Impact of a proprioceptive training on the functional capacity of the elderly people

Garcia, Sérgio; Cunha, Marisa; Mendes, Eugénia; Preto, Leonel; Novo, André; Garcia, Sérgio; Cunha, Marisa; Mendes, Eugénia; Preto, Leonel; Novo, André

doi:10.33194/rper.2019.v2.n1.12.4560

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Revista Portuguesa de Enfermagem de Reabilitação

versão impressa ISSN 2184-965Xversão On-line ISSN 2184-3023

RPER vol.2 no.1 Silvalde jun. 2019

https://doi.org/10.33194/rper.2019.v2.n1.12.4560

Articles

Impact of a proprioceptive training on the functional capacity of the elderly people

Sérgio Garcia¹²

Marisa Cunha²³

Eugénia Mendes⁴

Leonel Preto⁴

André Novo⁴⁵

^¹- ACES Tâmega II - Vale do Sousa Sul - UCC Paredes Rebordosa

^²- Reabilita.Lar

^³- ACES Tâmega II - Vale do Sousa Sul - UCC Cuidar Penafiel

^⁴- Escola Superior de Saúde do Instituto Politécnico de Bragança

^⁵- NurseID - CINTESIS

ABSTRACT

Introduction:

Human aging implies a reduction in the functional capacity of the elderly population, and physical exercise is fundamental to improve it.

Objective:

To evaluate the effects of a Rehabilitation Nursing program of self-training on functional capacity in a group of elderly people.

Method:

It is a quasi-experimental study with evaluation before and after intervention. The sample consisted of 24 elderly people distributed by the intervention group (n=12) and the control group (n=12). The intervention program included 24 sessions over 12 weeks of implementation. The unipodal balance test, the Tinetti index for balance and gait, and physical fitness by the Rikli & Jones test battery were used as measuring instruments.

Results:

In the intervention group there was a positive evolution in relation to all variables evaluated, with statistically significant differences in the two moments of evaluation. In the control group, there were no statistically significant changes.

Conclusion:

This program of proprioceptive training demonstrated gains in the functional capacity of the elderly.

Keywords: rehabilitation nursing; proprioception; aging; functional capacity

RESUMO

Introdução:

O envelhecimento humano acarreta uma diminuição da capacidade funcional dos idosos, sendo o exercício físico fundamental para a melhorar.

Objetivo:

Avaliar os efeitos de um programa de Enfermagem de Reabilitação de treino propriocetivo na capacidade funcional num grupo de idosos.

Método:

Estudo quasi-experimental com avaliação antes e após intervenção. A amostra é constituída por 24 idosos distribuídos pelo grupo de intervenção (n=12) e grupo de controlo (12). O programa de intervenção incluiu 24 sessões ao longo de 12 semanas de implementação. Foram utilizados como instrumentos de medida o teste de equilíbrio unipodal, o Índice de Tinetti para equilíbrio e marcha e aptidão física pela bateria de testes de Rikli & Jones.

Resultados:

No grupo de intervenção houve evolução positiva relativamente a todas as variáveis avaliadas, com diferenças estatisticamente significativas nos dois momentos de avaliação. No grupo de controlo não se verificaram alterações com significado estatístico.

Conclusão:

Este programa de treino propriocetivo demonstrou ganhos na capacidade funcional dos idosos.

Palavras chave: enfermagem de reabilitação; proprioceção; envelhecimento; capacidade funcional

RESUMEN

Introducción:

El envejecimiento humano acarrea una disminución de la capacidad funcional de los ancianos, siendo el ejercicio físico fundamental para mejorarla.

Objetivo:

Evaluar los efectos de un programa de Enfermería de Rehabilitación de entrenamiento propicio en la capacidad funcional en un grupo de ancianos.

Método:

Estudio cuasi-experimental con evaluación antes y después de intervención. La muestra está constituida por 24 ancianos distribuidos por el grupo de intervención (n=12) y el grupo de control (12). El programa de intervención incluyó 24 sesiones a lo largo de 12 semanas de aplicación. Se utilizaron como instrumentos de medida la prueba de equilibrio unipodal, el Índice de Tinetti para equilibrio y marcha, y aptitud física por la batería de pruebas de Rikli & Jones.

Resultados:

En el grupo de intervención hubo una evolución positiva en todas las variables evaluadas, con diferencias estadísticamente significativas en los dos momentos de evaluación. En el grupo de control, no hubo cambios significativos en el significado estadístico.

Conclusión:

Este programa de entrenamiento propuesto ha demostrado ser determinante en la mejora de la capacidad funcional de los ancianos.

Palabras clave: enfermería de rehabilitación; propiocepción; envejecimiento; capacidad funcional

INTRODUCTION

With increasing age, the human body goes through a period of changes that lead to a decline in physical abilities, such as decreased flexibility, agility, coordination, joint mobility and, especially, balance¹.

There is a progressive decrease in functional capacity that accompanies the aging process, but which should not be a factor of social exclusion, dependence or other limitations that lead to situations of loneliness or institutionalization².

Aging compromises the ability of the central nervous system to process vestibular, visual and proprioceptive signals responsible for maintaining body balance³.

Elderly people have proprioceptive losses that reduce their ability to detect movement and make it difficult to accurately reproduce joint movements, difficulting proprioception⁴.

The term proprioception derives from the Latin (re)ceptus (to receive) and proprios (ourselves).

Proprioception can be defined as the neural input from nerve endings called mechanoreceptors (sensory receptors for proprioception) located in the skin, tendons, muscles, joint capsules, and ligaments, which are responsible for sending information about movement, position or deformation that occurs in these structures to the Central Nervous System (CNS). This processes, organizes and commands the body in an adequate way to maintain the control and correct posture of the body⁵^,⁶.

Rossato et al., in 2013, state that through proprioception, stimuli occur in the receptors of the joint capsules, muscles and ligaments, which, in addition to ensuring good integrity of proprioceptive sensations, improve muscle strength, balance and gait⁷.

The aging process is accompanied by changes in the nervous, locomotor and sensory system that can cause changes in posture, balance and gait⁸. Bulksman and Vilela, in 2004, reported that in elderly people, motor responses to proprioceptive, visual and auditory stimuli are slower, which may interfere with the quality of gait and in the performance of activities of daily living (ADL)⁹.

Functional capacity can be represented by an individual's ability to perform ADL without difficulties¹⁰, in addition to being associated with clinical changes caused by aging. Changes in ADL can be useful to indicate future complications related to the health of the elderly, such as physical disability, frailty, institutionalization and mortality¹¹.

The functional capacity variables that were considered pertinent to evaluate in this study were balance and physical fitness, which are fundamental for the functional capacity of the elderly and which have become an important focus of health professionals due to their high impact on the elderly lives.

This study aimed to evaluate the impact of a Rehabilitation Nursing program of proprioceptive training on the functional capacity of the elderly. The following research question was formulated: What is the impact of a Rehabilitation Nursing program of proprioceptive training on the functional capacity of the elderly?

METHOD

A quasi-experimental study was carried out, with an intervention group and a control group.

Population and sample

General Practicioners were asked to collaborate in the referral of participants. The convenience sample consists of 24 elderly people, out of them 12 were in the intervention group (elderly people enrolled in the USF in Lordelo) and 12 in the control group (elderly enrolled in the USF in Rebordosa).

The following inclusion criteria were defined: age equal to or greater than 65 years-old, clinically stable, with musculoskeletal skills to perform the exercises included in the intervention program and in the two evaluation moments, with the ability to understand and comply simple orders. As an exclusion criterion, the contraindication for the practice of physical exercise by the family doctor was defined. All study participants missed 4 or fewer training sessions.

Instruments of assessment

To assess the impact resulting from the implementation of the Rehabilitation Nursing program of proprioceptive training on the functional capacity of the elderly, the Tinetti Index (balance and gait assessment), the unipodal balance test (static balance assessment) and the Rikli-Jones test battery (assessment of physical fitness).

All tests were performed in the two groups of elderly participants, with a 12-week interval between the two evaluation moments. In the intervention group, evaluations were carried out before the beginning of the program and at the end of it.

The assessments were carried out in both groups at the same time and in the same week, and all participants were asked to wear confortable sports clothing.

Functional capacity variables were evaluated, namely static and dynamic balance, unipodal balance and physical fitness.

Protocol of intervention

The program was carried out for 12 weeks, with 2 sessions per week of 60 minutes each. All exercises were performed by the participants without shoes, in order to enhance the proprioceptive effect of the exercises on the participants, with the exception of some exercises in which the elderly people did not feel so comfortable without shoes. The sessions consisted of 3 parts such as Brower, 2003 and Eyigor et al., 2007 described¹²^,¹³:

- Warming up/stretching (10 min);
- Proprioceptive exercises (40 min);
- Stretch/relax (10 min).

In Figure 1, the Proprioceptive Exercise Program can be seen schematically.

Figure 1 Proprioceptive exercise program

Stages of the proprioceptive exercise program

Over the 12 weeks, 54 different exercises were performed, created and adapted for the elderly people, which increased in intensity, complexity, speed and some with visual restriction, taking into account whether the participants were able to perform them without complaints or discomfort. Circuits were formed with several stations with different exercises in the various sessions, lasting 2 to 3 minutes in each exercise¹⁴. The exercises were performed in phases, divided into 3 stages of evolution of the elderly people (18 exercises each), considering the adaptation to the exercises, resistance, muscle strength and balance presented. In summary, the first 4 weeks represented the 1^st stage, from the 5^th to the 8^th week we considered the 2^nd stage and from the 9^th to the 12^th week the 3^rd stage.

Analysis and treatment of data

The statistical treatment of the data was carried out using the computer program Statistical Pachage for the Social Sciences Statistics (SPSS IBM), version 20, presenting descriptive statistics using the mean ± standard deviation and minimum and maximum values. The number of individuals determined by the evaluations is indicated by the sample n.

To study the comparison between the two moments of assessment of each group, the Wilcoxon non-parametric test of mean differences between subjects was applied. The significance level for this study was set at p≤0.05.

Ethical considerations

All participants signed an informed consent in a free and express way, with the objectives of the study and the nature of their participation being explained in detail, as well as authorization for the use of image and video. The study was authorized by ACeS Tâmega II - Vale de Sousa Sul and received a favorable opinion from the Ethics Committee for Health of ARS Norte (Opinion No. 51/2013).

RESULTS

The female gender predominated both in the intervention group (66.7%) and in the control group (75%), thus having a similar gender distribution in both groups.

Regarding the average age, there was a homogeneity of the two groups, with the intervention group having an average of 67.25 ± 2.01 years and the control group 68.08 ± 1.73 years, with a minimum of age is 65 years and the maximum is 71 years (in both groups).

Table 1 shows the results of the evaluations (intra-subjects) before and after the implementation of the intervention program, in the intervention and control groups (Wilcoxon Test, Z).

Table 1 Results of evaluations before and after the intervention program (intra-subjects), in the intervention and control groups (Wilcoxon Test, Z).

				Intervention group		Control group
			N	Average	p	Average	p
PHYSICAL APTITUDE	Getting up and sitting on the chair (repetitions)	Before	12	9.08 ± 2.10	0.002	10.42 ± 3.37	0.357
	Getting up and sitting on the chair (repetitions)	After	12	17.17 ± 5.02	0.002	10.08 ± 3.55	0.357
	Elbow flexion (repetitions)	Before	12	11.33 ± 3.91	0.002	15.58 ± 6.14	0.196
	Elbow flexion (repetitions)	After	12	21.33 ± 6.91	0.002	15.08 ± 5.79	0.196
	Sitting and reaching (cm)	Before	12	11.92 ± 12.06	0.002	7.92 ± 7.79	0.621
	Sitting and reaching (cm)	After	12	0.33 ± 8.13	0.002	8.25 ± 8.04	0.621
	Reaching behind their back (cm)	Before	12	26 ± 5.87	0.002	32.25 ± 9.72	0.072
	Reaching behind their back (cm)	After	12	18.33 ± 6.27	0.002	33.5 ± 10.20	0.072
	Getting up, walking 2.44m and sitting down again (seconds)	Before	12	11.5 ± 2.46	0.002	11 ± 3.46	0.272
	Getting up, walking 2.44m and sitting down again (seconds)	After	12	6.08 ± 1.50	0.002	11.7 ± 4.68	0.272
BALANCE	One-leg balancing Test (seconds)	Before	12	12.75 ± 12.37	0.002	4.92 ± 6.59	0.034
	One-leg balancing Test (seconds)	After	12	29.75 ± 21.75	0.002	3.75 ± 3.86	0.034
	Tinetti index - Balance	Before	12	14.08 ± 2.02	0.011	14.67 ± 2.38	0.046
	Tinetti index - Balance	After	12	15.67 ± 1.15	0.011	14.33 ± 2.27	0.046
	Tinetti index - Gait	Before	12	9.75 ± 1.13	0.003	10.83 ± 0.93	0.564
	Tinetti index - Gait	After	12	11.83 ± 0.57	0.003	10.75 ± 1.13	0.564

DISCUSSION

Regarding the Rikli & Jones battery tests for physical fitness, there was a statistically significant improvement in all parameters evaluated. In the elbow flexion test there was an improvement from 11.33 to 21.33 repetitions, on average. In the test stand up and sit down from a chair, from 9.08 to 17.17 repetitions, in the sit test and reach -11.92 to -0.33cm, in the test behind the back from -26cm to -18.33cm and in the test standing up, walking for 2.44m and sitting again there was an improvement from 11.5 to 6.08 seconds.

Avelar, in 2013, in a study whose objective was to evaluate a 12-week program of sensory circuits, found an improvement in the physical fitness of the elderly participants. In the study, Kim et al., in 2010, concluded that the implementation of a balance program resulted in an increase in muscle strength in the lower and upper limbs¹⁴^,¹⁵.

The improvement in the performance of “standing up, walking for 2.44m and sitting down again” is consistent with the results of studies that applied exercises similar to those in this study and with the same number of sessions⁴^,¹³^,¹⁴^,¹⁶^,¹⁷.

No proprioceptive training studies were found that directly assessed flexibility, but we can argue that the statistically significant differences in the present program are due to the diversity of proprioceptive component exercises based on another type of exercise, which implies stretching and increased flexibility in elderly people.

Sousa, in 2012, in a study that took place for 20 weeks with the elderly population, with the objective of evaluating a multicomponent physical activity program, found a significant improvement in the flexibility of the upper and lower limbs¹⁸.

In the present study, there was also a significant improvement in unipodal balance, static and dynamic/gait balance, according to the Tinetti Index.

In the one-leg balance test, in the intervention group, on average, the time in balance went from 12.75 seconds before the intervention to 29.75 seconds after the program. In the control group there was a slight decrease between the two assessments. The results agree with the consulted literature. Lustosa et al., in 2010, in a study that took place over 8 weeks with the participation of 7 elderly women, with the objective of testing a functional training, verified a significant improvement in the one-leg balance¹⁹.

Regarding static balance, in the intervention group, there was a statistically significant improvement in the mean score between assessments, from 14.08 to 15.67. As for the dynamic balance /gait, in the group of elderly people who performed this program, there was a statistically significant improvement in the score between the assessments, from 9.75 to 11.83. The results obtained are supported by several studies in the literature.

Nascimento et al., in 2012, in a study of 4 weeks of proprioceptive training in 9 elderly people, found a significant improvement in the postural balance of the elderly people²⁰. Silva et al., in 2018, found an improvement in the balance of elderly women after a proprioceptive program²¹, as did Costa et al., in 2009, who studied the effect of a multisensory exercise circuit in 26 elderly people during 10 sessions, with results with significant improvement²².

CONCLUSION

So-called civilized societies must be aware that investing in independent and healthy elderly people for as many years of life as possible is not only a bet for quality in health, but also for economic sustainability.

Rehabilitation Nurses can and should have an intervening and sustained role in their body of knowledge and specific skills and implement exercise programs aimed at improving the functional capacity of the elderly, providing them with skills that make them more independent in carrying out their daily activities. This study is part of this context, and proprioceptive training is our priority focus of attention, as it is specific exercise training and still little used in the elderly population, but with great potential for use, as demonstrated in this study.

We can now state that the Rehabilitation Nursing program of proprioceptive training implemented had a determining effect on improving the functional capacity of the elderly people, which allows us to fully respond to the outlined objective.

There was a statistically significant improvement in all parameters evaluated in the intervention group, while in the control group there was no significant improvement in any parameter evaluated, and there was still a statistically significant decrease in the unipedal balance parameter in the latter group.

The implementation of physical exercise programs is currently an area of expertise for Rehabilitation Nurses and it is in the interest of increasing our body of specific skills that will allow us to intervene in a more insightful, rigorous and scientific way in the elderly in our communities. The implementation of proprioceptive exercise programs by rehabilitation nurses, targeting the most vulnerable population, which includes the elderly, must be a systematic and systematized - professionalized - practice promoting gains in health and, at the same time, contributing to our position as fundamental elements in the health, social and economic system.

As limitations of this study, we point out the short period of time in which the training program took place, the small sample size and the shortage of scientific articles on the subject under study. As future suggestions, we point to the need to replicate this program with a greater number of elderly people and to implement it in different health programs of the General Directorate of Health, within the scope of increasing levels of physical activity and improving balance

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Received: March 03, 2019; Accepted: June 27, 2019

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