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 Table of Contents  
Year : 2021  |  Volume : 38  |  Issue : 3  |  Page : 180-186

The effect of an interactive tele rehabilitation program on balance in older individuals

1 Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Near East University, Nicosia, Cyprus
2 Department of Health Management, Faculty of Health Sciences, Near East University, Nicosia, Cyprus
3 Department of Biophysics, Faculty of Medicine, Near East University, Nicosia, Cyprus

Date of Submission04-May-2021
Date of Decision18-Jun-2021
Date of Acceptance22-Jun-2021
Date of Web Publication20-Sep-2021

Correspondence Address:
Murat Özgùren
Department of Biophysics, Faculty of Medicine, Near East University, 99138 Nicosia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/nsn.nsn_91_21

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Objective: To investigate the effect of a home-based interactive telerehabilitation program on balance performance in older people, and to compare the results with a nonsupervised home exercise (NHE) program. Subjects and Methods: A total of 50 participants (35 females), aged 65–90 years, were included in the study. The subjects were randomly assigned to one of three groups as the interactive telerehabilitation home exercise group (ITHE), NHE group or control group. The ITHE and NHE groups exercised three times per week for 8 weeks. The outcome measures were the Berg Functional Balance Scale (BBS), Timed Up and Go Test (TUG), Sway Balance Mobile Application, Trait Anxiety Inventory (TAI), and the World Health Organization Quality of Life Instrument-Older Adults Module (WHL). Results: In the control group, no difference was observed in the TUG and BBS scores, at the end of the 8 weeks compared with preexercise (pre-ex), whereas these scores increased significantly in the NHE (TUG: P < 0.001, BBS: P < 0.001) and ITHE groups (TUG: P < 0.001, BBS: P = 0.003). The WHL scores increased significantly in all three groups, and no difference was observed in the TAI scores. There was a significant difference in SWAY score only in the telerehabilitation group compared with pre-ex (P < 0.001). Conclusions: Although NHE and ITHE were effective on the improvement of balance, mobility and reduction of fall risk in older individuals, this effect was found to be greater in the ITHE group. Quality of life increased in all groups, but no change in anxiety level was observed.

Keywords: Aged, exercise, postural balance, telerehabilitation

How to cite this article:
Yerlikaya T, Öniz A, Özgùren M. The effect of an interactive tele rehabilitation program on balance in older individuals. Neurol Sci Neurophysiol 2021;38:180-6

How to cite this URL:
Yerlikaya T, Öniz A, Özgùren M. The effect of an interactive tele rehabilitation program on balance in older individuals. Neurol Sci Neurophysiol [serial online] 2021 [cited 2022 Jun 28];38:180-6. Available from: http://www.nsnjournal.org/text.asp?2021/38/3/180/326294

  Introduction Top

In the last decade, population aging has been recorded as a global phenomenon. In the aging process, a deterioration occurs in the somatosensory, visual, and vestibular systems, which control balance, and functional level decreases in all body systems, resulting in an increased tendency to falls.[1] Each year falls are experienced by approximately 30%–40% of community-dwelling individuals aged ≥65 years. Approximately half of the falls result in an injury, and 10% result in serious injuries with substantially increased medical costs.[2] Deficits can occur in many systems with aging, and are seen especially as a decrease in lower extremity muscle strength and flexibility, decrease in postural control ability and lack of physical activity, all of which have a negative effect on functional independence and quality of life, leading to falls.[3],[4],[5] Many treatment approaches including balance and strengthening exercises are used to prevent falls in the elderly.[6] Regular exercises can eliminate the risk of falling and provide stabilization by improving walking, balance, muscle strength, and mobility, thereby increasing their functional abilities.[7] In a systematic review by Cadore et al., it was shown that exercise programs, including strengthening, endurance training, and balance training, could significantly improve balance, muscle strength, gait, and physical function in chronically impaired older people with a tendency to fall.[8]

Exercise and treatment programs must be performed face-to-face to be disciplined and guided correctly. However, individuals who want to receive rehabilitation have to go to rehabilitation centers or hospitals, requiring time and cost. It has been determined worldwide that the most effective service that can be given to the elderly in terms of healthcare services is that which is performed in their own environment where the subject feels comfortable.[9] Home-based programs have been reported to be superior to center-based programs for older individuals, especially in terms of exercise adherence in the long term.[10] Throughout the COVID-19 pandemic, negative effects have been seen in protection and adaptation behaviors on physical activity and psychological state.[11] During the pandemic, enforced conditions of quarantine and social isolation to prevent contamination risk have increased the necessity of telerehabilitation.[12]

There are few studies in the literature that have investigated the effects of interactively administered telerehabilitation on balance in the elderly.[13],[14] As a common result of these studies, telerehabilitation has been found to be effective in improving balance. However, the lack of control group, exercise type, cost and equipment requirements in these studies increase the need for more comprehensive studies.[13],[15] Therefore, this study aimed to investigate the effectiveness of a home-based interactive telerehabilitation program compared with a nonsupervised home exercise (NHE) program in an older population.

  Subjects and Methods Top

This randomized controlled study was conducted between August 2020 and November 2020. The study included a total of 50 participants at risk of falling, comprising an interactive telerehabilitation home exercise (ITHE) group (n = 18) (mean age: 70.22 ± 5.53 years; 12 females), a NHE group (n = 16) (mean age: 71.81 ± 6.57 years; 12 females) and a control group (n = 16) (mean age: 75.62 ± 8.68 years; 12 females). The subjects included in the study were aged ≥65 years and were selected from subjects who responded to an announcement in randomly selected villages in the province of Nicosia, North Cyprus.

The allocation sequence was generated by the researcher at random in blocks of six in sealed envelopes. To ensure balance among the three groups, randomization was stratified by sex.[16] The subjects included in the study were those with a Mini-Mental test score of over 23, with a history of falling or fear of falling in the last 5 years, who were able to communicate while following instructions, had video internet access, and could walk with or without walking aids. Subjects were excluded from the study if they had any cardiovascular disease such as uncontrolled hypertension or cardiac arrhythmia, neurologic disease, recurrent dizziness, performed regular exercise in the last 3 months, or had severe vision or hearing loss. All participants signed an informed consent form before inclusion. The research study received ethical approval.

Outcome measures

Quality of life, emotional and cognitive status of participants

The Standardized Mini-Mental Test was used to evaluate orientation, recording memory, attention and calculation, recall, and language. The test, which consists of eleven items under five main headings, is evaluated over a total of 30 points.[17] The Trait Anxiety Inventory (TAI) consisting of 20 questions was used to determine anxiety levels, with higher scores indicating a higher anxiety level.[18] The World Health Organization Quality of Life Instrument-Older Adults Module (WHL) scale, which is used to evaluate the quality of life in the elderly, consists of 24 items and six sub-domains of sensory functions, autonomy, past, present and future activities, social participation, death, dying and intimacy. The higher the score, the better the quality of life.[19]

Balance, mobility and postural sway

First, the Timed-Up-and-Go test (TUG) was performed as a rapid assessment of dynamic balance, walking speed, and mobility. The subject was asked to stand up from a chair without holding on to the arms of the chair, to walk 3 meters without touching anything, to turn round and return to the chair and sit. The time was recorded in seconds.[20] The Berg Functional Balance Scale (BBS), consisting of 14 items, was used to evaluate balance in daily routine actions such as standing up from sitting, standing without support, sitting with support, sitting down from standing, transferring weight, standing without support, reaching forward, bending down and picking up objects, turning/turning the trunk, going up and down stairs, tandem stance, and standing on one leg.[21]

The Sway Balance Mobile Application (Sway) (SWAY Medical, USA) with a triaxial accelerometer, is a recently developed method to evaluate standing balance, used to measure postural sway.[22] The Sway protocol consists of five postures, including feet together, tandem stance (left foot forward), tandem stance (right foot forward), one leg stance (right) and one leg stance (left). Each stance is performed for 10 s on a solid surface with the eyes closed. During each stance, the subject holds the phone perpendicular to the midpoint of the rib cage. During the test, the therapist carefully stood beside the subject against the risk of falling. Three measurements are taken and the average value is automatically saved. The Sway balance system has been shown to be valid and reliable.[23],[24] An objective balance score can be obtained at minimal cost and experience without the need to attend a healthcare facility. In addition to the demographic and physical characteristics of the participants, data such as underlying diseases, fall history, walking ability, return, fear of going out alone and falling were recorded in face-to-face interviews.

Study design

After the baseline evaluations, the subjects were randomly assigned to one of three groups: ITHE, NHE, and the control group [Figure 1]. All participants were evaluated by the same therapist who was blinded to the groups, at baseline and 8 weeks later on the same day, in order. Considering the necessity of combining both strength and balance training in reducing the incidence of falling, the subjects were given simple balance and strengthening exercises that have been shown to be effective in improving balance.[25],[26] The same exercise program was given to the ITHE and NHE groups, 3 days per week, 40 min per day for 8 weeks, including 5–10 min of warm-up, 15 min of strengthening, 15 min of balance and 5 min of cooling down. In the following weeks, strengthening exercises can be performed by applying weight or increasing the number of repetitions; balance exercises progressed towards more difficult exercises. Squatting while holding on to a chair, heel-toe raises, lower extremity proximal area strengthening exercises, and standing up from a chair with arms crossed in front were given as the strengthening exercises, and marching, stepping over a bench, tandem walking (heel-to-toe walking in a straight line) and single-leg exercises were given for balance. Participants in the ITHE group exercised with a physiotherapist by connecting from their homes via video access platforms such as WhatsApp and Google Meet in groups of two or three. Before starting the exercises, 1–2 trial sessions were performed for practice and familiarization. Participants in the NHE group performed the exercises at home with a physiotherapist for the first session, and subsequently without supervision, using videos that showed how to perform the exercises. The subjects were asked to note the day of the exercise in the weekly exercise schedule, and the exercise program was followed up by the therapist at intervals by phone. Participants in the control group did not receive any exercise during the study. At the end of the study period, exercise training was given to the control group and relevant videos were shared.
Figure 1: Selection of individuals included in the study

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Statistical analysis

The SPSS Sample Power 3.0 software (IBM Corporation, Armonk, NY, USA) was used for sample size calculation. The minimum required sample size was estimated to be 11 individuals for each group for the desired power (β) of 80% with an assumed alpha level (α) of 0.05 to detect a minimum clinical difference of 3 s for TUG when the average TUG result in the elderly has been reported as 9.4 ± 2.5 s.[14] The data were analyzed using the SPSS Ver. 18.0 software and GraphPad Prism 8. One-way analysis of variance (ANOVA) was used for data that conformed with normal distribution, and for data not conforming with normal distribution, the Kruskal–Wallis test was used. A P < 0.05 was accepted as statistically significant in two-way repeated-measures ANOVA, and Sidak was used to compare the preexercise (pre-ex) and postexercise (post-ex) values within the groups.

  Results Top

Of the total 52 recruited subjects, two dropped out, thus the final analysis was conducted on 50 subjects [Figure 1], all of whom completed all procedures and fully complied with the study. No significant differences were determined between the groups in respect of physical characteristics [Table 1]. In the control group, no significant difference was determined between the pre-ex and post-ex mean values of TUG (pre-ex: 15.82 ± 5.88, post-ex: 15.92 ± 5.73) and BBS (pre-ex: 44.25 ± 8.02, post-ex: 46.87 ± 8.67). In the ITHE group, the post-ex values were significantly improved compared with the pre-ex values of mean TUG (pre-ex: 12.38 ± 1.59 post-ex: 8.98 ± 2.35) and BBS (pre-ex: 48.11 ± 5.66, post-ex: 53.33 ± 4.22). In the NHE group, the post-exercise values were significantly improved compared with the pre-ex values of mean TUG (pre-ex: 14.88 ± 3.80 post-ex: 10.61 ± 3.47) and BBS (pre-ex: 46.31 ± 6.32 post-ex: 52.12 ± 5.28). Although WHL scores increased significantly in all three groups (P < 0.05), no difference was observed in TAI scores. There was a significant difference in SWAY values only in the telerehabilitation group compared with pre-ex (P < 0.001). The findings are summarized in [Table 2] and [Table 3].
Table 1: Demographic and clinical characteristics of the subjects

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Table 2: Results of 8-week changes in control and nonsupervised home group parameters examined

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Table 3: Results of 8-week changes in interactive tele-rehabilitation home exercise group parameters examined

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  Discussion Top

The study was designed in such a way that the nonsupervised home exercise and interactive telerehabilitation home-based exercise program for older people at risk of falling could be performed completely remotely. The most important finding of this study was that balance exercises performed with telerehabilitation significantly improved all balance, mobility, and health values, especially in postural sway, and decreased the risk of falling. The NHE group showed some improvement in some values of balance and mobility, but in the control group, there was no improvement.

The rehabilitation field should proactively benefit from alternative strategies such as telerehabilitation to provide services that reduce the impact of social isolation on physical function and offer the opportunity to exercise at home, which eliminates the need for transport of the elderly. The home environment is an environment where the individual is well accustomed in terms of daily living conditions and activities, feels safe, and lives with memories. Recently, new methods based on telecommunication have been developed that enable patients to receive rehabilitation in their own homes and applications in many areas have been performed in the field of rehabilitation.[27]

Several studies on preventing falls and improving balance with tele-exercise programs in the elderly have shown positive results.[15],[28] Unlike related studies, in the current study, the ITHE and NHE groups were followed as well as a control group, and the effects of physical activity in daily routines were thus discounted. The ITHE group received a simultaneous and interactive program with a therapist. Wu et al. stated that interactive tai chi exercises performed via telerehabilitation with Polycom were more effective in preventing falls than video-based home exercises.[14] Simple balance and strengthening exercises were used in the current study to improve balance and mobility. These exercises, which can be performed at home, have also been found to be a good option to improve balance. As a result of joint studies, it has been seen that both types of exercises are as successful as ITHE. Another factor that distinguishes the current study is that it did not incur any additional cost by making use of existing facilities without the requirement of any special technology other than a smartphone.

It has been shown that nonsupervised home-based exercises improve balance. However, there have also been conflicting results on postural sway, as a balance parameter.[29],[30],[31] In the current study, the NHE group showed improved balance and mobility parameters but not postural sway. This result may be due to conditions such as not taking into account the number of repetitions by the individual performed during a certain exercise that is not performed under the supervision of a physiotherapist, and not performing the exercise properly and in a disciplined manner.

In a review study, combined strength, endurance, and balance training were cited as the best strategies for reducing fall rates and improving mobility, balance, and strength in older individuals. Of the two training programs that have been proven to reduce falls, combined balance and step training over 10 weeks have been shown to provide better improvements in balance, step-taking, and functional mobility than tai chi exercises.[8],[32] The current study supports these findings with the improvement in balance and mobility.

It has been shown that short-term strengthening and balance exercises provide an increase in muscle strength while making a minimum contribution to the control of postural stability, although Wong et al. found that coordination exercises performed for 3 months were effective on postural stability.[33],[34] In the current study, the observation of a decrease in postural sway in only the ITHE group showed that the 8-week ITHE exercise program was quite successful.

Balance and coordination exercises increase the quality of life.[35] The reason for the significant improvement, which was also seen in the control group, was the removal during the study period of some restrictions imposed during the COVID-19 pandemic and the consequent increase in social interaction. No difference was observed in trait anxiety levels in any group. Home-based 6-month physical activity has been shown to reduce anxiety in older adults, but it has also been reported that symptoms may improve over time, regardless of the intervention.[36],[37] In a recent study, an 8-week exercise program did not affect anxiety level. Even though the attitude towards the disease affected the anxiety level during the pandemic, exercise alone was not sufficient to reduce the anxiety level under normal conditions.[38]

Considering the results of the current study, the elderly should receive telerehabilitation exercise services to reduce the risk of falling because these can be performed more easily, and those who cannot perform the exercises via telerehabilitation or going to centers should be guided by a brochure or video support for exercises that can be performed at home.

In this study, it was planned to perform Sway measurements remotely under coronavirus pandemic conditions and for other tests to be performed completely remotely, but as the lockdown regulations were eased, it was possible to add face-to-face measurements. To the best of our knowledge, this is the first study on balance in the elderly, designed to be performed remotely with valid and appropriate tests that can be completed entirely in the home environment. No possible quarantine and restrictions presented a risk to the continuation of the study. Nevertheless, this study had some limitations. Due to the pandemic conditions, some evaluation criteria were not suitable for remote application. If muscle strength and joint position sense could be evaluated, the reasons for the change in balance could be explained better.

  Conclusions Top

When the fall risk and balance values of the three groups were compared, no improvement was observed in the control group, but an increase in functional balance and mobility was observed in the NHE and ITHE groups. It was observed that postural sway improved only in the ITHE group. Exercises performed using telerehabilitation are effective and affordable options for the elderly. Therefore, the field of rehabilitation should proactively leverage alternative strategies, such as telerehabilitation, to provide services that reduce the effects of quarantine on physical function, eliminate the transport problem for the elderly, and provide home exercise plans. Programs with easier interaction are needed to reduce the risk of falling and increase the quality of life in the elderly.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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