Additional circuit classes can improve balance
outcomes for inpatient rehabilitation participants: a
randomised controlled trial
Treacy D1,2, Schurr K2 ,Lloyd B3, Sherrington C1
1
The George Institute for Global Health, University of Sydney, NSW
2 Bankstown-Lidcombe Hospital, NSW
3 Center for Education and Workforce Development
The University of Sydney
1
Background
 Poor balance and mobility leads to an increased risk of
falling
 Specific balance exercise has been shown to improve
balance and reduce falls within the community setting
 Systematic reviews
• - Howe et al 2007
• - Sherrington et al 2008
2
Sherrington et al 2008
Reduction in falls in studies
with this component
Reduction in falls in
studies without this
component
Variability
explained
(%)
Reduction
(%)
95% CI
Studies
n
Reductio
n (%)
95% CI
Studies
n
Exercise that aims to
provide a moderate or high
challenge to balance
22
14-30
43
0
0-14
17
15
Exercise that aims to
provide a high challenge to
balance
25
15-34
30
6
0-17
30
16
Total exercise dose more
than 50 hours
23
13-32
30
7
0-8
30
19
Inclusion of walking training
10
0-22
30
23
11-32
30
8
A high risk study population
10
0-20
39
27
14-37
21
15
CI = confidence interval
3
Standing balance circuit classes
 Seven different stations
• - All stations aim to challenge people’s balance with minimal
hand usage for support







Therapist encourage to increase difficulty
6 minutes each
Patients perform 6 of the 7 stations
2 therapists
Maximum of 8 participants
3 times a week for 1 hour
Participants count number of repetitions of exercise
performed
4
Standing balance circuit classes
stations
 Stepping forward
 Sideways Stepping
 Stepping grid
5
Standing balance circuit classes
stations
 Catching and
passing
 Reaching and
moving objects
6
Standing balance circuit classes
stations
 Weight shifting
 Heel raises
7
Standing balance circuit classes
8
Research Question
Does two weeks of standing balance circuit
classes, in addition to usual therapy, lead to
greater improvements in balance among
rehabilitation inpatients than usual therapy
alone
9
Eligibility Criteria






Admitted to the ward for rehabilitation
Able to stand for 30 seconds without physical assistance or
the help of an assistive device
Have no medical contraindications to exercise, such as
uncontrolled hypertension or unstable cardiac disease
Be able to fully weight bear as ordered by a medical officer
Suitable for a group exercise class with minimal supervision
as determined by the treating physiotherapist.
No multi-resistant organism infection or other infection that
would pose a significant risk to others in a group setting
10
Outcome measures
Primary Outcome
• Composite Balance measure → 5 tests: feet apart,
feet together, semi-tandem, tandem, and single leg
stance.
Secondary Outcomes
• Mobility
• Physical Functioning
• Falls
• Rehabilitation LOS
• Hospital readmissions
11
Recruitment and flow of
participants
Admitted to
rehabilitation
ward
(n = 384)
Eligible for
trial
(n = 202)
Reasons for exclusion:
•Not admitted for rehabilitation (n=51)
•Infection risk to others (n=52)
•Unable to participate with min supervision (n=33)
•Unable to stand for 30 sec (n=37)
12
Recruitment and flow of
participants
Admitted to
rehabilitation
ward
(n = 384)
Intervention
group
(n = 81)
Lost to follow
up at 2 weeks
(n = 1)
Lost to follow
up at 3 months
(n = 13)
Control
group
(n = 81)
Lost to follow
up at 2 weeks
(n = 0)
Lost to follow
up at 3 months
(n = 11)
Eligible for
trial
(n = 202)
13
Demographics
Intervention
Control
82.6 (7.3)
81.4 (7.8)
51 (62)
53 (65)
24.7 (3.1)
25.3 (3.2)
Cerebrovascular accident
12 (15)
9 (11)
Congestive cardiac failure
8 (10)
10(12)
Ischemic heart disease
7 (9)
9 (11)
Type two diabetes mellitus
18 (22)
24 (30)
COPD
12 (15)
11 (14)
Dementia
8 (10)
7(9)
Age (years), mean (SD)
Gender, n female (%)
MMSE (score/30), n (SD)
Co-morbidities, n (%)
14
Compliance
Number of classes completed
n (%)
Six
33 (41)
Five
26 (32)
Four
13 (16)
Three or less
9 (11)
Reason for not attending classes
n (%)
Discharged
47 (58)
Not on ward
6 (7)
Medically unwell
Refused
Public holiday
11(14)
6 (7)
11 (14)
15
Amount of practice
Repetitions per class
Repetitions per
intervention period
Average (median)
Range
427 (412)
149 - 748
2156 (2140)
433 - 4318
16
Amount of practice – cumulative
frequency
Ave repetitions per class
100%
80%
60%
40%
20%
0%
> 600
> 500
> 400
> 300
> 200
>100
17
Primary outcomes
18
Secondary outcomes - mobility
19
Secondary outcomes – self
reported physical functioning
20
Secondary outcomes – falls
Intervention
(n = 81)
Control
(n = 81)
Between-group
differences
Falls at two
weeks
7
11
0.64 (0.21 to 1.99)
p = 0.446
Falls at three
months
60
54
1.13 (0.65 to 1.96)
p = 0.662
21
Secondary outcomes – LOS and readmissions
Rehabilitation
length of stay
Hospital readmissons
Intervention
(n = 81)
Control
(n = 81)
Betweengroup
differences
95% CI
p
22.7
26.8
-4.1
-8.3 to 0.16
p = 0.059
30
44
0.70
0.42 to 1.18
p = 0.184
Conclusion
 Two weeks of additional balance exercises delivered
within a group environment in addition to usual therapy
resulted in improved balance at two weeks and these
improvement may be maintained at three months
 A high intensity challenging balance exercise program
can be provided safely in a group environment setting
 Elderly patients with a high number of co-morbidities
are able to perform a high number of repetitions of
exercise
23
Standing balance circuit classes
Delivered to:
 Bankstown-Lidcombe
• General rehabilitation ward
• Stroke Unit
• Acute aged care
 3 other rehabilitation hospitals
Futher work
 Economic analysis of standing balance circuit classes
24
Further Information
 Treacy D, Schurr K and Sherrington C. Balance circuit
classes to improve balance among rehabilitation
inpatients: a protocol for a randomised controlled trial
BMC Geriatrics 2013, 13:75
 Treacy D, Schurr K, Lloyd B and Sherrington C.
Additional standing balance circuit classes during
inpatient rehabilitation improved balance outcomes: an
assessor blinded randomised controlled trial. Age and
Ageing 2015, 44: 580-6
25