INTRODUCTION

The aging of the world population is a reality that imposes new challenges and requirements in health promotion and disease prevention¹. Increasing age, physical inactivity, associated with degenerative processes in the central nervous and muscle systems result in a decline in proprioception, balance and muscle strength, which consequently leads to an increased risk of falls in the elderly population.

From the literature it emerges that the risk of falling is present in about 30% of people aged 65 and over and who suffer at least one fall per year, about 10 to 15% of serious injuries^2).

Proprioception is the a capacity that the body has to adapt to different postures, an unconscious consequence of feeling, interpreting and interacting with movement and position in space³. It is characterized by cumulative neural afferents that originate from mechanoreceptors.

Body balance is described as the ability to maintain the center of body mass within the base of support. The body must be able to acquire and control certain postures to achieve a goal, with the ability to move quickly and accurately, in a multidirectional way, with coordination, safety and in the face of external disturbances⁴.

Studies report that balance and proprioception training improved the person's physical condition, increasing muscle mass and strength, increasing physical endurance and improving body balance, which, in turn, enhance functional abilities, obtaining gains in mobility as well as in self-confidence. When intervening in the elderly population with appropriate training programs that can improve performance in activities of daily living that demand proprioception and balance, these become essential to reduce the risk of falling⁵.

A deficit in proprioception and body balance in the elderly person, associated with limited mobility and fear of falling, are conditioning factors for the reduced ability to perform daily activities and physical exercise, increasing the risk of falling. In this more fragile generation, serious injuries such as fractures or head traumas lead to prolonged hospitalizations, with an increase in the economic burden not only for the elderly and for the family, but also for the whole society⁶.

This association of factors can then culminate in an important commitment to the quality of life of the elderly population, in which the occurrence of a fall can be the precipitating factor for a health/disease transition, moving from autonomy to a situation of dependence.

Thus, rehabilitation, as a multidisciplinary specialty, comprises a body of specific knowledge and procedures that help people with acute, chronic or sequelae to maximize their functional potential and independence. Its general objectives are to improve the function, promote the person's independence and maximum satisfaction and, in this way, preserve self-esteem⁷.

The Rehabilitation Nurse (RN) designs, implements and monitors differentiated rehabilitation nursing plans, based on people's real and potential problems. The high level of knowledge added to experience allows the RN to make decisions regarding health promotion, prevention of secondary complications, treatment and rehabilitation, maximizing the person's potential. Its intervention aims to promote early diagnosis and preventive actions in Rehabilitation Nursing, in order to ensure the maintenance of the necessary needs of clients, prevent complications and avoid disabilities, as well as provide therapeutic treatment aimed at improving residual functions, maintaining or recovering the independence⁷.

In this way, the RN has an interventional and preponderant action in the prevention of falls in the elderly, through the implementation of exercises and training programs that can be replicated in the home environment.

In this line of thought, the preparation of this scoping review comes from identifying the need to prevent falls in the elderly population and what can be done to minimize this risk whose impact on the person, family and society is so relevant?

Balance and proprioception training programs are useful and effective in preventing injuries, but what impact do they have on preventing falls in this population? Thus, we are directed to the question of what is the effect of proprioceptive training and postural balance in the elderly for the prevention of falls.

METHODOLOGY

In scientific research, different goals and issues can be identified using new approaches. Scoping reviews are a type of approach designed to synthesize in a more effective and rigorous way the evidence, the mapping of knowledge about a certain area of ​​investigation⁸.

The option to carry out a scoping review is based on the fact that it is a type of review whose main objectives are: to map the existing evidence underlying a research area, to identify gaps in the existing evidence, to constitute a preliminary exercise that justifies and informs the realization of a systematic review of the literature. Thus, the use of this methodology, according to the objectives described above, is not to find the best evidence, but to map the existing scientific evidence⁸.

Studies that included balance and proprioception exercise training programs without the use of technologies and/or equipment were sought, with the objective of being able to be performed at home by elderly people without specific underlying pathological conditions.

The search was carried out through the databases, MEDLINE, CINAHL and PEDro. Primary studies, randomized controlled studies and systematic literature reviews were included. Using the participants, concept and context (PCC) strategy, the scoping review covered studies that: a) regarding the type of participants, elderly people aged 65 years-old or over; b) regarding the concept, the effect of proprioceptive training and postural balance; c) regarding the context, the prevention of falls.

RESULTS

As shown in Figure 1, the initial search identified a total of 1924 articles in the three databases. After including the aforementioned limiters, we identified a total of 981 potentially relevant articles. Afterwards and once removed the 219 duplicate articles, the final sample consisted of 762 studies.

From this sample and according to the inclusion criteria, 44 studies were involved. After reading the articles in full, 5 were excluded for illegible language, 2 articles for being inaccessible, 3 addressed other intervention models for the prevention of falls, 16 articles for using technology and equipment and 5 for addressing only theoretical content about the fall in the elderly.

13 articles were included for this scoping review.

The studies were carried out by physiotherapists, occupational therapists, orthopedists, professors in the areas of geriatrics, sports science and sports medicine, and only one study was carried out by Portuguese RN. The articles are from Australia, Japan, South Korea, United Kingdom, Sweden, Germany, Spain and Portugal. The research included a systematic review and 12 primary studies.

The proprioception and postural balance training programs in the elderly showed variability in the number of training weeks, from 4 to 52 weeks, where the authors analyzed balance recovery, functional capacity, physical mobility, gait, proprioceptive vestibular system, muscle strength, physical endurance and fear of falling.

The general population refers to elderly people over 65 years-old, the object of study, inserted in the community and without associated pathological conditions. The average age was around 70-75, mostly female. Only 4 studies mention that the selected population had already experienced one or more falls.

The population, in general, was evaluated using questionnaires and application of performance tests. Among which, we highlight: Mini Mental State Examination (MMSE) according to the version of each country, Geriatric Depression Scale, The Late Life Function and Disability Instrument, Physical Activity Scale (PASE), Body Mass Index (BMI), Freiburger Questionnary of Physical Activity ) FQoPA) and Health Related Quality of Life (HRQOL). With regard to gait, speed, gait cycle and uni and bipodal support were considered. The authors used some assessment scales, such as 10 Meter Walk Test and Step Test. Muscle strength tests were determined using dynamometers.

The balance tests have excelled in variety. Among them we highlight: Functional Range Test (TAF), Romberg Test, Timed Up and Go Test (TUG), Berg Balance Scale (BBS), Fullerton Advanced Balance Scale (FAB), 5 Times Site to Stand (5XSST). The Vestibular Stepping Test (VST), Proprioceptation Test (PT), Functional Reach Test (FRT). They were decisive to assess proprioception.

The risk of falling and the fear of falling were assessed by some researchers using the scales - Fall Risk Index (FRI), Fall Risk Assessment Tool (FRAT), Falls Efficacy Scale International (FES-I) and The CONFbal Scale.

DISCUSSION

The aim of this scoping review was to analyze and map articles that addressed the effect of proprioceptive training and postural balance in the elderly people for the falls prevention.

The various articles included address isolated exercise and exercise programs and contribute to minimizing the risk of falling and the fear of falling in the elderly people.

Article number 2¹⁰ addresses an exercise program called LiFE, which consists of the practice of balance and muscle strength exercises to be performed at home, based on activities of daily living.

Elderly people who have already experienced falls were selected and followed for 12 months. Of the three study groups, the LiFE group had the best results with the fewest falls/year (172 falls), the overall incidence of falls in the LiFE program was 1.66 per person/year, compared to 1, 90 (193 falls) in the structured exercise group (SG) and 2.28 (249 falls) in the control group (CG). There was a significant 31% reduction in the rate of falls in the LiFE group compared to the CG (incidence rate 0.69), (95% confidence interval 0.48 to 0.99). between SG and CG was not significant=0.81 (0.56 to 1.17).

Static balance, muscle strength, ankle function and participation were significantly better in the LiFE group than in the CG. The LiFE and SG group had a significant impact on improving dynamic balance compared to the CG.

The authors of this article concluded that this type of exercise program had a significant impact and a moderate improvement in dynamic balance in the population studied.

Thus, LiFE program offers an alternative to traditional exercise to consider for fall prevention with an intervention focus on functional exercise.

Article number 3⁴ refers to the OTAGO program. This training program was specifically designed to prevent falls. It consists of a set of exercises for muscle strengthening of the lower limbs and balance training with progressive difficulty - home exercise program. The exercises last 30 minutes, participants must exercise three times a week and walk at least twice a week.

This study evaluated the effectiveness of a home balance and strength exercise intervention in the elderly population, being systematically evaluated as having mild balance dysfunction.

The 83 intervention group (IG) participants received a six-month home strength and balance exercise program (prescribed by a physical therapist based on the OTAGO Exercise Program and Visual Health Information Balance and Vestibular Exercise Kit). The 82 CG participants continued with their usual activities.

After six months of study, the IG significantly improved compared to the CG for: the Functional Range Test (mean difference 2.95 cm, 95% confidence interval [CI] 1.75 to 4.15), in the Test of Step (2.10 steps / 15 seconds, 95% CI 1.17 to 3.02), hip abductor strength (0.02; 95% CI 0.01 to 0.03) and in the gait step width (2.17 cm, 95% CI 1.23 to 3.11).

The authors conclude that the prescription of a home exercise program such as OTAGO, aimed at balance and muscle strength, was effective in improving balance and reducing falls in elderly people with compromised body balance.

FaME (Falls Management Exercise) is a physical exercise training program that was studied in article number 10 ¹⁷, based on the fitness and mobility of physical exercise. This program, known since 2006 in Canada, aims to increase balance and muscle strength in seniors, as they are the class most predisposed to the risk of falling.

It consists of specific, individualized training aimed at dynamic balance, muscle strength, endurance, flexibility, gait and functional abilities to avoid falling. The exercise was performed three times a week for one hour, in which one session was held in a group and the rest at home, under the supervision of a physiotherapist and/or an occupational therapist, for three months.

Static balance improved as well as activity participation (22.90 ± 5.55 to 32.35 ± 11.16 points) and the fall index decreased from 64.60 ± 27.00 to 51.40 ± 22.84 points. However, there were no significant differences in any category for participation before and after the intervention. Nevertheless, these investigators report that other fall prevention exercise programs are as effective as the FaME program.

Reflecting on these three exercise training programs for the prevention of falls mentioned above, they are described by researchers that provide evidence for the promotion of balance, muscle strengthening and increased participation of the elderly population in the practice of physical exercise. We can admit that a home exercise program for the prevention of falls can have a positive effect on participation in activities of daily living and on balance in seniors.

The ProAct65+, discussed in article number 12¹⁹, is a clinical trial in which the effectiveness of a home exercise program (OTAGO) and a physical exercise program (FaME) was investigated, in comparison with the usual care to increase moderate to vigorous physical activity (MVA), in reducing falls and associated injuries.

The FaME group experienced a significant reduction in harmful falls compared to the incidence rate (IRR) 0.55, 95% CI 0.31, 0.96; p = 0.04) and this continued through the 12 months after the end of the intervention (IRR 0.73, 95% CI 0.54, 0.99; p = 0.05).

There was also a significant reduction in the incidence of all falls (harmful and non-harmful) in the FaME group compared to usual care (IRR 0.74, 95% CI 0.55, 0.99; p = 0.04) in the period of 12 months after the termination of the intervention. In the OTAGO group, the reduction was not significant in the incidence of all falls compared to usual care (IRR 0.76, 95% CI 0.53, 1.09; p = 0.14) in the 12 months following cessation of the intervention.

After 24 months, the effects of training programs on fall prevention did not persist in any exercise group. However, a sample from the FaME group that continued to perform 150 minutes of MVA per week post-intervention showed a significant reduction in the incidence of falls (IRR = 0.49; 95%CI 0.30; 0.79; p = 0.004 ) compared to those who did not maintain their regular physical activity.

The researchers found that the elderly undergoing the FaME program did not fall during the training program. After 12 months they had fallen less and had fewer injuries associated with falls. However, 24 months after the program, the benefits of the intervention ended, except for those who maintained moderate physical activity. The OTAGO program was less effective in preventing falls.

It emphasizes here the importance and benefit of continuing regular physical exercise to prevent falls in the elderly population.

Article number 13²⁰ assesses the impact of a strength and balance training program, the Balance and Strength Training (BST) for 12 weeks, followed by the same period of inactivity time, with and without professional supervision.

The exercise program was performed three times a week, which included progressive exercises, with different levels of intensity. The program protocol consisted of static balance exercises, dynamic balance (walking) and strength/power exercises for the lower limbs and trunk muscles (squats, plank, among others). The participant's body weight and small equipment such as towels, bottles and balls were used as resources.

The supervised elderly group performed training three times a week, with one training session being held without supervision at home. The unsupervised group performed the same exercises at home three times a week.

The results revealed that there was an improvement in the balance tests, improvements in the Romberg Test, in the step speed, in the Timed Up and Go Test and in the Chair Stand Test, even after the inactivity period, in favor of the supervised group.

The investigators in this article conclude that there have been improvements in strength and balance in the elderly when these exercises are performed under the supervision of a professional.

ProBalance is a rehabilitation program carried out by Portuguese RN that includes various types of exercise: balance, coordination, functional task training, gait training, strengthening and flexibility exercises, inspired by the FallProof balance and mobility program.

The ProBalance program takes a multifactorial approach to balance and mobility in independent elderly people with balance deficits.

In article number 11¹⁸, its effectiveness in improving balance and reducing the risk of falling in this age group is highlighted.

Each training session included six key exercise components: multisensory training (visual, somatosensory, and vestibular system); center of gravity control training; proactive and reactive postural strategy training, gait training, strengthening and resistance exercises and flexibility training for 12 weeks.

After the program, the two groups (intervention and control) were evaluated, in relation to balance, and the group submitted to the program obtained significantly better results: 5.15 (2.81) for the intervention group and ± 1.45 (2.80) for the control group on the Fullerton Advanced Balance scale (FAB). The authors also report that after a period of inactivity, the loss of balance is more evident.

This study demonstrated that the rehabilitation nursing program based on an exercise program for the prevention of falls is effective in improving balance and reducing risk in groups of elderly people with impaired balance.

Article number 7¹⁴ has investigated the effect of a complex exercise program on balance, gait, vestibular and proprioceptive senses when the visual sense is blocked, aimed at elderly people who have already suffered a fall. The group of participants was divided into blocked view group and allowed view group. The participants started the training with muscle warm-up exercises (about 10 minutes of stretching and 20 minutes of walking). After a three-minute rest, they started an obstacle course, proprioceptive training, for 10 minutes, with the help of an assistant.

There were significant improvements in the 10 meter walking test (10MWT), vestibular test (VST) and proprioceptive test (PT) performed by the vision-blocked group after the intervention (p < 0.05) compared to the vision-allowed group. No significant difference was identified in the stair up/down test(SUDT) and in the Berg Balance Scale (BBS) within each group between before and after the intervention.

The authors of the article conclude that the exercise program applied to the group with blocked vision contributed to a significant improvement in balance and gait capacity and improved the vestibular sense of the elderly people’s intervening.

The complex program of vestibular and proprioceptive training exercises for the elderly helped to improve the balance and gait capacity, as well as improved the participants' vestibular sense. When the visual senses are blocked, the muscular response is mainly organized and postural control is accomplished more quickly, because the maintenance of vestibular and proprioceptive function increases the capacities of postural control.

This is an exercise program for the prevention of falls that is useful to improve the balance and walking ability of elderly people who have already experienced a fall.

In view of the aforementioned studies, it is evident and recommended that in the prescription of an exercise program for the falls prevention, the continuity of physical practice by the elderly population is essential, as a decline in balance is verified after a period of physical inactivity, as well as the respective supervision of the professional to reduce falls and associated injuries.

Some articles in our research refer to specific balance exercises.

The study number 1⁹ addresses the Flamingo's Dynamic exercise. This exercise consists of standing in an orthostatic position on one leg with eyes open for one minute, three times a day for six months. The aim of this study was to determine the effects of balance exercise in preventing falls and fractures in elderly people with impaired balance.

In the intervention group, significant differences were observed in increased time spent on one leg with eyes open (was increased approximately 3 times), body weight decreased; there was an improvement in independence in women's daily lives.

A greater number of fractures occurred in the non-exercise group (10 women and 1 man) than the exercised group (3 women and 1 man). The number was higher in the group without exercise, but there was no significant difference, according to the authors of this study. The number of fractures was not significantly different for men or women.

Dynamic flamingo exercise leads to gains in increased standing, on one leg and in decreased body weight, but no significant difference in fracture prevention has been demonstrated in elderly women with impaired balance.

In article number 9¹⁶, the physiotherapists analyzed the effects of balance exercises and elastic resistance exercises on muscle strength and balance in the elderly over 75 years, over a eight-week program, with the objective of preventing falls . The elderly people were divided into three groups, intervention 1 (INT 1), intervention 2 (INT 2) and control group (CON). The INT 1 group performed balance exercises and the INT 2 group performed elastic resistance exercises and the CON group performed the exercises after eight weeks, as the intervention period had already ended.

Sessions consisted of one hour, five times a week for eight weeks, for a total of 40 sessions. The elderly performed the exercises in groups, under supervision, twice a week. On the remaining days, they performed the exercises at home, alone. The one-hour training sessions consisted of 10 minutes of warm-up and stretching, 40 minutes of core exercise, and 10 minutes of final stretch. The exercises were performed in three sets, with 10 repetitions per set, and there was a rest period of 30 seconds between each set and a period of three to five minutes of rest between each exercise. The balance exercises consisted of six types of exercise: stepping, tiptoeing, backwards walking, walk in cuicuits of eight, one-legged position with arms crossed anteriorly, and application of an external disturbance. The eight resistance exercises consisted of: squat, heel lift, hip flexion and extension, knee flexion and extension, and ankle dorsiflexion and plantar flexion.

The INT 1 group showed a statistically significant improvement in the muscle strength in five of the seven muscle groups, but not at the level of the knee flexors and ankle plantar flexors, being better in the INT 2 group, which improved in all seven muscle groups.

Both the INT 1 and INT 2 groups showed improvements in the fall index, obtaining better results compared to CON group, as well as the latter showed no differences in the strengths of any muscle group after eight weeks.

The INT 1 and INT 2 groups showed significant improvements after the intervention, which proves that both balance and resistance exercises are effective in improving balance. Although elastic resistance exercises were shown to be more effective than balance exercises in strengthening the ankle plantar flexors, there was not a large difference in the effectiveness of the two types of exercises.

The authors concluded that both types of exercise (balance and elastic resistance) showed statistically significant improvements in muscle groups after the intervention, as well as an improvement in the fall index, thus being acceptable as fall prevention exercises for the elderly population.

In 2013, a systematic review was carried out (article number 5)¹², on the effects of different interventions of exercise, walking ability and balance in seniors in preventing the risk of falling.

The aim of this review was to recommend training strategies that optimize functional capacity in physically frail older adults, focusing especially on supervised exercise programs that improve muscle strength, balance and gait ability, reducing the risk of falling. Researchers argue that exercise intervention programs (strength, endurance and balance training) will be the best strategy to improve all of these components, as well as decrease the rate of falls in the elderly. Most of the studies included in the systematic review¹² describe improvements in gait, balance and risk of falling after applying a multi-component physical training program.

However, studies in which systematic resistance training was performed (alone or as part of multiple physical exercise components) revealed greater strength gains in elderly people with physical frailty or severe functional decline.

The absence of changes in strength and functional outcomes that have been measured in some of the investigations indicates that exercise prescription must be carefully adapted and provide sufficient stimulus to improve the capacity of frail subjects. In addition, this review focused only on the domains of physical function, the concepts of frailty and physical frailty. Thus, this systematic review is only able to recommend strategies to improve the function of physically frail individuals.

Based on recent evidence, exercise strategies to improve cardiovascular parameters and functional performance in frail older adults should include the following:

1. Resistance training programs should be performed three times a week, with three sets of 8 to 12 repetitions at an intensity that starts at 20%-30% and progresses to 80%:

2. To optimize individuals' functional capacity, endurance, training programs should include exercises that simulate daily activities such as sit-to-stand exercise.

3. Endurance training should include walking with changes in pace and direction, treadmill walking, step-ups, stair climbing and static bycicle. Resistance exercise can start in 5-10 minutes during the first few weeks of training and progress to 15-30 minutes for the remainder of the program. The perceived exertion rate scale is an alternative method for prescribing exercise intensity, and an intensity of 12-14 on the Borg scale appears to be well tolerated.

4. Balance training should include various exercise stimuli such as tiptoeing, multidirectional weigh lifting on tiptoes, heel/toe walkking, line walking, standing on one leg, weight transfers (from one leg to the other) and modified Tai Chi exercises.

5. Multi-component training programs should include gradual increases in exercise volume, intensity and complexity, along with simultaneous performance of resistance and balance exercises.

In all the studies selected in this scoping review, in a global way and described by the authors in the conclusions of their studies, proprioceptive and balance training are of greater value for health promotion and fall prevention in the elderly people.

In addition to proprioceptive and balance training, three studies address the fear of falling.

In article number 4¹¹, the long-term effects of a progressive and specific program based on balance training in healthy elderly people with increased risk of falling were addressed, establishing the relationship between fear of falling and balance training. This type of progressive and specific program described by the authors, based on balance training with dual and multiple tasks for elderly people at risk of falling, provided important short-term positive benefits for gait, balance function and fear of falling.

Fast walking speed, dual task performance and fear of falling were improved in the training group at nine months of follow-up. Only the self-perceived fear of falling remained significantly better at 15 months of follow-up. Although brisk walking speed decreased to baseline in the training group (1.49 m/s) it remained significantly higher than in the control group (1.37 m/s) at the end of the study.

This new, progressive and specific program, based on balance groups, with dual and multiple tasks for older adults at risk of falling, provided important short-term positive benefits for gait, balance function and fear of falling. These benefits diminished over time, suggesting that periodic participation in balance training should be encouraged.

In article number 8¹⁵ the fear of falling in elderly people with deficits in self-perception of balance was analyzed. The objective was to assess the effects of a 12-week balance training program on self-rated function and disability in healthy community-dwelling older adults with balance deficits and fear of falling.

The intervention group reported improvement in global function (p = 0.016), as well as in basic function (p = 0.044) and advanced lower limb function (p = 0.025) compared with the control group. The study showed no improvement in upper limb function.

In this study, the authors conclude that a balance training program based on static and dynamic balance exercises, using gait disturbances, improves the elderly's self-perception of balance deficits and fear of falling.

Article number 6¹³ compares the effects of an exercise program with the physical and psychological component of the risk of falling, addressing balance, strength, function and fear of falling. The Timed Up and Go test, the five-repetition chair test and the modified Romberg test were used for physical assessment of the risk of falling. For psychological results, the German version of the Falls Efficacy Scale - International (FES-I) was used.

The elderly who participated in the intervention group showed an improvement in the Timed-Up-and-Go (TUG) test: 1.5 seconds greater than that shown by the control group, equivalent to a small to moderate effect. For balance, a relative improvement of 0.8 seconds was achieved, and anxiety about falling was reduced by 3.7 points on the Falls Efficacy Scale-International (FES-I) in the intervention group compared to the control group.

The authors of this study concluded that intervention with complex exercises to prevent falling effectively improved balance, physical condition and led to a reduction in fear of falling in the elderly population studied.

In the articukes published by Yang et al.; Marques, L; and Peters et al.^4,6,8, the respective conclusions emphasize that balance training should be encouraged and maintained to minimize the elderly person's fear of falling.

A stable balance, greater muscle strength and elastic resistance lead to a considerable improvement in gait and a reduction in the fear of falling, which consequently contributes to a reduction in the falls risk.

CONCLUSION

After a detailed analysis of the selected articles, it appears that, for the most part, training programs or specific exercises for the recovery of balance and muscle strength in the prevention of falls in the elderly are addressed. Other articles address training programs with intervention in the improvement of functional capacity and physical mobility, through the implementation of more specific programs. Unique exercise programs to increase muscle strength and balance are also described, some of which intervene in improving gait and the vestibular system, and others focus on balance and resistance exercises.

Generally speaking, they all consider that the implementation of training programs of this nature has a positive and significant impact on the importance of proprioceptive training and postural balance in the elderly, playing a significant role in the falls preventio.

There are several authors who defend the continuity of physical exercise, balance and proprioception training programs, because in their absence, the risk of falling in the elderly people increases substantially.

In short, the prescription of an exercise training program for the prevention of falls in the elderly population must take into account the individuality of each person and the type of exercise (balance, strength, resistance). The fear of falling, in this more fragile population, is always present, and the supervision and presence of a health professional is essential, not only to prevent falls due to the safety transmitted, but also to encourage the continuation of physical exercise.