (28.72) <0.01
Hype lipidemia 30 (57.69) 177 (43.06) 36 (39.56) 243 (43.08) 0.56
Mean (SD) Mean (SD) Mean (SD) Mean (SD) p- alue
b
Pos hoc
Age, yea s 77.97 (3.97) 76.13 (3.98) 74.37 (3.25) 76.05 (3.97) <0.01
c,
**
d,
**
e,
*
Mini Men al
S a e Examina ion
(MMSE)
28.02 (1.74) 27.84 (1.68) 27.45 (1.5) 27.85 (1.68) 0.41
a
Chi-squa ed es .
b
ANOVA Games Howell pos hoc es .
c
ail s. p e- ail.
d
ail s. obus .
e
p e- ail s. obus .P- alue.
*p<0.05.
** p<0.01.
Table 2
Pe cen age o exe cise days and mean numbe o e- isi s o esol ing pa icipan doub s abou exe cises.
F ail (n= 60) P e- ail (n= 399) Robus (n= 90) To al (n= 549) p- alue
a
Pe cen age o exe cise days n(%) n(%) n(%) n(%)
25% 0 (0) 0 (0) 19 (21.1) 19 (3.5) <0.01
26% o 50% 7 (10.7) 101 (25.3) 35 (38.9) 143 (26.0)
51% o 75% 38 (64.3) 187 (46.9) 12 (13.3) 237 (43.2)
76% o 100% 15 (25) 111 (27.8) 24 (26.7) 150 (27.3)
Mean (SD) Mean (SD) Mean (SD) Mean (SD) p- alue
b
Re- isi s 4.3 (3.17) 5.35 (3.4) 5.15 (3.47) 5.22 (3.51) 0.105
The pe cen ages we e calcula ed on he basis o a o al o 250 days (100%) pe yea . A e deduc ing weekends, public holidays and a holiday mon h.
a
Chi-squa ed es .
b
ANOVA.P- alue: *p<0.05; **p<0.01.
Table 3
Be o e-a e dis ibu ion o ail y pheno ype in alle s and by weekly hou s o physical ac i i y.
G oup n P e- es (%) p- alue
a
nPos - es (%) p- alue
a
Falle s F ail 34 54.84 <0.01 5 15.62 0.03
P e- ail 152 36.98 104 26.59
Robus 13 14.29 31 24.8
Recu en alle s F ail 20 58.82 0.25 3 60 <0.01
P e- ail 67 44.07 29 27.8
Robus 5 38.46 15 48.38
Physical ac i i y <3 h/w F ail 62 100 <0.01 25 78.12 <0.01
P e- ail 180 43.79 137 35.03
Robus 2 0.2 5 0.04
Physical ac i i y 36 h/w F ail 0 0.0 7 21.87
P e- ail 127 30.9 149 38.11
Robus 39 44.85 64 51.2
Physical ac i i y >6 h/w F ail 0 0.0 0 0
P e- ail 104 25.3 105 26.86
Robus 50 54.95 26 44.8
Falle s: 1 all o e ollow-up. Recu en alle : 2 alls o e ollow-up.
a
Chi-squa e es .
440 P. P
e ez-Ros e al. / Ge ia ic Nu sing 41 (2020) 436444

The published li e a u e is unclea as o which ype o exe cise
is mos app op ia e o hese popula ions,
16,36
wi h di e en s ud-
ies assessing p op iocep ion, ai chi,
37
and mul icomponen
3841
and esis ance exe cise.
42
Va iables such as pa ien s’ unc ional
s a us and como bidi y, polypha macy, and indi idual e sus
g oup se ings can influence he choice o ac i i y.
8
In olde adul s
who a e ail and p e- ail, s a ing wi h a p op iocep ion p og am
may be he mos app op ia e app oach, as he low in ensi y o
hese exe cises is sui able o people wi h unc ional limi a ions,
inc easing he likelihood o adhe ence.
While g oup exe cise is he mos e ec i e modali y, g oup s udies
a e di ficul o pe o m due o a lack o space in which o ca y ou he
ac i i ies and limi ed economic esou ces o paying ins uc o s.
22,23
Home exe cises like he ones in ou s udy ha e p o en e ec i e in
educing alls,
18
bu ensu ing pa ien s’adhe ence is mo e di ficul , as
obse ed in ou obus pa icipan s, who ac ually saw a sligh inc ease
0
20
40
60
80
100
120
P e- es Pos - es
poin s
Ba hel Index
F ail
*
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
P e- es Pos - es
e en s
Falls
F ail
P e ail
Robus
**
**
**
0
5
10
15
20
25
30
35
P e- es Pos - es
poin s
FESI
F ail
P e ail
Robus
0
2
4
6
8
10
P e- es Pos - es
poin s
Law on Index
F ail
P e ail
Robus
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
P e- es Pos - es
poin s
Tine Index
F ail
P eF ail
Robus
0
2
4
6
8
10
12
14
16
P e- es Pos - es
poin s
sMNA
F ail
P e ail
Robus
0
5
10
15
20
25
30
35
40
45
P e- es Pos - es
kg/m2
BMI
F ail
P e ail
Robus
0
10
20
30
40
50
P e- es Pos - es
%
Fa Mass
F ail
P e ail
Robus
**
0
5
10
15
20
25
30
35
40
45
P e- es
kg
Handg ip
F ail
P e ail
Robus
**
**
*
**
**
**
**
**
*
**
**
Pos - es
**
Fig. 2. Resul s o he g oup x ime compa a i e analysis, showing he e ec s o he in e en ion. Falls, FES-I (Falls E ficacy Scale In e na ional), Ba hel Index, Law on Index, Tine i
Index, MNAÒ-SF (Mini Nu i ional Assessmen Sho Fo m), BMI (Body Mass Index), Fa Mass, Handg ip. FES-I (Falls E ficacy Scale In e na ional) F: ail pa icipan s; PF: P e- ail pa -
icipan s; R: obus pa icipan s. FES-I assesses ea o alling based on a scale o 1664; a maximum sco e indica es maximum ea . The Ba hel Index assesses unc ion e e ed o
ac i i ies o daily li ing based on a scale o 0100; a maximum sco e indica es independency. The Law on Index assesses unc ion ela ed o ins umen al ac i i ies o daily li ing
on a scale o 08; a maximum sco e indica es independency. The Tine i Index e alua es gai and balance based on a scale o 028; a maximum sco e indica es no isk. MNAÒ-SF
assesses nu i ional s a us based on a scale o 016; a maximum sco e is indica i e o op imal s a us. Significan a *p<0.05, **p<0.01.
P. P
e ez-Ros e al. / Ge ia ic Nu sing 41 (2020) 436444 441
in he incidence o alls wi h espec o he p e ious yea . This g oup’s
pe cep ions o hei good heal h may ha e led hem o unde es ima e
hei ulne abili y o alls and o dis ega d he impo ance o adhe ing
o an exe cise p og am.
43
A he same ime, he e was no dec ease in ecu en alle s,
esul s ha a e consis en wi h he sca ce e idence on he e ec i e-
ness o home-based p og ams o educing he numbe o ecu en
alls in ail olde people.
44
Fu he esea ch is hus equi ed in his
specific popula ion. A baseline, he ea o alls was g ea e in alle s
and ecu en alle s; howe e , by s udy end, hese be ween-g oup
di e ences had disappea ed, co obo a ing he esul s om o he
s udies showing he e ec i eness o he in e en ion.
22,45
The s udy sample was unc ionally independen in he pe o -
mance o basic and ins umen al ac i i ies o daily li ing, including
mobili y, wi h no di e ences acco ding o ail y s a us. In con as ,
se e al s udies
4,5
ha e epo ed ha ail y is ela ed o disabili y;
his di e ence is p obably a ibu able o ou inclusion c i e ia (inde-
penden walke s li ing in he communi y). We also obse ed ha
ail y is associa ed wi h ad anced age, obesi y, inc eased an h opo-
me ic pa ame e s, and lesse handg ip s eng h, esul s ha
con adic con en ionally held belie s abou he associa ion be ween
ail y and hinness.
4648
The inc ease in physical ac i i y p o ed beneficial o educing
an h opome ic pa ame e s such as BMI and body a pe cen age.
Such findings complemen e idence om he li e a u e showing ha
egula physical ac i i y is sa e o obus and ail olde people alike,
educing hei isk o majo ca dio ascula and me abolic diseases,
obesi y, alls, cogni i e impai men , os eopo osis, and muscle weak-
ness.
23
In addi ion o he dec ease in alls and imp o emen in he
clinical pa ame e s, ou pa icipan s imp o ed hei ail y s a us
compa ed o baseline. Al hough mul icomponen exe cise p og ams
a e suppo ed by a la ge body o e idence ega ding he e e sal o
ail y,
21
ou esul s sugges ha home-based p og ams may also be
beneficial. Con inuous ollow-up o e 12 mon hs, wi h mon hly ele-
phone calls and qua e ly isi s, may encou age adhe ence by making
pa ien s eel suppo ed by heal h p o essionals and accoun able o
ollowing heal hie physical ac i i y beha io s.
Home-based p op iocep ion p og ams a e a iable al e na i e
whe e esou ce limi a ions p eclude g oup exe cises. The exe cise
ins uc ions a e simple o p op iocep ion han o mul icomponen
Table 4
In e ac ion e ec s o g oups and assessmen ime poin s in ela ion o ou comes in ail (N= 60), p e- ail (N= 399), and obus (N= 90) pa icipan s.
Ou comes by ail y pheno ype P e Mean (SD) Pos Mean (SD) Mean di e ence (95% CI) F
a
p- alue h
2
Falls (n)
F ail 1.46 (2.24) 0.53 (1.01) 0.93 (1.32 o 0.54)** 10.86 <0.01 0.058
P e- ail 0.66 (1.2) 0.36 (0.73) 0.3 (0.045 o 0.15)**
Robus 0.23 (0.67) 0.48 (0.93) 0.24 (0.07 o 0.56)
FES-I (scale 1664; highe sco e = mo e ea o alling)
F ail 28.16 (2.07) 20.91 (2.14) 7.25 (14.64 o 0.14)*9.12 <0.01 0.052
P e- ail 18.85 (0.8) 19.71 (0.83) 0.86 (1.46 o 3.19)
Robus 10.95 (1.69) 20.12 (1.74) 9.17 (5.26 o 13.09)**
Ba hel Index (scale 0100; highe sco e indica es mo e independence on ADL)
F ail 92.18 (10.47) 92.58 (10.9) 0.50 (0.56 o 1.56) 2.63 0.07 0.01
P e- ail 93.64 (9.78) 93.7 (9.38) 0.13 (0.62 o 0.37)
Robus 94.89 (7.96) 93.61 (8.51) 1.22 (2.19 o 0.25)*
Law on Index (scale 08; highe sco e indica es mo e independence on ins umen al ADL)
F ail 7.15 (0.14) 7.13 (1.11) 0.02 (0.15 o 0.11) 0.13 0.87 0.001
P e- ail 7.32 (0.06) 7.35 (0.05) 0.03 (0.04 o 0.09)
Robus 7.46 (0.95) 7.47 (0.85) 0.01 (0.10 o 0.12)
Tine i Index (scale 028; highe sco e indica es lowe isk ela ed o gai and balance)
F ail 25.47 (0.43) 25.45 (0.41) 0.02 (0.54 o 0.51) 0.01 0.99 0.001
P e- ail 25.85 (0.16) 25.86 (0.16) 0.01 (0.15 o 0.15)
Robus 25.93 (0.35) 25.95 (0.33) 0.02 (0.43 o 0.48)
MNA-SF (scale 014; highe sco e indica es be e nu i ional s a us)
F ail 13.45 (0.07) 13.548 (0.07) 0.03 (0.26 o 0.10) 0.69 0.5 0.003
P e- ail 13.61 (0.03) 13.62 (0.03) 0.01 (0.05 o 0.07)
Robus 13.46 (0.79) 13.49 (0.79) 0.03 (0.11 o 0.18)
BMI, kg/m
2
F ail 31.83 (0.58) 31.51 (0.57) 0.12 (0.76 o 0.13) 0.02 0.8 0.001
P e- ail 30.13 (0.22) 29.9 (0.24) 0.23 ( 0.37 o 0.10)**
Robus 29.08 (0.46) 28.9 (0.42) 0.16 (0.48 o 0.16)
Body a , %
F ail 41.60 (7.29) 41.24 (7.32) 0.36 (1.04 o 0.32) 1.8 0.17 0.007
P e- ail 39.2 (6.95) 38.15(7.1) 1.05 (1.46 o 0.64)**
Robus 34.64 (6.49) 34.3 (6.09) 0.33 ( 1.04 o 0.38)
Handg ip, kg
F ail 14.26 (4.93) 16.05 (5.26) 1.79 (1.02 o 2.57)** 1.22 0.29 0.004
P e- ail 18.93 (7.69) 20.55 (7.7) 1.59 (1.23 o 1.96)**
Robus 31.17 (6.85) 32.17 (6.71) 1.00 (0.34 o 1.3)*
ADL: ac i i ies o daily li ing; BMI (Body Mass Index). MNA-SF (Mini Nu i ional Assessmen - Sho Fo m); FES-I (Falls E ficacy Scale In e na ional); SD: s anda d de ia ion.
Significan a .
*p<0.05.
** p<0.01.F
a
: wo-way ANOVA ( epea ed measu es). h
2
= e a squa ed (e ec size). Th esholds o h
2
:>0.01, small; >0.059, mode a e; >0.138, la ge.
442 P. P
e ez-Ros e al. / Ge ia ic Nu sing 41 (2020) 436444
p og ams, can be applied by nu ses and physio he apis s, and can
each a la ge popula ion.
Limi a ions
The nu ses conduc ing he in e en ion we e no exemp om
possible in e p e a ional e o s o he isk o in o ma ion bias,
despi e he simplici y o he i ems assessed. Fu he mo e, he numbe
o alls in he p e ious 12 mon hs may ha e been unde - eco ded due
o ecall bias o epo ing bias (e.g. due o shame) on he pa o pa -
icipan s. The ime, wea he condi ions and loca ion o he alls we e
no compiled, and he ollow-up pe iod was limi ed o 12 mon hs.
Addi ionally, measu emen bias may ha e a ec ed he isk ac o s o
alls, and in e - a e eliabili y was no es ablished among he a ing
nu ses. On he o he hand, he sample was igo ously selec ed, wi h
ew d opou s, and he sample size was la ge and su ficien o he
es ima ions made. A final limi a ion was ha cogni i e s a us was
assessed only a baseline, and al hough olde people wi h mode a e
o se e e cogni i e impai men we e excluded, some pa icipan s
may ha e los cogni i e abili y o e he cou se o he s udy.
CONCLUSIONS
A 12-mon h home p op iocep ion exe cise p og am dec eased he
incidence o alls in ail and p e- ail communi y-dwelling olde
adul s. The p og am was mo e e ec i e in ail and p e- ail g oups
han in obus pa icipan s. Adhe ence o exe cise educes he inci-
dence o alls and he p esence o ail y c i e ia in communi y-dwell-
ing olde people.
Decla a ion o Compe ing In e es
The au ho s decla e ha hey ha e no conflic s o in e es in ela-
ion o he p esen s udy.
CRediT au ho ship con ibu ion s a emen
Pila P
e ez-Ros: Concep ualiza ion, Da a cu a ion, Fo mal analy-
sis, W i ing - e iew & edi ing. Ra ael Vila-Candel: Concep ualiza-
ion, Da a cu a ion, Fo mal analysis, W i ing - e iew & edi ing.
F ancisco Miguel Ma ínez-A nau: Concep ualiza ion, Da a cu a ion,
Fo mal analysis, W i ing - e iew & edi ing.
Acknowledgmen s
The au ho s wish o hank all he membe s o he La Ribe a Heal h
Depa men o helping o make his s udy possible.
Funding
The ansla ion o he manusc ip has been financed by he Uni-
e sidad Ca 
olica de Valencia San Vicen e M
a i . None o he au ho s
ecei ed mo e financial suppo o his s udy. No mo e unding was
ecei ed o his s udy. The Go e nmen au ho i ies, Uni e si y o
Valencia and Hospi al Uni e si a io de la Ribe a played no ole in he
conduc ion o his s udy.
Supplemen a y ma e ials
Supplemen a y ma e ial associa ed wi h his a icle can be ound
in he online e sion a doi:10.1016/j.ge inu se.2020.01.017.
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