Study Design: A Quasi Experimental Single Group Pre-Test Post-Test. Objectives: The aim of this study was to determine the effects of sensory stimulation and motor control cueing of the foot on balance in females over the age of 65. Background: Balance deficits in the elderly population have shown to have detrimental consequences. Evidence suggests that sensory stimulation and motor control of the foot improve postural sway, however, studies have yet to compare the effects of both interventions on balance. Method and Measures: A total of 40 participants were contacted to complete the study with 32 participants meeting inclusion criteria for data collection and completing the research study. Two data collection days were utilized to perform pre and post-test outcome measures using the Functional Reach Test and Overall Sway Index (collected using the Biodex Medical System Inc., Biodex Biosway Portable Balance System). The interventions were 2-minute sensory stimulation to the sole of each foot on day one, and the “short foot” motor control cue on day two. Four related sample T-tests were conducted with the interventions as the dependent variable and the time of observation (pre and post) as the independent variable. Results: The results revealed sensory stimulation significantly improved balance as indicated by a decline in postural sway from pretest (5.92 ± 3.05) to posttest (5.00 ± 2.92) (p = 0.045) and a significant increase in Functional Reach from pretest (8.01 ± 2.55) to posttest (8.70 ± 2.66) (p < 0.001). Motor control cueing demonstrated mixed results on balance with an increase in postural sway from pretest (5.52 ± 3.50) to posttest (6.66 ± 4.06) (p = 0.015), and an increase in Functional Reach from pretest (8.47 ± 2.34) to posttest (9.01 ± 2.37) (p = 0.004). Conclusion: Based on the results, researchers concluded that sensory stimulation is a viable intervention to utilize in order to improve balance in the elderly population. Further research to identify the appropriate prescription of sensory stimulation to maximize effects should be completed.
The focus of our research is to determine which intervention has a greater measurable improvement on balance of the elderly female population, sensory stimulation or motor control cueing of the foot. Delving deeper into this research topic we can help to determine if neurological losses due to the natural aging process can be restored with physical therapy intervention and therefore help elderly patients regain age-related balance losses.
Balance is one of the most common concerns for the elderly population as age-related balance losses put this population at a significantly higher risk of falling [
The use of afferent stimulation for the effect it has on proprioception and balance has been researched in the elderly population. With losses to the somatosensory system, there is an increased risk of falling or losing one’s balance [
As supported by Priplata et al. [
Rothermel et al. [
Jung et al. [
The purpose of our research is to determine whether sensory stimulation or motor control cueing of the foot improves balance in the elderly female population. This is an important area of research because as stated decreased balance of the elderly is the leading cause of falls and therefore injury. Physical therapist must play an active role as health care providers in improving patient balance and therefore minimizing patient risk of falling.
We hypothesize that sensory stimulation will be more effective than motor control cueing in increasing balance in elderly female patients. As well as a null hypothesis of, neither sensory stimulation nor motor control cueing will have a positive effect on balance in the female elderly population.
The study is a Quasi-Experimental Single Group Pretest-Posttest design approved by Dominican College Institutional Review Board (IRB approval # 2018-0325-01). Participants received both interventions on two separate data collection days. The sensory stimulation intervention was performed on the first data collection day. The motor control cue was given as the second intervention on the second data collection day.
Subjects were recruited from three assisted living facilities. The sample size consisted of 40 participants between the ages of 67 to 97 years old (mean 82; SD 6.25). In order to be included in the study, subjects needed to be female and over the age of 65 years old. The exclusion criteria were as follows: resting HR < 50 bpm, resting HR > 100 bpm, oxygen saturation < 90%, BP < 90/60mmHg, BP > 140/90mmHg, recent surgery or fracture, severe neuropathy, weight-bearing restrictions, and a Mini-Mental State Exam score (MMSE) of ≤20 [
Research materials required for this study included a blood pressure cuff, stethoscope, pulse oximeter, a yardstick for the Functional Reach Test, the Biodex BioSway Portable Balance System, a reflex hammer to provide sensory stimulation, printed versions of the MMSE. A stopwatch was required to limit patient practice time and sensory stimulation time respectively.
On the first day of data collection, Researcher One screened participants for exclusion criteria by providing participants with a demographics sheet. Researcher One then distributed the MMSE to each participant and took vitals for each participant including; heart rate, blood pressure and peripheral oxygen capillary saturation rate. Vitals were taken on day 1 and day 2 prior to pre and post testing. Researcher One also provided participant identifications including the participants initials followed by a number in order to maintain confidentiality. This identification was used to save results on the Biodex Biosway Portable Balance System and log participant paperwork. Researcher Two collected baseline balance information on the Biodex Biosway Portable Balance system (Biodex Medical System, Inc., Shirley, New York) first and then Researcher One collected the Functional Reach baseline measurement. The Sensory stimulation intervention was performed, and outcome measures were collected immediate after intervention.
The second data collection day was scheduled for a week following the first data collection day. Same tests and assessments were done on the second data collection day prior motor cue intervention. Researcher Three provided each participant with a motor control cue and practiced with motor cue exercise for 3 minutes. Post-test assessments were collected after motor cue intervention.
Neither participants nor researchers were blinded to the interventions. Guarding of participants while assessments of balance were being performed was crucial to ensure patient safety and was stressed throughout the duration of participant testing.
Cognitive assessment: The Mini-Mental State Examination (MMSE) was be used to determine the participant’s mental status and exclude any participants with cognitive impairments. This examination is a commonly administered screening tool for dementia and any cognitive impairment. Research shows that the MMSE is effective as an exclusion tool [
Functional reach test: The Functional Reach Test measures the distance a person can reach forward while maintaining a fixed base of support. When performing this test, the subject was asked to have their feet shoulder width apart in a comfortable position. The subject was then instructed to raise their arms parallel to the floor, make a fist, and reach forward as far as possible keeping both feet planted on the floor. With the third metacarpal head as a reference point, the distance in inches, was then measured from start point to end point. The test was being repeated 3 times and the average was taken. The test-retest and inter-rater reliability for the FRT has been shown to be excellent for adults between the ages of 20 to 87 years old [
Balance assessment: The Biodex Biosway Portable Balance System is a valid and reliable tool used for balance assessment and balance training (Biodex Medical System Inc., Shirley, New York) [
Interventions:
Sensory stimulation intervention: The first intervention given to the participants on data collection day one was sensory stimulation to the sole of the foot. Researchers Priplata et al. [
Motor cueing: The second intervention performed on participants on day two was the “short foot” motor control cue. Participants were instructed to think of shortening the foot by bringing the toes closer to the heel of the foot and lifting the arch. Jung et al. [
The statistical analyses were completed using the IBM Statistical Package for the Social Sciences (SPSS) Version 25. The data was analyzed utilizing pre-test and post-test scores of balance obtained with the Biodex Biosway and the functional reach test. The pre-test post-test analysis was performed using the Repeated Measures Analysis of Variance (ANOVA). The confidence interval (CI) was set at 95% and the alpha level for significance was p < 0.05.
Initially 40 participants were contacted to participate in this study. The data of thirty-two participants was used to complete this study. Four participants were excluded due to sensory deficits (peripheral neuropathy), three participants due to excessively high blood pressure, and one participant due to a foot injury prior to the study. Participants’ demographics collected on the first day of data collection. Average age was 82.0 (SD = 6.25) years, MMSE score was 28.7 (SD = 12.6), and daily walking time was 24 (SD = 8.4) minutes. The 75% of the participants were not using assistive device. The participants’ demographic can be found on
With sensory stimulation intervention, balance (postural sway) as the dependent variable, there was a significant difference between pretest and post-test balance scores, t(31) = 2.089, p = 0.045, d = 0.37 [95% CI 0.22 - 1.83]. The results (M ± SD) showed that postural sway declined from pretest 5.92 ± 3.05 to posttest (5.00 ± 2.92). With motor control intervention, balance (postural sway) as the dependent variable, there was a significant difference between pretest and post-test scores, t(31) = −2.578, p = 0.015, d = −0.46 [95% CI −2.04 - −0.24]. The results (M ± SD) showed that postural sway increased from pretest (5.52 ± 3.50) to posttest (6.66 ± 4.06) (
With sensory stimulation intervention, functional reach test as the dependent variable, there was a significant difference between pretest and post-test measurements, t(31) = −3.942, p < 0.001, d = −0.70 [95% CI −1.05 - −0.33]. The results (M ± SD) showed that functional reach test distance increased from pretest (8.01 ± 2.55) to posttest (8.70 ± 2.66). With motor control intervention, functional reach test as the dependent variable, there was a significant difference between pretest and post-test measurements, t(31) = −3.135, p = 0.004, d = −0.55 [95% CI −0.89 - −0.19]. The results (M ± SD) showed that functional reach test distance increased from pretest (8.47 ± 2.34) to posttest (9.01 ± 2.37) (
Mean | SD | Min | Max | n (%) | |
---|---|---|---|---|---|
Age (year) | 82.0 | 6.25 | 67 | 96 | |
Weight (pound) | 154.9 | 27.59 | 107 | 220 | |
Height (inches) | 62.7 | 2.55 | 57 | 71 | |
Mini Mental State Examination Score | 28.7 | 1.26 | 26 | 30 | |
Sedentary Time (minute) | 125 | 85.88 | |||
Walking Time (minute) | 24 | 8.40 | |||
Assistive Device (AD) Usage No AD 1 AD 2 AD | 24 (75) 4 (12.5) 4 (12.5) |
This study aimed to investigate the immediate effect of sensory stimulation and motor control cueing on standing balance in older females. After providing both sensory stimulation and motor control cueing interventions to the 32 participants, the results showed that sensory stimulation was more effective than motor control cueing in improving balance as demonstrated by improved balance measures for both outcome measures.
Several studies have looked at age related changes affecting touch sensation and its impact on postural stability in the elderly [
Mulligan and Cook [
Findings of this research are important for health care providers because of the prevalence of the geriatric population requiring physical therapy services. Age-related balance losses are a common complaint in those over 65 years old, putting this population at a significantly higher risk of falling. Thus, the importance in maintaining adequate balance is needed to decrease risk of falls and associated consequences. This study is providing therapists with the knowledge of another potential intervention to address balance deficits. Physical Therapist can utilize sensory stimulation for patients with decreased postural control resulting in poor balance. By improving balance and postural control in the elderly female population a decrease in fall risk and the secondary impairments associated with falls can be prevented.
Having found a statistically significant result in the sensory stimulation group for balance is an added strength to our research study. In addition, there was one week between interventions and data collection days to prevent a maturation threat or interaction between treatment session threat. Further research needs to be performed with a larger randomized population with different utilization of instruments to determine the generalizability of these findings, as well as the long-term effectiveness of sensory stimulation on improving balance.
Based upon the results, a conclusion can be made that sensory stimulation to the sole of the foot is more effective than motor control cueing of the “short foot”, in improving both static and dynamic balance in the elderly female population. Sensory stimulation has shown to be a feasible, simple, and a cost-efficient intervention to address balance in this specific population. In the clinic, physical therapists can utilize sensory stimulation for patients with decreased postural control resulting in poor balance. By improving balance and postural control in the elderly female population a decrease in fall risk and the secondary impairments associated with falls can be prevented.
Institutional Review Board Approval (# 2018-0325-01).
The authors declare no conflicts of interest regarding the publication of this paper.
Wilmot, S., Alfonso, A., Velez, J. and Edeer, A.O. (2019) The Effect of Sensory Stimulation versus Motor Control Cueing of the Foot on Balance in Elderly Females: Single Group Pretest-Posttest Study. Advances in Aging Research, 8, 119-128. https://doi.org/10.4236/aar.2019.86009