Randomized Controlled Trial
Due to the complexities of clinical decision making that a physical therapist has to face everyday, the need to develop good clinical reasoning skill is essential. Although clinical reasoning can be developed through experience, confiding entirely on this, can result in faulty decisions as it can be influenced by biases and heuristics (Crist, McVay & Marocco, 2015). Employing the best, current evidence available to compliment our clinical skills and patient values can promote good patient outcome.
To facilitate successful evidence collection, appraisal, and integration, the first step is to recognize the need for information and develop a focused and searchable clinical question (Crist, McVay & Marocco, 2015). Currently, I provide care to …show more content…
elderly people who, other than suffering from multiple health conditions, are at risk of falls. Balance is adversely affected by intrinsic and extrinsic factors. Muscle weakness and unreliable postural reflexes secondary to sensory loss are two intrinsic factors that can be improved with physical therapy interventions. Consequently, this leads me to examine the issues in the efficacy of balance training interventions used in my practice. Typically, traditional balance training such as weight shifting, single leg balance, gait training on even and uneven surfaces, and so on are used. Strengthening of the key muscles of the lower extremities through progressive resistance exercise is given minor attention. Consequently, I came to develop this clinical question “Is progressive resistance exercise more effective than traditional balance exercise in improving balance to decrease fall risk among healthy community-dweller elderly ages 65 years and over?”
To guide me through this clinical research, I utilized the acronym PICO.
Table 1. Formulating foreground question using PICO.
P OPULATION Elderly adults ages 65+
I NTERVENTION Progressive resistance exercise
C OMPARISON Traditional balance exercise
O UTCOME Improved balance In my pursuit to answer my question, I used the following database:
PubMed
PubMed is a freely available search engine which is fairly easy to use and gives the most number of articles. The feature that records my search activity assisted me in identifying the terms which are sensitive in my query. The absence of an option to search only peer-reviewed journals are something that I dislike about this database.
CINAHL
Cumulative Index of Nursing and Allied Health Literature (CINAHL) database has a user friendly interface with has an option to narrow search to only peer- reviewed journals. It offers many options to narrow one’s search and also offers suggested terms to use in the search.
To begin my search, I identified keywords that best describes the information that I need. I started with the terms used in my question, which are falls, progressive resistance exercise, balance training exercise, elderly, and balance. Effectiveness and improving were not included since it is already expected that only studies that addresses improvement will be considered. Next, I rank the following terms from the most significant to the least significant making. Hence, balance came first, followed by progressive resistance exercise, balance exercise, falls and elderly respectively. The terms aged and older were considered as they also pertain to elderly.
To further narrow my search, only peer reviewed articles from 2011- 2016 were included. Most of the studies that came up were systematic reviews. While systematic review appraised numerous studies and does not give detailed information to a specific treatment, I further narrowed my search to only include randomized control trials.
The following peer reviewed articles that best answered my clinical question are the following:
Granacher, U., Muehlbauer, T., Zahner, L., Gollhofer, A., and Kressig, R. (2011). Comparison of traditional and recent approaches in the promotion of balance and strength in older adults. Sports Medicine, 41(5), 377-400. http://dx.doi.org.ezproxy.utica.edu/10.2165/11539920-000000000-00000
Ishigaki, E., Ramos, L., Carvalho, E. and Lunardi, A. (2014). Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review. Brazilian Journal of Physical Therapy 18(2), pp. 111-118 doi: 10.1590/S1413-35552012005000148
Joshua, A., D'Souza, V., Unnikrishnan, B., Mithra, P., Kamath, A., Acharya, V. and Venugopal, A. (2014). Effectiveness of progressive resistance strength training versus traditional balance exercise in improving balance among the elderly - a randomised controlled trial. Journal of Clinical and Diagnostic Research 8(3), pp. 98–102. doi: 10.7860/JCDR/2014/8217.4119
Lee, I. and Park S. (2013). Balance improvement by strength training for the elderly. Journal of Physical Therapy Science, 25 (12), pp 1591-1593. doi: 10.1589/jpts.25.1591
Sung, M.S., Kyung, W.K., Na Kyung, L., Seok, H. N., Jung W.K., and Kyoung, K. (2013). Influence of isokinetic strength training of unilateral ankle on ipsilateral one-legged standing balance of adults. Physical Therapy Science (10), pp. 1313- 1315. doi: 10.1589/jpts.25.1313
All these articles are experimental studies on interventions for improving balance.
A brief description of each study is described in Table 2.
Table 2. Research design of intervention studies in improving balance.
Article Research Design
Effects of a Fall Prevention Exercise Program on Muscle Strength and Balance of the Old-old Elderly Randomized Controlled trial (RCT)
Comparison of traditional and recent approaches in the promotion of balance and strength in older adults.
Systematic Review
Balance Improvement by Strength Training for the
Elderly Randomized Controlled trial (RCT)
Effectiveness of Progressive Resistance Strength Training Versus Traditional Balance Exercise in Improving Balance Among the Elderly - A Randomized Controlled Trial. Randomized Controlled trial (RCT)
Influence of Isokinetic Strength Training of Unilateral Ankle on Ipsilateral One-legged Standing Balance of Adults Randomized Controlled trial (RCT)
The study of Joshua et al. (2013) is the most relevant to answer my clinical question as it has the same characteristics of my patients and the interventions used were realistic to my …show more content…
practice. The chosen article is a single-blind study where the subjects were randomly assigned and concealment allocation was done. Furthermore, the baseline variables were analyzed to achieve a homogenous sample population. Outcome measure that were utilized were valid and reliable in measuring balance among older adults in the community (Conradsson, et al.,2007; Duncan,1990). Although, during the six-month period of the study, nine dropped out, the reasons for discontinuance was stated. To prevent bias due to the loss of data as an effect of attrition, the researchers used both intention to treat and on-protocol analyses to have strong confidence in the results. The researchers account on the factors that could bias the results made me believe that study was done with rigor, which is needed for evidence based practice.
However, a sample size of 54 subjects may affect the generalizability of the study. Portney & Watkins (2006) defined power as the ability to find significant difference when they exist, therefore a small sample may limit the precision of results a study may yield.
Overall, I am confident to use this study on my patients to improve balance and promote safe mobility in the community. PRT which specifically target the ankle musculature to improve forward limits of stability on balance will be emphasized in my future treatment plan.
The shift towards the use of research and scientific evidence has permeated through physical therapy practice to improve patient outcomes. Throughout this activity I have acknowledged the gap between scientific evidence and clinical practice. This activity taught me to strengthen my practice by following the five steps in evidence based practice process. For my future research, I will formulate a more focused, well-developed clinical question to improve efficiency in my data search. In addition, I would not limit myself on the authors’ conclusion, instead I will read through the results tables and figures to better develop my understanding of statistics.
Clinical research and appraisal is only one way to optimize patient care. To support our commitment to evidence based practice, understanding all the sources of evidence remains crucial to achieve the best possible outcome.
Coradsson, M., Lundin-Olsson,L., Lindelöf, N., Littbrand, H., Malmqvist, G.and Rosendahl E. 2007. Berg balance scale: Intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities. Journal of Amercan Physical Therapy Association. doi: 10.2522/ptj.20060343
Crist, M., McVay, D. & Marocco, S. (2015). Module 4, Week1 tutorial video 2-Evidence-Based Practice II, Utica College.
Duncan, W., Weiner, K., Chandler, J., Studenski, S. 1990. Functional reach: a new clincal measure of balance. Journal of Gerantology, 45 (6), 192-197. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/2229941
Granacher, U., Muehlbauer, T., Zahner, L., Gollhofer, A., and Kressig, R. (2011). Comparison of traditional and recent approaches in the promotion of balance and strength in older adults. Sports Medicine, 41(5), 377-400. http://dx.doi.org.ezproxy.utica.edu/10.2165/11539920-000000000-00000
Ishigaki, E., Ramos, L., Carvalho, E.
and Lunardi, A. (2014). Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review. Brazilian Journal of Physical Therapy,18(2),111-118 doi: 10.1590/S1413-35552012005000148
Joshua, A., D'Souza, V., Unnikrishnan, B., Mithra, P., Kamath, A., Acharya, V. and Venugopal, A. (2014). Effectiveness of progressive resistance strength training versus traditional balance exercise in improving balance among the elderly - a randomised controlled trial. Journal of Clinical and Diagnostic Research, 8(3), 98–102. doi: 10.7860/JCDR/2014/8217.4119
Lee, I. and Park S. (2013). Balance improvement by strength training for the elderly. Journal of Physical Therapy Science, 25 (12), 1591-1593. doi: 10.1589/jpts.25.1591
Portney, L., and Watkins, M. (2009). Foundation of clinical research application to practice (3rd ed.). Boston, MA: Pearson Education, Inc..
Sung, M.S., Kyung, W.K., Na Kyung, L., Seok, H. N., Jung W.K., and Kyoung, K. (2013). Influence of isokinetic strength training of unilateral ankle on ipsilateral one-legged standing balance of adults. Physical Therapy Science,10, 1313- 1315. doi: 10.1589/jpts.25.1313
Crist, M., McVay, D. & Marocco, S. (2015). Module 4, Week1 tutorial video 2-Evidence-Based Practice II, Utica
College.
To facilitate successful evidence collection, appraisal, and integration, the first step is to recognize the need for information and develop a focused and searchable clinical question (Crist, McVay & Marocco, 2015). Currently, I provide care to …show more content…
elderly people who, other than suffering from multiple health conditions, are at risk of falls. Balance is adversely affected by intrinsic and extrinsic factors. Muscle weakness and unreliable postural reflexes secondary to sensory loss are two intrinsic factors that can be improved with physical therapy interventions. Consequently, this leads me to examine the issues in the efficacy of balance training interventions used in my practice. Typically, traditional balance training such as weight shifting, single leg balance, gait training on even and uneven surfaces, and so on are used. Strengthening of the key muscles of the lower extremities through progressive resistance exercise is given minor attention. Consequently, I came to develop this clinical question “Is progressive resistance exercise more effective than traditional balance exercise in improving balance to decrease fall risk among healthy community-dweller elderly ages 65 years and over?”
To guide me through this clinical research, I utilized the acronym PICO.
Table 1. Formulating foreground question using PICO.
P OPULATION Elderly adults ages 65+
I NTERVENTION Progressive resistance exercise
C OMPARISON Traditional balance exercise
O UTCOME Improved balance In my pursuit to answer my question, I used the following database:
PubMed
PubMed is a freely available search engine which is fairly easy to use and gives the most number of articles. The feature that records my search activity assisted me in identifying the terms which are sensitive in my query. The absence of an option to search only peer-reviewed journals are something that I dislike about this database.
CINAHL
Cumulative Index of Nursing and Allied Health Literature (CINAHL) database has a user friendly interface with has an option to narrow search to only peer- reviewed journals. It offers many options to narrow one’s search and also offers suggested terms to use in the search.
To begin my search, I identified keywords that best describes the information that I need. I started with the terms used in my question, which are falls, progressive resistance exercise, balance training exercise, elderly, and balance. Effectiveness and improving were not included since it is already expected that only studies that addresses improvement will be considered. Next, I rank the following terms from the most significant to the least significant making. Hence, balance came first, followed by progressive resistance exercise, balance exercise, falls and elderly respectively. The terms aged and older were considered as they also pertain to elderly.
To further narrow my search, only peer reviewed articles from 2011- 2016 were included. Most of the studies that came up were systematic reviews. While systematic review appraised numerous studies and does not give detailed information to a specific treatment, I further narrowed my search to only include randomized control trials.
The following peer reviewed articles that best answered my clinical question are the following:
Granacher, U., Muehlbauer, T., Zahner, L., Gollhofer, A., and Kressig, R. (2011). Comparison of traditional and recent approaches in the promotion of balance and strength in older adults. Sports Medicine, 41(5), 377-400. http://dx.doi.org.ezproxy.utica.edu/10.2165/11539920-000000000-00000
Ishigaki, E., Ramos, L., Carvalho, E. and Lunardi, A. (2014). Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review. Brazilian Journal of Physical Therapy 18(2), pp. 111-118 doi: 10.1590/S1413-35552012005000148
Joshua, A., D'Souza, V., Unnikrishnan, B., Mithra, P., Kamath, A., Acharya, V. and Venugopal, A. (2014). Effectiveness of progressive resistance strength training versus traditional balance exercise in improving balance among the elderly - a randomised controlled trial. Journal of Clinical and Diagnostic Research 8(3), pp. 98–102. doi: 10.7860/JCDR/2014/8217.4119
Lee, I. and Park S. (2013). Balance improvement by strength training for the elderly. Journal of Physical Therapy Science, 25 (12), pp 1591-1593. doi: 10.1589/jpts.25.1591
Sung, M.S., Kyung, W.K., Na Kyung, L., Seok, H. N., Jung W.K., and Kyoung, K. (2013). Influence of isokinetic strength training of unilateral ankle on ipsilateral one-legged standing balance of adults. Physical Therapy Science (10), pp. 1313- 1315. doi: 10.1589/jpts.25.1313
All these articles are experimental studies on interventions for improving balance.
A brief description of each study is described in Table 2.
Table 2. Research design of intervention studies in improving balance.
Article Research Design
Effects of a Fall Prevention Exercise Program on Muscle Strength and Balance of the Old-old Elderly Randomized Controlled trial (RCT)
Comparison of traditional and recent approaches in the promotion of balance and strength in older adults.
Systematic Review
Balance Improvement by Strength Training for the
Elderly Randomized Controlled trial (RCT)
Effectiveness of Progressive Resistance Strength Training Versus Traditional Balance Exercise in Improving Balance Among the Elderly - A Randomized Controlled Trial. Randomized Controlled trial (RCT)
Influence of Isokinetic Strength Training of Unilateral Ankle on Ipsilateral One-legged Standing Balance of Adults Randomized Controlled trial (RCT)
The study of Joshua et al. (2013) is the most relevant to answer my clinical question as it has the same characteristics of my patients and the interventions used were realistic to my …show more content…
practice. The chosen article is a single-blind study where the subjects were randomly assigned and concealment allocation was done. Furthermore, the baseline variables were analyzed to achieve a homogenous sample population. Outcome measure that were utilized were valid and reliable in measuring balance among older adults in the community (Conradsson, et al.,2007; Duncan,1990). Although, during the six-month period of the study, nine dropped out, the reasons for discontinuance was stated. To prevent bias due to the loss of data as an effect of attrition, the researchers used both intention to treat and on-protocol analyses to have strong confidence in the results. The researchers account on the factors that could bias the results made me believe that study was done with rigor, which is needed for evidence based practice.
However, a sample size of 54 subjects may affect the generalizability of the study. Portney & Watkins (2006) defined power as the ability to find significant difference when they exist, therefore a small sample may limit the precision of results a study may yield.
Overall, I am confident to use this study on my patients to improve balance and promote safe mobility in the community. PRT which specifically target the ankle musculature to improve forward limits of stability on balance will be emphasized in my future treatment plan.
The shift towards the use of research and scientific evidence has permeated through physical therapy practice to improve patient outcomes. Throughout this activity I have acknowledged the gap between scientific evidence and clinical practice. This activity taught me to strengthen my practice by following the five steps in evidence based practice process. For my future research, I will formulate a more focused, well-developed clinical question to improve efficiency in my data search. In addition, I would not limit myself on the authors’ conclusion, instead I will read through the results tables and figures to better develop my understanding of statistics.
Clinical research and appraisal is only one way to optimize patient care. To support our commitment to evidence based practice, understanding all the sources of evidence remains crucial to achieve the best possible outcome.
Coradsson, M., Lundin-Olsson,L., Lindelöf, N., Littbrand, H., Malmqvist, G.and Rosendahl E. 2007. Berg balance scale: Intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities. Journal of Amercan Physical Therapy Association. doi: 10.2522/ptj.20060343
Crist, M., McVay, D. & Marocco, S. (2015). Module 4, Week1 tutorial video 2-Evidence-Based Practice II, Utica College.
Duncan, W., Weiner, K., Chandler, J., Studenski, S. 1990. Functional reach: a new clincal measure of balance. Journal of Gerantology, 45 (6), 192-197. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/2229941
Granacher, U., Muehlbauer, T., Zahner, L., Gollhofer, A., and Kressig, R. (2011). Comparison of traditional and recent approaches in the promotion of balance and strength in older adults. Sports Medicine, 41(5), 377-400. http://dx.doi.org.ezproxy.utica.edu/10.2165/11539920-000000000-00000
Ishigaki, E., Ramos, L., Carvalho, E.
and Lunardi, A. (2014). Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review. Brazilian Journal of Physical Therapy,18(2),111-118 doi: 10.1590/S1413-35552012005000148
Joshua, A., D'Souza, V., Unnikrishnan, B., Mithra, P., Kamath, A., Acharya, V. and Venugopal, A. (2014). Effectiveness of progressive resistance strength training versus traditional balance exercise in improving balance among the elderly - a randomised controlled trial. Journal of Clinical and Diagnostic Research, 8(3), 98–102. doi: 10.7860/JCDR/2014/8217.4119
Lee, I. and Park S. (2013). Balance improvement by strength training for the elderly. Journal of Physical Therapy Science, 25 (12), 1591-1593. doi: 10.1589/jpts.25.1591
Portney, L., and Watkins, M. (2009). Foundation of clinical research application to practice (3rd ed.). Boston, MA: Pearson Education, Inc..
Sung, M.S., Kyung, W.K., Na Kyung, L., Seok, H. N., Jung W.K., and Kyoung, K. (2013). Influence of isokinetic strength training of unilateral ankle on ipsilateral one-legged standing balance of adults. Physical Therapy Science,10, 1313- 1315. doi: 10.1589/jpts.25.1313
Crist, M., McVay, D. & Marocco, S. (2015). Module 4, Week1 tutorial video 2-Evidence-Based Practice II, Utica
College.