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Article

Are There Sex Differences in Balance Performance after a Short-Term Physical Intervention in Seniors 65+? A Randomized Controlled Trial

by
Milada Krejčí
1,*,
Jiří Kajzar
1,
Rudolf Psotta
1,
Miroslav Tichý
1,
Radmila Kancheva
2,
Václav Hošek
1 and
Martin Hill
2,*
1
College of Physical Education and Sport PALESTRA, 19700 Prague, Czech Republic
2
Institution of Endocrinology, 11694 Prague, Czech Republic
*
Authors to whom correspondence should be addressed.
Appl. Sci. 2022, 12(7), 3452; https://doi.org/10.3390/app12073452
Submission received: 22 February 2022 / Revised: 21 March 2022 / Accepted: 25 March 2022 / Published: 29 March 2022
(This article belongs to the Special Issue Human Performance Monitoring and Augmentation)
Versions Notes

Abstract

:
A systematic review and meta-analysis of studies demonstrated a relationship between sex and balance determinants in seniors; however, no study has focused on sex-related differences in static and dynamic balance performance after a physical intervention as primary interest. The aim was to investigate sex differences in the static and dynamic balance performance after a 4-week physical intervention based on yoga in seniors 65+ years of age. Five-hundred participants (234 males, 266 females) were assessed with the Tinetti Balance Assessment Tool in pre-and post-testing. The experimental group (122 males, 140 females) underwent the intervention, while the control group (112 males, 126 females) ran their usual daily program. ANCOVA model was used for the statistical evaluation of the results. No sex differences were found in balance performance after a short-term physical intervention in seniors 65+ years of age. At the same time, a significant positive shift was demonstrated in performance in both static and dynamic balance.

1. Introduction

Balance performance represents an important prerequisite for independent activities in daily life of seniors 65+ years of age. In aging, deterioration of physical functions may slow down the movements and balance responses and generally the motor system as well [1,2,3]. It is very important in terms of fall prevention. In aging, fall rates in seniors 65+ years of age are the highest among adults in all regions of the world [4,5,6]. Balance control changes with age, resulting in a postural instability. There are declared correlations between age and balance performance in seniors 65+ years of age. Examination of the relationship between balance and age among seniors living in senior houses proved that as age advances, the balance performance deteriorates [7,8]. Therefore, the question is to what extent of balance performance can be expected to improve after a physical intervention in correlation with increasing age [9,10].
Cross-sectional surveys suggest that some factors of balance performance may be sex-specific in the seniors over 60 years old. Males were characterized by a lower level of postural stability compared with females and worse performance when sitting down [11]. A systematic review and meta-analysis of the previous studies demonstrated a relationship between sex and balance determinants in seniors; however, none have focused on sex-related differences in balance performance after the physical intervention as primary interest [12,13]. Other authors [14] declare that the influence of sex on balance is still controversial in seniors 65+ years of age. Using a modified Clinical Test of Sensory Interaction on Balance, they declared that sex has no effect on static balance abilities between male and female seniors.
Balance performance represents a multifactorial quality that can be probably effectively increased by exercise training means in both sexes of seniors. Therefore, it is fundamental to promote balance performance in form of physical intervention in aging, being that a negative effect on balance performance has been seen in the no-intervention control groups. The control groups of seniors which received no physical intervention showed a decline in the ability to balance, suggesting that inactivity plays a pivotal role in seniors in the mechanisms involved in maintaining balance [15,16]. Various studies have examined different kinds of exercise, from Pilates and stair climbing to dancing and yoga in seniors 65+ years of age [17,18,19].
A multicomponent physical intervention with yoga components seems to provide positive outcomes on the improvement of balance performance [20,21]. Yoga exercises may represent the adequate program for seniors´ balance development because they are slowly performed, with breathing improvement. Yoga exercises may counterbalance muscle imbalances and ensure adequate exercise load for the musculoskeletal system. Breathing, relaxation, and balance exercises result in movement control, soothe the nervous system, and promote flexibility [22,23].
For balance performance augmentation, there are declared results of a 4-week yoga intervention which indicated that seniors’ balance and range of motion on shoulder flexion and abduction improved in both sexes [24]. Similar physical intervention studies in seniors suggest positive effects on balance performance promotion after only a 4-week intervention [25,26].
The study was focused on sex differences of balance performance in seniors 65+ years of age. The aim was to investigate sex differences in the static and dynamic balance performance after a 4-week physical intervention based on yoga exercises. The physical intervention was adapted so that seniors 65+ years of age could participate without any risk for injures in the study. Based on a theoretical analysis, we assumed that completing the physical intervention would significantly affect the performance of static and dynamic balance in both sexes of seniors 65+ years of age in the experimental group compared with the control group.

2. Subjects and Methods

2.1. Subects and Procedures

Five-hundred seniors aged 65+ (234 males with an average age of 74.5 SD ± 7.74; 266 females with an average age of 76.9 SD ± 7.23) selected by stratified randomized sampling from all the regions of the Czech Republic participated in the examination. While randomizing, an equal or very similar number of participants for both groups were kept in the particular homes/centers. The participants were grouped into the Experimental group (n = 162; 122 males, age average 72.8, SD ± 7.44, median 71 (67.0, 78.0); 140 females, age average 76.1, SD ± 8.03, median 76.0 (69.0, 81.0)) and the Control group (n = 112 males, age average 72.2, SD ± 6.54, median 71.0 (67.0, 74.0); 126 females, age average 72.9, SD ± 7.32, median 70.5 (67.0, 76.0)).
According to the ICH GCP, an approval of the study was obtained from both Ethics Committees of the College of Physical Education and Sport PALESTRA in Prague and of the Institute of Endocrinology in Prague. All participants signed informed consent forms before any study procedures were performed. In addition, enough time was given to the participants to read the informed consent form and for any subsequent questions to be addressed accordingly. Inclusion criteria for the study were: (i) age of 65 years and above, (ii) males and females, and (iii) ability to cooperate with the physical activity as required by the study protocol. The exclusion criteria were determined according to the White Book on Physical and Rehabilitation Medicine in Europe [27] and were as follows: (i) human to human infectious diseases and bacillus carrier, (ii) all acute-stage diseases and conditions in which destabilization of health state can be reasonably expected, (iii) cachexia of various etiologies, (iv) malignant tumors, (v) active attacks or phases of psychoses and mental disorders with asocial manifestations or with reduced communication, and (vi) 2nd and 3rd degree of urinary incontinence and stool incontinence. The standardized medical anamnesis protocol was performed by a physician using a standardized protocol specifically focused on the current health status of seniors, drug therapy, injuries, and surgeries [28]. The physician who carried out the medical evaluation recommended whether to include an individual into the study. The participants were randomly assigned in a 1:1 ratio to the experimental or control group. They had a 50% chance to be in either group.

2.2. Methods

2.2.1. Methods and Instruments

Investigation started with the assessment of body height, body weight, and body composition provided by an anthropologist with two assistants. Body height was measured using the Tanita Leicester Height Measure device (Invicta Plastics, Leicester, UK) with an accuracy of 0.1 cm. A tetrapolar multi-frequency bioelectrical impedance device InBody 230 (InBody, Seoul, Korea) was used to discern basic body characteristics such as body weight, body fat percentage, and total muscle mass [29].

2.2.2. Tinetti Balance Assessment Tool

A physiotherapist conducted an individual balance examination using the Tinetti Balance Assessment Tool, which was used to measure the static and dynamic balance score [30]. The higher the score, the better the performance. The static balance test was assessed on the basis of observation of an individual’s bodily behavior during sitting and standing positions and their changes which were defined by 9 items and the dynamic balance (gait) test was judged by 8 items that involve characteristics of gait manifested in an individual during a 4.5-m walkway, first at a usual pace, then at a rapid pace. Participants in the experimental group underwent the 4-week yoga-based intervention, while the control group ran the standard daily routine program in their senior homes or centers. One to six days after the 4-week intervention, the post-measurements were performed in the same conditions [31].

2.3. Intervention

The 4-week intervention in the experimental group was focused on body posture and balance control, flexibility, muscle strength, breathing, and release. The exercises were carried out according to the Yoga in Daily Life System [32], without contraindications for the seniors, whilst sitting on a chair or standing by a chair including: Pulling arms up, Turning the shoulders, Leg stretch, Hamstring Stretch, Shoulder stretch, Fingers stretch, Toes stretch, Bottom lift, Knee bends, Forward band, the Balance exercises standing behind a chair with support, Stand on one leg, diaphragm breath, modified “cat pose” breathing, “lion grimace” breathing, exercises to relax the muscles of the face and neck, vibration exercises with vibrational effects in the diaphragm, lung and brain areas, etc. The intervention protocol always included a warm-up and cool-down phase [33,34]. Always once per week, the main training lesson lasting 90 min was conducted with 10–12 participants under the guidance of a coach and two assistants. After this main training lesson, each participant received an educational sheet with an exercises overview for the week. During the week, participants repeated the learned exercises daily for 30 min under the supervision of the assistants.

2.4. Statistical Analysis

Power analysis was set as follows: power > 0.80 (beta < 0.2) for alpha < 0.05 and to test whether the analysis was not underpowered. ANCOVA model consisting of Subject factor (explaining the inter-individual variability), between subject factors Sex (males vs. females), Group (experimental vs. control), within-subject factor Stage (after intervention (Stage 2) vs. before intervention (Stage 1), covariate Age and a full set of between-factor interactions was used. For post hoc analysis, the least significant multiple comparisons were used. To eliminate skewed data distribution and heteroscedasticity, the original data were transformed to attain symmetric distribution in dependent variables and, at the same time, to stabilize the variance (attaining homoscedasticity), by a power transformation, as described in detail previously [35]. After performing the statistical tests, the data were then retransformed into the original scale using a recurrent formula. A robust Mann-Whitney test was used to evaluate the differences between the experimental and control groups at the beginning of the trial. The NCSS 12 statistical software from (Number Cruncher Statistical Systems, Kaysville, UT, USA) was used for the Mann-Whitney test and power analysis. Power transformations were accomplished using the statistical software Statgraphics Centurion 18 from Statgraphics Technologies, Inc. (The Plains, VA, USA) and ANCOVA testing was performed with the use of jamovi statistical software (The jamovi project (2021). jamovi. (Version 2.2) (Computer Software). Retrieved from https://www.jamovi.org accessed on 20 March 2022).

3. Results

3.1. Baseline Characteristics of Subjects

To test the effectiveness of the applied physical intervention, a randomized selection of subjects was conducted. Our aim was to create comparable groups with a high comparable compliance before the intervention. As shown in Table 1, the subjects of the experimental group (n = 262) and control group (n = 238) did not differ in baseline variables.

3.2. Intervention Effects on Static Balance Performance in Monitored Males and Females

The positive effect of the applied physical intervention on the static balance performance was significant in both sexes of the experimental group compared with the control group, where no significant improvement of the static balance performance was noticed in the post-measurements in both sexes of the control group.
Significant positive improvements of the static balance performance in participated males and females after the intervention were observed, as visible from the values of the statistical analysis, i.e., Group × Stage: F = 5.5, p = 0.019, Effect size ηp2 = 0.013, (Table 2), and from Table 3.
Positive significant shifts in static balance performance were very similar for both males and females in the experimental group.

3.3. Intervention Effects on Dynamic Balance Performance in Monitored Males and Females

The positive effect of the applied physical intervention on the dynamic balance performance was also significant in both sexes of the experimental group compared to the control group, where no significant improvement of the dynamic balance performance was noticed in the post-measurements in both sexes of the control group.
Significant positive improvements of the dynamic balance performance in participated males and females after the intervention were observed, as visible from the values of the statistical analysis, i.e., Stage × Group: F = 13.6, p < 0.001, Effect size ηp2 = 0.032, (Table 4), and from Table 5.
Positive significant shifts in static balance performance were very similar for both males and females in the experimental group, as seen from Table 5.
Based on the results above, our assumptions were confirmed, i.e., completing the physical intervention significantly affected the performance of static balance in both sexes of participants 65+ years of age in the experimental group compared with the control group and also significantly affected the performance of dynamic balance in both sexes of participants 65+ years of age in the experimental group compared with the control group.

4. Discussion

The findings of our study showed significant changes in balance performance indicated in static balance performance, and dynamic balance performance as well, after the intervention without any sex differences of monitored subjects of the age 65+. This may indicate the universality of the applied physical intervention with respect to both sexes. Furthermore, the results indicated high effectiveness of the applied physical intervention in terms of the possibility of static and dynamic balance performance optimization, in a relatively short period, although some authors [36] emphasize that in old age, the loss of muscle mass and thus muscle strength in females can reach a critical level earlier than in males, which can subsequently be reflected in the deterioration of postural balance and gait in females.
The findings of the intervention effects on static balance performance can be summarized as follows: (1) In both sexes of the experimental group, all measurements of static balance performance were significantly improved after the applied physical intervention; (2) In accordance with our assumptions, it was found that already short-term physical intervention led to a significant increase in static balance of performance in seniors, males and females, of the experimental group in comparison with the control group.
Our results correspond to those from previous studies examining the impact of physical interventions on static balance measurements in seniors. For example, according to the studies [37,38], the authors stated that static postural balance training for both males and females 65+ years of age must be developed in a controlled manner, under the supervision of a coach and assistants, to achieve significant progress in the static balance performance. They also mentioned that the question of whether performance development in static balance differs significantly between females and males has not been convincingly answered according to the fact that due to the performed physical intervention the static balance improved in both sexes, but the improvement was more pronounced in females compared to males. The aim of our study was not to primarily examine the relationship between the effectiveness of intervention with control and supervision; however, we believe that interpreted positive effects of supervised balance performance training are particularly pronounced and obvious. In accordance with that and on the basis of the realized physical intervention in our study, we may recommend the inclusion of supervised lessons in balance training programs in both sexes of seniors 65+ years of age in order to effectively improve balance and muscle strength, which is in line with the recommendations of experts who have dealt with this issue more deeply [39]. Of course, the biomechanical organic aspect of the analyzed result plays a significant role in male and female balance performance. The results are also in line with the authors [40] stating that differences between females and males in terms of dynamic balance performance increase with age to the detriment of women.
Other authors [41,42] examined the effect of physical intervention training on static balance traits in seniors 65+ years of age living in senior homes compared with seniors living in their own residences. In comparison, the training group in the senior homes showed a better improvement in their static balance performance (i.e., less postural swing and greater reach) than the group of seniors living in their own residences, undergoing intervention within senior clubs. We may emphasize on the need for regular balance training in senior houses, using a short term physical intervention based on simple and safe exercises, for both sexes of seniors 65+ years of age to maintain the optimization of static and dynamic balance skills. Our study showed that the applied physical intervention is feasible for seniors living in senior homes. Its application is real in the senior homes, including in seniors with different types of disabilities as declared by the authors [43,44] when using a chair in the physical intervention focused on balance skills improvement was incorporated. The authors outlined that the motivation of seniors to absolve the intervention was high, which is in accordance with our study.
Finally, the authors [45] studied seniors who completed a 4-week physical intervention in a spa facility. They found an improvement in static and dynamic balance performance compared with physical balance development. The results of this study suggested that balance treatment may be a suitable exercise regimen to improve balance performance in healthy seniors 65+ years of age in spa conditions. In accordance with the authors [46,47], therefore, the interplay among the balance ability and psychosocial indices in relation to sex, age, and the individual specifics of seniors should be taken into consideration.
The purpose of the presented study was fulfilled. We are aware of some limitations of the study. The physical activity level of participants and story of falls were not evaluated before the intervention. Despite all efforts to follow the basic research methodology, the examined sample could not fully reflect the general population of seniors aged 65+. A larger sample size would be beneficial for the future research. Another hurdle was the lack of previous research studies on this topic to enable comparing the achieved results. We recommend further research to confirm the results. This study can use a single-blind design to avoid potential bias and criticism. We would like to emphasize follow-up studies should monitor sustainability and stability of the results after 1–3–6 months following the intervention in both sexes.

5. Conclusions

The analysis of the obtained results revealed that no sex differences were found in balance performance after a short-term physical intervention in seniors 65+ years of age. After the application of the 4-week physical intervention based on yoga in seniors 65+ years of age, no sex differences in the static and dynamic balance performance were proved. At the same time, a significant positive shift was demonstrated in performance in both static and dynamic balance.
To our knowledge, this is the first randomized trial to test a physical intervention based on yoga, investigating sex differences in the static and dynamic balance performance in seniors 65+ years of age. The study findings indicated excellent feasibility and acceptability, although future studies, with larger sample sizes, are needed to confirm the results.

Author Contributions

Conceptualization, M.K. and M.H.; methodology, M.K. and V.H.; resources, R.P. and M.K.; data curation, J.K.; writing—original draft preparation, M.K.; software, M.H.; validation, M.H., R.P. and J.K.; formal analysis, M.K.; investigation, M.K. and J.K.; resources, R.P.; data curation, J.K.; writing—original draft preparation, M.K.; writing—review and editing, M.H. and R.K.; visualization, M.T.; supervision, M.T.; project administration, J.K. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the CZECH SCIENCE FOUNDATION, grant number GACR ID 17-25710S “Basic research of balance changes in seniors”.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Ethics Committee of the COLLEGE OF PHYSICAL EDUCATION AND SPORT PALESTRA (protocol code: GACR_01_2016; date: 17.03.2016).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data sharing not applicable due to the General Data Protection Regulation (GDPR), legislatively valid protection of personal data in the European Union, valid in the Czech Republic since 25 May 2018.

Acknowledgments

The research presented was supported and funded by the Czech Science Foundation under the grant GACR ID 17-25710S “Basic research of balance changes in seniors”. The authors would like to acknowledge and thank all participants and assistants who participated in this study.

Conflicts of Interest

The authors declare no conflict of interest.

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Table
Table 1. Baseline characteristics (shown as median with quartiles) of monitored males and females (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
Table 1. Baseline characteristics (shown as median with quartiles) of monitored males and females (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
VariableControl GroupExperimental Groupp-Value *
Age (years) males71 (67, 74) 73 (68, 80) 0.186
Age (years) females70 (67, 76) 73 (68, 80) 0.034
Height (cm) males174 (170, 178) 174 (170, 180) 0.790
Height (cm) females164 (160, 168) 163 (158, 166) 0.409
Weight (kg) males82 (74, 94) 85 (78, 90) 0.575
Weight (kg) females73 (64, 81) 71 (63, 83) 0.487
Body fat (%) males26 (22, 35) 26 (22, 33.3) 0.838
Body fat (%) females34 (30, 42) 35 (27, 45) 0.959
Muscle mass (kg) males34 (29, 39) 35 (30, 40) 0.388
Muscle mass (kg) females30 (25, 32) 30 (24, 32) 0.528
* Mann-Whitney test.
Table
Table 2. ANCOVA model highlighting the dependence of the Tinetti static balance score on sex, group, age, and stage of the trial (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
Table 2. ANCOVA model highlighting the dependence of the Tinetti static balance score on sex, group, age, and stage of the trial (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
Factor/InteractionFpηp2
Stage1.400.2380.003
Stage × Age0.020.877<0.001
Stage × Male0.410.5220.001
Stage × Group5.540.0190.013
Stage × Male × Group0.340.5620.001
Male0.730.3950.002
Group2.210.1380.005
Male × Group1.330.2490.003
Age94.12<0.0010.184
ηp2~0.01, 0.06, and >0.14 represent small, medium and large effect size, respectively.
Table
Table 3. Tinetti balance score during the trial.
Table 3. Tinetti balance score during the trial.
StageGroupSexMean (95% Confidence Interval)p-Value (LSD Multiple Comparisons)
1ExperimentalFemale14.5 (14.3–14.7)
Male14.2 (13.8–14.5)
ControlFemale14.2 (13.8–14.5)
Male14.2 (13.7–14.6)
2ExperimentalFemale14.8 (14.5–15.0)<0.001
Male14.4 (14.1–14.8)<0.001
ControlFemale14.2 (13.9–14.5)1
Male14.3 (13.9–14.7)1
Table
Table 4. ANCOVA model highlighting the dependence of the Tinetti dynamic balance score on sex, group, age, and stage of the trial (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
Table 4. ANCOVA model highlighting the dependence of the Tinetti dynamic balance score on sex, group, age, and stage of the trial (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
Factor/InteractionFpηp2
Stage0.170.681<0.001
Stage × Age0.230.630.001
Stage × Male0.010.912<0.001
Stage × Group13.57<0.0010.032
Stage × Male × Group2.040.1540.005
Male1.470.2260.004
Group0.850.3580.002
Male × Group0.130.724<0.001
Age55.31<0.0010.117
Table
Table 5. Tinetti dynamic balance score during the trial (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
Table 5. Tinetti dynamic balance score during the trial (n = 500; Experimental group n = 262; 122 males, 140 females; Control group n = 238; 112 males, 126 females).
StageGroupSexMean (95% Confidence Interval)p-Value
(LSD Multiple Comparisons)
1ExperimentalFemale10.9 (10.7–11.1)
Male10.7 (10.4–10.9)
ControlFemale10.8 (10.5–11.0)
Male10.7 (10.4–11.0)
2ExperimentalFemale11.0 (10.9–11.2)<0.001
Male10.9 (10.6–11.1)<0.001
ControlFemale10.8 (10.6–11.1)1
Male10.7 (10.3–11.0)1
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Krejčí, M.; Kajzar, J.; Psotta, R.; Tichý, M.; Kancheva, R.; Hošek, V.; Hill, M. Are There Sex Differences in Balance Performance after a Short-Term Physical Intervention in Seniors 65+? A Randomized Controlled Trial. Appl. Sci. 2022, 12, 3452. https://doi.org/10.3390/app12073452

AMA Style

Krejčí M, Kajzar J, Psotta R, Tichý M, Kancheva R, Hošek V, Hill M. Are There Sex Differences in Balance Performance after a Short-Term Physical Intervention in Seniors 65+? A Randomized Controlled Trial. Applied Sciences. 2022; 12(7):3452. https://doi.org/10.3390/app12073452

Chicago/Turabian Style

Krejčí, Milada, Jiří Kajzar, Rudolf Psotta, Miroslav Tichý, Radmila Kancheva, Václav Hošek, and Martin Hill. 2022. "Are There Sex Differences in Balance Performance after a Short-Term Physical Intervention in Seniors 65+? A Randomized Controlled Trial" Applied Sciences 12, no. 7: 3452. https://doi.org/10.3390/app12073452

APA Style

Krejčí, M., Kajzar, J., Psotta, R., Tichý, M., Kancheva, R., Hošek, V., & Hill, M. (2022). Are There Sex Differences in Balance Performance after a Short-Term Physical Intervention in Seniors 65+? A Randomized Controlled Trial. Applied Sciences, 12(7), 3452. https://doi.org/10.3390/app12073452

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