Performance-based clinical tests of balance and muscle strength used in young seniors: a systematic literature review

Background: Many balance and strength tests exist that have been designed for older seniors, often aged ≥70 years. To guide strategies for preventing functional decline, valid and reliable tests are needed to detect early signs of functional decline in young seniors. Currently, little is known about which tests are being used in young seniors and their methodological quality. This two-step review aims to 1) identify commonly used tests of balance and strength, and 2) evaluate their measurement properties in young seniors. Methods: First, a systematic literature search was conducted in MEDLINE to identify primary studies that employed performance-based tests of balance and muscle strength, and which aspects of balance and strength these tests assess in young seniors aged 60–70. Subsequently, for tests used in ≥3 studies, a second search was performed to identify method studies evaluating their measurement properties. The quality of included method studies was evaluated using the Consensus-based Standards for selection of health Measurement Instruments (COSMIN) checklist. Results: Of 3454 articles identified, 295 met the inclusion criteria. For the first objective, 69 balance and 51 muscle strength tests were identified, with variations in administration mode and outcome reporting. Twenty-six balance tests and 15 muscle strength tests were used in ≥3 studies, with proactive balance tests and functional muscle power tests used most often. For the second objective, the search revealed 1880 method studies, of which nine studies (using 5 balance tests and 1 strength test) were included for quality assessment. The Timed Up and Go test was evaluated the most (4 studies), while the Community Balance and Mobility (CBM) scale was the second most assessed test (3 studies). For strength, one study assessed the reliability of the Five times sit-to-stand. Conclusion: Commonly used balance and muscle strength tests in young seniors vary greatly with regards to administration mode and outcome reporting. Few studies have evaluated measurement properties of these tests when used in young seniors. There is a need for standardisation of existing tests to improve their informative value and comparability. For measuring balance, the CBM is a new and promising tool to detect even small balance deficits in balance in young seniors

Concurrent validity and reliability of the Community Balance and Mobility scale in young-older adults

Background: With the growing number of young-older adults (baby-boomers), there is an increasing demand for assessment tools specific for this population, which are able to detect subtle balance and mobility deficits. Various balance and mobility tests already exist, but suffer from ceiling effects in higher functioning older adults. A reliable and valid challenging balance and mobility test is critical to determine a young-older adult’s balance and mobility performance and to timely initiate preventive interventions. The aim was to evaluate the concurrent validity, inter- and intrarater reliability, internal consistency, and ceiling effects of a challenging balance and mobility scale, the Community Balance and Mobility Scale (CBM), in young-older adults aged 60 to 70 years. Methods: Fifty-one participants aged 66.4 ± 2.7 years (range, 60–70 years) were assessed with the CBM. The Fullerton Advanced Balance scale (FAB), 3-Meter Tandem Walk (3MTW), 8-level balance scale, Timed-Up-and-Go (TUG), and 7-m habitual gait speed were used to estimate concurrent validity, examined by Spearman correlation coefficient (ρ). Inter- and intrarater reliability were calculated as Intra-class-correlations (ICC), and internal consistency by Cronbach alpha and item-total correlations (ρ). Ceiling effects were determined by obtaining the percentage of participants reaching the highest possible score. Results: The CBM significantly correlated with the FAB (ρ = 0.75; p < .001), 3MTW errors (ρ = − 0.61; p < .001), 3MTW time (ρ = − 0.35; p = .05), the 8-level balance scale (ρ = 0.35; p < .05), the TUG (ρ = − 0.42; p < .01), and 7-m habitual gait speed (ρ = 0.46, p < .001). Inter- (ICC2,k = 0.97), intrarater reliability (ICC3,k = 1.00) were excellent, and internal consistency (α = 0.88; ρ = 0.28–0.81) was good to satisfactory. The CBM did not show ceiling effects in contrast to other scales. Conclusions: Concurrent validity of the CBM was good when compared to the FAB and moderate to good when compared to other measures of balance and mobility. Based on this study, the CBM can be recommended to measure balance and mobility performance in the specific population of young-older adults. Trial registration Trial number: ISRCTN37750605 . (Registered on 21/04/2016)

Protocol for the PreventIT feasibility randomised controlled trial of a lifestyle-integrated exercise intervention in young older adults

Introduction The European population is rapidly ageing. In order to handle substantial future challenges in the healthcare system, we need to shift focus from treatment towards health promotion. The PreventIT project has adapted the Lifestyle-integrated Exercise (LiFE) programme and developed an intervention for healthy young older adults at risk of accelerated functional decline. The intervention targets balance, muscle strength and physical activity, and is delivered either via a smartphone application (enhanced LiFE, eLiFE) or by use of paper manuals (adapted LiFE, aLiFE). Methods and analysis The PreventIT study is a multicentre, three-armed feasibility randomised controlled trial, comparing eLiFE and aLiFE against a control group that receives international guidelines of physical activity. It is performed in three European cities in Norway, Germany, and The Netherlands. The primary objective is to assess the feasibility and usability of the interventions, and to assess changes in daily life function as measured by the Late-Life Function and Disability Instrument scale and a physical behaviour complexity metric. Participants are assessed at baseline, after the 6 months intervention period and at 1 year after randomisation. Men and women between 61 and 70 years of age are randomly drawn from regional registries and respondents screened for risk of functional decline to recruit and randomise 180 participants (60 participants per study arm). Ethics and dissemination Ethical approval was received at all three trial sites. Baseline results are intended to be published by late 2018, with final study findings expected in early 2019. Subgroup and further in-depth analyses will subsequently be published. Trial registration number NCT03065088; Pre-results

Preventing functional decline in young seniors: Development and evaluation of interventions and smartphone-based tests

Decline in physical function in seniors leads to falls, decreased physical activity, dependence in activities of daily living, and reduced quality of life, constituting a major burden for the individual itself, and an economic burden for the health care system. In addition, the age composition of the worlds’ population is changing fast; life expectancy is increasing, and fertility rates are decreasing, which is prospected to put stress on health care services. This thesis is based on the recognition that there is a need to find effective methods to prevent functional decline in younger seniors. By preventing functional decline, seniors can achieve more active years without disability and dependence in everyday activities. Research has indicated that sensor technology might increase the utility of clinical tests in measuring physical function. Furthermore, studies have shown that exercise programmes where activities for muscle strength and balance have been integrated in daily habits and routines can be more effective in falls prevention compared to traditional exercise programmes. The thesis aims to provide new knowledge on how we can use instrumented performance-based tests to measure and monitor physical function, and how interventions can be designed to help to improve physical function and increase physical activity. The aim of this thesis, which includes one literature review, one feasibility study, one usability study and one method study, was fourfold: 1) to systematically review the literature on commonly used tests of balance and strength and to evaluate their measurement properties in young seniors; 2) to evaluate the feasibility of an intervention, the adapted Lifestyle-integrated Functional Exercise (aLiFE) programme, adapted to be more challenging and suitable for preventing functional decline in young seniors; 3) to describe the development and usability testing of three smartphone-based self-tests of physical function using an iterative design in a home-setting; 4) to evaluate whether an instrumented Timed Up and Go (iTUG)-test can predict the score on a advanced test of balance and mobility. Further, we wanted to evaluate whether the iTUG model was equally or more predictive compared to a model of traditional clinical measurements in geriatric outpatients and healthy community-dwelling seniors. The systematic review identified 3454 papers with a total number of 120 performance-based tests of physical function that had been used in healthy young seniors. Of these, 30 tests were most commonly used. The second step of the review identified 9 studies which had evaluated the measurement properties of 6 different tests: the Timed Up and Go (TUG), Short Physical Performance Battery (SPPB), 10-second Tandem stance, Five Times sit-to-stand, and the Community Balance and Mobility Scale (CBMS). Of the identified tests, the CBMS seemed like the one most suited for application in healthy young seniors as it has no ceiling or floor effects and was found valid and reliable in healthy young seniors in the included method studies. The feasibility study of the aLiFE programme showed that overall it was feasible and well accepted by the young seniors. The participants implemented most of the activities during the 4-week intervention period, and perceived the programme to be helpful, adaptable to their lifestyle, appropriately challenging, and safe. Although the study was not designed to evaluate effectiveness, moderate improvements in physical function measured by the CBMS were found. A larger study with longer follow-up is needed to establish effectiveness of the programme, as well as its ability to induce long-term adherence through behavioural change. In the usability study, a human-centered design was used when developing and testing the applications (apps) for three clinical tests of physical function, through 3 iterations. Results showed that young seniors made several errors while self-administering the clinical tests with a smartphone in an unsupervised setting, and that rate of errors was affected by changes made across the iterations. Although smartphone-based self-testing of physical function is promising, validation of outcome measures is needed before being offered to end-users. Finally, we found that in a supervised lab-setting, the instrumented Timed Up and Go could predict the score on the Community Balance and Mobility Scale with a high and similar accuracy as compared to standard clinical tests, in a mixed sample of geriatric patients and community-dwelling seniors. This thesis showed that there is a need for functional tests which are more sensitive, available, valid and reliable in young seniors. Important insight was provided about what usability problems may arise when developing smartphone-based functional self-tests, and how changes to the apps affect such problems. Furthermore, with a partial least squares regression analysis it was found that by instrumenting the TUG with a smartphone, a seemingly simple clinical test which otherwise is not sensitive for detecting functional decline in young seniors, could predict higher-level balance and mobility as measured with the CBMS. The findings indicate that smartphone apps can be feasible for home-based assessments and monitoring of physical functions, potentially motivating the end-user to become more physically active and prevent functional decline. Future work should aim to further develop and validate the self-tests and integrate these tests into a solution that combines testing with an exercise intervention tailored to the user based on the test results. A life-style integrated exercise-approach was evaluated in the thesis, and the results were promising, however more research is needed to verify its effectiveness

Assessment of muscle activity using elastic resistance in strength exercise

Strength exercise is associated with many positive health effects. However, many people do not have the opportunity to use conventional strength exercise equipment. Studies have shown that elastic resistance can induce similar levels of muscle activity as when exercising with isotonic resistance. The exercises previously investigated is however limited, and few studies have investigated whether muscle activation differ in the different phases of a contraction. In this study, face pulls, rowing, lateral pull-down, flies, reversed flies, and squat was performed by 29 subjects to assess the muscle activity level with elastic vs. isotonic resistance. Muscle activity was measured for three muscles in each exercise, using surface electromyography (EMG). The root-mean-square EMG signal was normalized to the maximal EMG (i.e., EMGmax) elicited during a maximal voluntary contraction. A linear encoder was also used so that any differences in muscle activity between the specific phases of a contraction could be assessed. The load used during the two modalities was matched using a 10 repetition maximum protocol. A significant main effect of exercise modality on muscle activity was found in 12 of the 18 combinations (three muscles in six exercises). Among these, eight combinations showed a significantly higher muscle activity using isotonic resistance, and four with elastic resistance. In the remaining six combinations, no significant differences were found. Significant interaction effects were found in 16 of the 18 combinations, i.e., muscle activity was affected by contraction phase. Overall, the absolute difference in muscle activity between elastic and isotonic resistance was small and not likely to have any physiological relevance. In conclusion elastic bands seem to be a feasible alternative to conventional strength exercise equipment for everyone interested in the benefits associated with strength exercise

Muscle Activity in Upper-Body Single-Joint Resistance Exercises with Elastic Resistance Bands vs. Free Weights

Elastic resistance bands require little space, are light and portable, but their efficacy has not yet been established for several resistance exercises. The main objective of this study was to compare the muscle activation levels induced by elastic resistance bands versus conventional resistance training equipment (dumbbells) in the upper-body resistance exercises flyes and reverse flyes. The level of muscle activation was measured with surface electromyography in 29 men and women in a cross-over design where resistance loadings with elastic resistance bands and dumbbells were matched using 10-repetition maximum loadings. Elastic resistance bands induced slightly lower muscle activity in the muscles most people aim to activate during flyes and reverse flies, namely pectoralis major and deltoideus posterior, respectively. However, elastic resistance bands increased the muscle activation level substantially in perceived ancillary muscles, that is deltoideus anterior in flyes, and deltoideus medius and trapezius descendens in reverse flyes, possibly due to elastic bands being a more unstable resistance modality. Overall, the results show that elastic resistance bands can be considered a feasible alternative to dumbbells in flyes and reverse flyes.publishedVersionThis article has been published in Journal of Human Kinetics, https://doi.org/10.1515/hukin-2017-0137. This version is free to view and download for private research and study only. Not for re-distribution, re-sale or use in derivative works. © copyright holde

App-based Self-administrable Clinical Tests of Physical Function: Development and Usability Study

Background: Objective measures of physical function in older adults are widely used to predict health outcomes such as disability, institutionalization, and mortality. App-based clinical tests allow users to assess their own physical function and have objective tracking of changes over time by use of their smartphones. Such tests can potentially guide interventions remotely and provide more detailed prognostic information about the participant’s physical performance for the users, therapists, and other health care personnel. We developed 3 smartphone apps with instrumented versions of the Timed Up and Go (Self-TUG), tandem stance (Self-Tandem), and Five Times Sit-to-Stand (Self-STS) tests. Objective: This study aimed to test the usability of 3 smartphone app–based self-tests of physical function using an iterative design. Methods: The apps were tested in 3 iterations: the first (n=189) and second (n=134) in a lab setting and the third (n=20) in a separate home-based study. Participants were healthy adults between 60 and 80 years of age. Assessors observed while participants self-administered the tests without any guidance. Errors were recorded, and usability problems were defined. Problems were addressed in each subsequent iteration. Perceived usability in the home-based setting was assessed by use of the System Usability Scale, the User Experience Questionnaire, and semi-structured interviews. Results: In the first iteration, 7 usability problems were identified; 42 (42/189, 22.0%) and 127 (127/189, 67.2%) participants were able to correctly perform the Self-TUG and Self-Tandem, respectively. In the second iteration, errors caused by the problems identified in the first iteration were drastically reduced, and 108 (108/134, 83.1%) and 106 (106/134, 79.1%) of the participants correctly performed the Self-TUG and Self-Tandem, respectively. The first version of the Self-STS was also tested in this iteration, and 40 (40/134, 30.1%) of the participants performed it correctly. For the third usability test, the 7 usability problems initially identified were further improved. Testing the apps in a home setting gave rise to some new usability problems, and for Self-TUG and Self-STS, the rates of correctly performed trials were slightly reduced from the second version, while for Self-Tandem, the rate increased. The mean System Usability Scale score was 77.63 points (SD 16.1 points), and 80-95% of the participants reported the highest or second highest positive rating on all items in the User Experience Questionnaire. Conclusions: The study results suggest that the apps have the potential to be used to self-test physical function in seniors in a nonsupervised home-based setting. The participants reported a high degree of ease of use. Evaluating the usability in a home setting allowed us to identify new usability problems that could affect the validity of the tests. These usability problems are not easily found in the lab setting, indicating that, if possible, app usability should be evaluated in both settings. Before being made available to end users, the apps require further improvements and validation