Effects of action observation therapy with Otago exercises on balance and quality of life in older adults (2024)

Authors

• Shah Ahmed Mehram Shah Rehabilitation Centre, Rawalpindi. Pakistan https://orcid.org/0009-0001-1957-7737
• Farah Manzoor International Institute of Science Arts and Technology Gujranwala Pakistan. https://orcid.org/0009-0002-1365-6220
• Hafsa Naseem International Institute of Science, Arts and Technology Gujrawala Pakistan https://orcid.org/0009-0000-5389-9169
• Amna Qandil Ansari Mehram Shah Rehabilitation Centre, Rawalpindi. Pakistan https://orcid.org/0009-0005-8164-1727

DOI:

Abstract

Background: Balance problems and falls are prevalent issues, especially among older adults. Otago exercise is one ofthe interventions applied to the geriatric population to prevent falls and balance problems, The Action observation therapy with the Otago exercise program can be a more beneficial intervention method to decrease the prevalence of falls and balance issues among older people.

Objective: to evaluate the effectiveness of Otago exercise in combination with action observation training (AOT) on balance and quality of life among the elderly.

Methods: A randomized clinical trial was conducted on n=54 elderly between 60-80 years and moderate risk of fall Berge balance scale from May 2022 to July 2023. The participants were included in the study after fulfilling the selection criteria. Then the participants were randomly assigned into two AOT plus Otago (n= 27) groups and Otago exercise alone group (n= 27). The static and dynamic balance were assessed with the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Functional Reach Test (FRT) respectively. Additionally, quality of life was measured with the SF-36 questionnaire among older adults. The data was collected at baseline, 6^th week, and 12^th week.

Results: Significant improvements (p<0.05) were observed in balance and quality of life as measured by the Berg Balance Scale and SF-36 respectively in both intervention groups but did not reveal any significant difference (p≥0.05) between the groups.

Conclusion: the current study showed no additional effects of action Observation training (AOT) with Otago exercises among the elderly. However, the addition of AOT may improve the balance, physical functioning, and ultimately quality of life among the elderly, if incorporated into routine rehabilitation of this population.

Clinical trial #: NCT06008665

INTRODUCTION

Automatic human activities like standing and walking require active control of balance, which prevents the risk of falls. However, aging has a serious detrimental effect on balance ultimately leading to an increased risk of falls. The history of falls among those over 65 years is at least once per year or even more[1]. Balance declining with age is a complex sensory-motor process that requires the coordinated work of the visual, vestibular, and musculoskeletal system to maintain postural stability and decrease the risk of falls. Poor balance leads to musculoskeletal injury, fractures, poor quality of life, and disability[2]. Interventions include balance and postural control that can help older people to avoid falling, through tai chi methods, gait training, strengthening exercises, and balance training programs[3, 4].

The Otago Exercise Program was developed by the New Zealand's Otago University. It can be done at home it consists of strengthening and balance exercises, gait exercises, and aerobic activities. These all exercises are individualized depending on individual tolerance and are easily added to the home exercise plan[5]. Jahanpeyma P reported that significantly reduced fall frequency among 65-year-old participants[6]. A meta-analysis reported that Otago exercises decreased the mortality rate and risk of falls among community-dwelling older adults[7].

Action Observation Therapy (AOT) is a novel approach used to improve brain motor learning through performance observation[8, 9]. The literature suggests that AOT improves functional ability by motivating and providing appropriate pathways to recovery may include the mirror neuron system, and is beneficial for different neurological along with conventional rehabilitation strategies [10]. Watching recordings of everyday activities and hand movements significantly improved upper extremity function in chronic stroke patients [11].

To improve treatment outcomes beyond what either approach could do alone, the study integrates Action Observation Therapy (AOT) with Otago exercises. Although Otago exercises are useful and easily accessed, AOT offers a distinctive way to acquire motor skills through action observation, which may increase motor relearning and cognitive engagement. For those with specific neurological problems, this dual approach may be extremely helpful, improving functional abilities or facilitating a better recovery. As part of the efforts to validate and innovate present procedures, the study intends to ascertain whether the extra complexity and monitoring of AOT can considerably improve rehabilitation.

METHODS

Study Design & Setting: a single-blinded, randomized clinical trial (NCT06008665) was conducted for 1 year from May 2022-June 2023 at the Baghbaan Old Age Home (Baghbaan-19102023) and Najjat Old Age Home (Ref/NT/5-6-2023), Rawalpindi Pakistan. The research and ethical committee (REC) of the Faculty of Rehabilitation and Allied Health Sciences (with Ref# Riphah/RCRS/REC/01345) at Riphah International University approved the study.

Participants:The Participants between the ages of 60 to 80 years both genders participated in this study, having Berg balance score of falls between 20 to 40 (moderate risk of fall) were included through non-probability purposive sampling technique. Participants who experienced fall more than one time in the last 6 months were included in this study. Participants having abnormalities in the vestibular, hearing, or visual systems, any limb defects, history of recent fractures, and Participants with Cardiovascular, Cerebrovascular disease or traumatic brain injury and Epilepsy were excluded from the study.

Sample Size:The G Power was used for sample size calculation while keeping the effect size small (0.24), α error=0.05. To avoid β error the power (1- β) was set at 0.95%. A total of n=54 sample size was determined. A total of n=75 participants were assessed for eligibility and n=65 fulfilled the inclusion criteria, 11 elderly declined to participate. Then n=54 participants were randomly allocated to group A (n=27), which Otago Exercise, and group B (n=27) which received Otago with action observation. A total of n=54 participants were analysed at the end of the study. (Figure 1)

Figure 1: CONSORT flow diagram

Randomization: The enveloped sealed method combined with computerized random number generator software was used for randomization. The allocation at random was done by a person who had no direct involvement in the research. Before the trial began, the numbers that were chosen at random were then inscribed on the list of cards and put within a substantial, opaque sealed envelope. The respective intervention has been provided by the Physical therapist, after written informed consent from the participants. The study was single-blinded in which assessing physical therapist was blinded.

Intervention: Action observation and Otago were performed by the participants. Both groups received intervention for 12 weeks. The assessment was done at the baseline, after 6 weeks and 12 weeks. Otago Exercise Program(Group A) includes specific exercises for strength and balance improvement. (Table 1) These exercises were conducted three times a week with the guidance of a therapist. Each training session lasted for 35-40 minutes, preceded by a 5-minute warm-up and followed by a 5-minute cool-down. Exercises were demonstrated to each participant and were given individualized load and progression. Each exercise has been started with 10 repetitions initially.In Group B Otago exercise program was performed with action observation training (AOT). Participants were instructed to watch a video on a 22-inch screen positioned 1 meter away from them, while comfortably seated in a chair with armrests. They were not allowed to follow along or engage in any movement while watching the video. The video featured a model who was 70 years old or older, like the participants. The duration of the video viewing was 17 minutes (1 minute for each video), followed by a 35-minute (2 minutes maximum per session) Session physical training session conducted by a therapist, based on the content of the video. To ensure the effectiveness of the action observation training, the video viewing took place at a designated time in a quiet environment, supervised by the same investigator throughout the entire study. The activities done during the physical education workshops and pieces of training were featured in the videos played during the actual observation training sessions. (Table 1)

Table 1: Detail Intervention Protocol

Assessment: After approval from the research ethics committee, participants were selected based on inclusion criteria. The subjects were provided informed consent before participation. TheBalancewas Assessed through tools like the Berg Balance scale (BBS), Time up and go test (TUG test), and functional reach test (FRT).For Quality of Life, the SF36 questionnaire was filled out by participants before and after the intervention.The BBSis used to objectively determine a patient's ability to safely balance during a series of predetermined tasks.The BBS scoring is as follows: 0-20 (high risk of fall), 21-40 (moderate risk of fall), 41-56 (low risk of fall). In the TUG test,An older adult who takes ≥12 seconds to complete the TUG is at risk for falling.Functional Reach Test (FRT) is a clinical outcome measure and assessment tool for ascertaining dynamic balance in one simple task. Participants whosescoreswere6inchesor less indicate a significantly increased risk for falls. A score between 6-10 inches indicates a moderate risk for falls.

Data Analysis Procedure:Data analyzed by SPSS version 21. The mixed ANOVA was applied to see the interaction effect between intervention and assessment level of BBS. The interaction effects were significant so for the main effects Repeated measure ANOVA with pairwise comparison was applied and for between the group comparison Way ANOVA was applied along with their effect sizes. Univariate ANCOVA was applied to determine the individual domains of Quality of Life. A significance level of p<0.05 was considered statistically significant.

RESULTS

The mean age of individuals in the Otago group is 70.15±2.22 years and the Action Observation with the Otago group is 68.61±2.28 years. A total of n=36 was male and the remaining n=18 was female in the study. (Figure 2)

Figure2: Gender frequency

Mixed ANOVA result showed that there is significant interaction effect {F_(1.10,57.56)=4.21, p=0.041, η_p²=0.07} observed between Interventions and balance's assessment level.(Figure 3)

Figures: 3 Interaction effect between intervention and level of assessment (BBS)

For in-group changes, RM ANOVA was applied and shows within-group changes in the BBS scores for the two groups: Group B, who underwent additional training(AOT) in addition to theOtago exercise, and Group A, which adhered to the Otago exercise program. At baseline, 6^th week, and 12^th week, assessments were given to both groups. The result showed significant improvement in BBS score from the baseline to the end of intervention with moderate effect size in Group A (p<0.001,ɳp²=0.296), while in Group B (p<0.001,ɳp²=0.647)large effect size respectively. Pair-wise comparison showed that in both groups, The BBS scores significantly increased (p<0.05) with time, from baseline to the end of the 6^th week and then 7^th week to the 12^th Week. (Table 2)

Table 2: With-in group (Main effects) changes in both groups (Berg Balance Scale Score)

The result of One-way ANOVA on each level of assessment no significant difference (p≥0.05) was observed between groups. (Table 3)

Table 3: Between Group Comparison (Balance)

The within-group changes of quality of life among participants showed that in group A, no significant changes p≥0.05) were observed in physical functioning, role limitation due to physical and mental, pain, and energy/vitality, except social functions, mental health and over general health was significantly improved (p<0.05) after 12-week intervention. Group B where AOT performed in addition to Otago exercises showed improvement in all domains of quality of life (SF-36), except pain (p=0.059). (table 4)

Table 4: With-in Group changes in quality of life (SF-36)

There is no statistically significant difference between the Otago and action observation with the Otago group on the Quality of life in all domains while controlling the baseline. Wilks' Λ= 0.835 p≧0.05. partial η2 = 0.153. Univariate ANCOVA was applied to determine the individual domains of quality of life and the value shows there is no significant (p≧0.05) differences in all domains of quality of life. (Table 5)

Table 5: Between Group Comparison of SF-36

DISCUSSION

The purpose of the current study was to assess the additional effects of Action observation training with the Otago group, on balance, and quality of life in a population of individuals with impaired balance. The result reveals that the effect of intervention on balance differs across the levels of balance assessment. Both individual groups showed improvement in quality of life, but the AOT plus Otago group showed improvement in all domains as compared to Otago alone. While comparing for the main effect. there is no difference relating to the intervention on quality of life among the participants at the end of the study.

Research has demonstrated that the Otago exercise program enhances various aspects of older persons' lives, including health-related quality of life, functional mobility, balance, physical performance, functional capacity, muscle strength in the lower limbs, and thelikelihood of falling[12, 13] These results align with the current study's findings, which indicated that Group A had a modest impact size and considerable improvement. There is a noticeable decrease in falls with the Otago Exercise Program[6, 7, 14, 15]. This is probably the result of these important areas' combined effects of improved physical function[14]. Furthermore, as individuals experience increased strength and stability, they might also feel more self-assured in their movements, which could result in higher activity levels and additional health benefits. Improved strength and balance also increasefunctional mobility and physical performance[6, 14], so the advantages go beyond just preventing falls. In turn, this leads to an improvement in life quality as daily tasks become easier. A person's ability to function as they age can also be preserved by maintaining their muscle strength and flexibility[12].

The highly significant effect size of Group B implies that AOT and Otago exercises could work in combination. This may be because the effects of Otago exercises alone are enhanced by additional cognitive and motor stimulation that AOT offers.This enhancement's possible mechanism ismirroring neurons, which fire when a person performs an action and when they observe someone else perform the same action. The motor circuits in the brain may be stimulated by this observation, which could enhance learning and motor function[16, 17]. After a 12-week intervention, Group B improved in every category except pain, which is interesting to note in terms of quality-of-life improvements. In contrast, Group A demonstrated considerable gains in some categories. This is consistent with research indicating that moderate gains in physical and mental health composites can result from exercise programs[18, 19]. A four-month video-supported Otago exercise program significantly enhancedlower extremity strength, functional balance, and mobility. Improvements in walking speed, stride length, and sitting time have been verified in older individuals with AOT, includingstanding, sitting, and walking training[20].

Both interventions appear to be effective, however, their effects on quality of life may be similar when baseline levels are taken into consideration, as seen by the lack of significant differences between the groups in quality-of-lifeareas when correcting for baseline. Environmental, social, psychological, and physical factors all have an impact on quality of life (QoL), which is a multifaceted concept[12, 15, 21]. Because of their complexity, short study duration, and inherent aging processes, interventions like Otago exercises and AOT may improve physical function but not always other QoL aspects

Limitation of the study: the absence of a screening test to assess cognitive impairment and drug usage along with the small sample size is another limitation, which may affect the results

CONCLUSION

The current study showed no additional effects of action Observation training (AOT) with Otago exercises among the elderly. However, the addition of AOT may improve the balance, physical functioning, and ultimately quality of life among the elderly if incorporated into routine rehabilitation of this population. Future research is recommended, while considering the confounders among the Pakistani population, to ensure external validity.

DECLARATIONS & STATEMENTS

Author’s Contribution

The following format should be used for the author’s contribution.

SA and AQA: substantial contributions to the conception and design of the study.

SA, AQA: acquisition of data for the study.

SA: analysis of the data for the study.

SA and AQA: interpretation of data for the study.

SA, FM and HN: drafted the work.

SA, FM, HN and AQA: revised it critically for important intellectual content.

SA, FM, HN and AQA: final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.

Ethical Statement

The study was conducted at the Baghbaan Old Age Homes (Baghbaan-19102023) and Najjat Old Age Home (Ref/NT/5-6-2023), Rawalpindi Pakistan. The research and ethical committee (REC) of the Faculty of Rehabilitation and Allied Health Sciences (with Ref# Riphah/RCRS/REC/01345) at Riphah International University approved the study.

ConsentStatement

Informedconsent was obtained from all subjects involved in the study.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgments

The authors expressed their gratitude to the old home's management for facilitating the research work and thanked them for their wonderful collaboration.

Conflicts of Interest

The authors declare no conflict of interest.

Funding

The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

REFERENCES

1. Xing L, Bao Y, Wang B, Shi M, Wei Y, Huang X, et al. Falls caused by balance disorders in the elderly with multiple systems involved: Pathogenic mechanisms and treatment strategies. Front Neurol. 2023;14:1128092.[CrossRef] [PubMed]
2. Jeon W, Ramadan A, Whitall J, Alissa N, Westlake K. Age-related differences in lower limb muscle activation patterns and balance control strategies while walking over a compliant surface Age-related differences in lower limb muscle activation patterns and balance control strategies while walking over a compliant surface. Scientific Reports. 2023;13(1):16555.[CrossRef]
3. Mao M, Mercer VS, Li F, Gross MT, Blackburn T, Yu B. The effect of Tai Chi lower extremity exercise on the balance control of older adults in assistant living communities. BMC Complement Med Ther. 2024;24(1):112.[CrossRef] [PubMed]
4. Penn IW, Sung W-H, Lin C-H, Chuang E, Chuang T-Y, Lin P-H. Effects of individualized Tai-Chi on balance and lower-limb strength in older adults. BMC Geriatrics. 2019;19(1):235.[CrossRef] [PubMed]
5. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Falls prevention over 2 years: a randomized controlled trial in women 80 years and older. Age Ageing. 1999;28(6):513-8.[CrossRef] [PubMed]
6. Jahanpeyma P, Kayhan Koçak F, Yıldırım Y, Şahin S, Şenuzun Aykar F. Effects of the Otago exercise program on falls, balance, and physical performance in older nursing home residents with high fall risk: a randomized controlled trial. Eur Geriatr Med. 2021;12(1):107-15.[CrossRef] [PubMed]
7. Chiu HL, Yeh TT, Lo YT, Liang PJ, Lee SC. The effects of the Otago Exercise Programme on actual and perceived balance in older adults: A meta-analysis. PLoS One. 2021;16(8):e0255780.[CrossRef] [PubMed]
8. Sarasso E, Gemma M, Agosta F, Filippi M, Gatti R. Action observation training to improve motor function recovery: a systematic review. Arch Physiother. 2015;5:14.[CrossRef] [PubMed]
9. Karamat S, Saeed A, Khan FM, Tariq AJTRJ. Effect of mirror therapy versus repetitive facilitation exercise on upper limb function in post stroke patient. T Rehabili J. 2022;6(02):351-6.[CrossRef]
10. Zhang B, Kan L, Dong A, Zhang J, Bai Z, Xie Y, et al. The effects of action observation training on improving upper limb motor functions in people with stroke: A systematic review and meta-analysis. PLoS One. 2019;14(8):e0221166.[CrossRef] [PubMed]
11. Stenum J, Hsu MM, Pantelyat AY, Roemmich RT. Clinical gait analysis using video-based pose estimation: Multiple perspectives, clinical populations, and measuring change. PLOS Digit Health. 2024;3(3):e0000467.[CrossRef] [PubMed]
12. Mgbeojedo UG, Akosile CO, Okoye EC, Ani KU, Ekechukwu EN, Okezue OC, et al. Effects of Otago exercise program on physical and psychosocial functions among community-dwelling and institutionalized older adults: a scoping review. 2023;60:1-16[CrossRef] [PubMed]
13. Yang Y, Wang K, Liu H, Qu J, Wang Y, Chen P, et al. The impact of Otago exercise programme on the prevention of falls in older adult: A systematic review. Front Public Health. 2022;10:953593.[CrossRef] [PubMed]
14. Wu S, Guo Y, Cao Z, Nan J, Zhang Q, Hu M, et al. Effects of Otago exercise program on physical function in older adults: A systematic review and meta-analysis of randomized controlled trials. Arch Gerontol Geriatr. 2024;124:105470.[CrossRef] [PubMed]
15. Yi M, Zhang W, Zhang X, Zhou J, Wang Z. The effectiveness of Otago exercise program in older adults with frailty or pre-frailty: A systematic review and meta-analysis. Arch Gerontol Geriatr. 2023;114:105083.[CrossRef] [PubMed]
16. Leem SH, Kim JH, Lee BH. Effects of Otago exercise combined with action observation training on balance and gait in the old people. J Exerc Rehabil. 2019;15(6):848-54.[CrossRef] [PubMed]
17. Mancuso M, Tondo SD, Costantini E, Damora A, Sale P, Abbruzzese L. Action observation therapy for upper limb recovery in patients with stroke: a randomized controlled pilot study. Brain Sci. 2021;11(3).[CrossRef] [PubMed]
18. Ali A, Tabassum D, Baig SS, Moyle B, Redgrave J, Nichols S, et al. Effect of exercise interventions on health-related quality of life after stroke and transient ischemic attack: a systematic review and meta-analysis. Stroke. 2021;52(7):2445-55.[CrossRef] [PubMed]
19. Gillison FB, Skevington SM, Sato A, Standage M, Evangelidou S. The effects of exercise interventions on quality of life in clinical and healthy populations; a meta-analysis. Soc Sci Med. 2009;68(9):1700-10.[CrossRef] [PubMed]
20. Benavent-Caballer V, Rosado-Calatayud P, Segura-Ortí E, Amer-Cuenca JJ, Lisón JF. The effectiveness of a video-supported group-based Otago exercise programme on physical performance in community-dwelling older adults: a preliminary study. Physiotherapy. 2016;102(3):280-6.[CrossRef] [PubMed]
21. Kadir MI, Hardiyanty N, Adliah F. A pilot study of the effect of Otago exercise program on fall risk and quality of life of older women. 2021;2(1):1-4.[CrossRef]

Author Biographies