1. VISUAL IMPAIRMENT, BALANCE AND MOBILITY
Affiliated with the University of Sydney
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2. A Randomized Controlled Trial
Improving physical functioning in older adults with visual impairments to reduce the risk of falls
A Randomized Controlled Trial
Michael Gleeson
Cathie Sherrington
Serigne Lo
Lisa Keay

3. Rationale: Age-Related Changes
Nerve conduction speeds slow with age (Verdu et al, 2000)
Older adults have more difficulty maintaining balance
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4. Rationale: Age-Related Changes
Rely more on vision
especially for dynamic balance control
Implications for those with visual impairments
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5. Rationale: Visual Impairment
Exhibit increased postural sway
Greater use of hip strategy
Increased risk of falls on unstable surfaces
(Ray et al, 2008)
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6. Older Adults with Visual Impairments
Well designed exercise programs reduce falls in the general population
(Sherrington et al, 2011)
Not found effective in the population with visual impairments – compliance?
(Campbell et al, 2005)
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7. The Current Research Question
“Training programs should be studied for their effectiveness in physiotheraputically increasing postural control in individuals with vision loss, thereby reducing the susceptibility for falls within this population” (Ray et al, 2008)
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8. Proprioception is Crucial
Yoga, soft gymnastics have large proprioceptive component
Improve balance with eyes closed
Multimodal exercise and Tai Chi classes also beneficial
Multimodal exercise includes strength and balance training
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9. Pilot Studies
"Tai Chi for people with visual impairments: a pilot study."
Journal of Visual Impairment & Blindness 98(1): 5-13.
Miszko, Ramsey, and Blasch (2004)
"Yoga for persons with severe visual impairment: a feasibility study."
Alternative Medicine Studies 2(e5):
Jeter, Dagnelie, Khalsa, Haaz, and Bittner. (2012).
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10. Systematic Review Community-dwellers
No Evidence That Multimodal Exercise Prevents Falls
A factorial trial (n = 391) found a home-safety program reduced the rate of falls
(incidence rate ratio 0.59, 95%CI 0.42 to 0.83)
a home-based exercise intervention did not (incidence rate ratio 1.15, 95%CI 0.82 to 1.61).
(Campbell et al, 2005)
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11. Systematic Review Residential settings
Multimodal exercise1,2 and Tai Chi3 improve physical functioning
Individual verbal and manual support provided
1. Kovács et al, 2012
2. Cheung et al, 2008
3. Chen et al, 2012
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12. Meta-analysis: multimodal exercise trials 1,2
significant positive impact of multimodal exercise on the Berg Balance Score (Hedges’ g, 0.64, 95% CI, 0.13 to 1.14; P = 0.013)
not on the Timed Up and Go test (0.26, to 0.67, P = 0.206).
One trial1 (n = 41) found a reduced time to first fall (p = 0.049) but larger sample sizes are needed to verify any impact on fall rates
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13. Community-dwelling Adults with Visual Impairments Many have difficulties with group setting
Travel to unfamiliar location
Increases exposure to risk of injury
Difficulty following directions
Need more individual attention
Have to practice unsupervised
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14. The Alexander Technique A possible solution
Can be home-based
Hands-on: verbal feedback and guided movement
Does not require vision
Does not use repetitive exercises
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15. RCT : Can the Alexander Technique Help?
Baseline 120 clients of
Guide Dogs NSW/ACT
Control (60) Usual care Guide Dogs
Intervention (60)
12 AT lessons, usual care
Re-assess at 12 weeks
Re-assess at 12 weeks
12 month follow-up
12 month follow-up
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16. Primary Outcomes Short Physical Performance Battery (Guralnik, Simonsick et al. 1994)
Standing Balance Test
5 x Chair Stand Test
Timed 4 meter walk
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17. Secondary Physical Outcomes
Maximal balance range test
Physiological Profile Assessment
Sway firm surface, eyes open and closed
Sway foam, eyes open and closed
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18. Results: Short Physical Performance Battery
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19. Results: Other Secondary Outcomes
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20. Effect size at 3 months MAIN ANALYSIS Step length (4 meters)
(-0.90 steps, 95%CI: to -0.23, p <0.01)
Sway: quiet standing
(-29.59mm, 95%CI: to -9.67, p = 0.004)
MULTIPLE FALLERS
4 meter walking speed
(0.19m/sec, 95%CI: 0.03 t0 0.36, p = 0.02)
(-2.20 steps, 95%CI: to -0.62, p <0.01)
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21. Effect size at 12 months MAIN ANALYSIS Maximal balance
(1.14 cm, 95%CI: to 2.38, p = 0.07)
MULTIPLE FALLERS
Chair stand test
(-5.40 seconds, 95%CI: to -2.02, p <0.01)
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22. Effect size Increased step length = improved walking confidence
reduced sway = improved balance confidence
0.10 m/s is a substantial meaningful change in gait speed
The study was powered to detect 0.10 m/s
Improvement of 0.19 m/s in the multiple fallers at 3 months
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23. Falls : Primary Unadjusted Analysis (study not powered to measure the impact on fall rates)
33% lower rate of falls in the intervention group compared to the control group
(IRR = 0.67, 95%CI: 0.36 to 1.26, p = 0.22)
51% lower rate of injurious falls in the intervention group compared to the control group
(IRR = 0.49, 95%CI: 0.22 to 1.11, p = 0.089)
These results were not statistically significant
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24. Falls : Adjusted for past falls (study not powered to measure the impact on fall rates)
21% lower rate of falls in the intervention group compared to the control group
(IRR = 0.79, 95%CI: o.44 to 1.42, p = 0.43)
40% lower rate of injurious falls in the intervention group compared to the control group
(IRR = 0.60, 95%CI: 0.28 to 1.29, p = 0.19)
These results were not statistically significant
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25. Adjusted for past falls, duration of impairment and visual field status
36% lower rate of falls in the intervention group compared to the control group
(IRR = 0.64, 95%CI: 0.34 to 1.15, p = 0.13)
Not statistically significant

26. Conclusions
Improvements in quiet standing balance and step length in the intervention group suggest increased confidence
Improved gait speed and step length in the multiple fallers suggest improvement in physical function in the most vulnerable
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27. Conclusions
Reduction in the rate of falls in the intervention group was similar for multiple fallers and non-multiple fallers (p = 0.71)
Suggest an effect of the Alexander Technique on fall rates in older adults with vision impairments
This requires verification in a larger trial
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28. Funding Sources In-kind support Guide Dogs NSW/ACT
Australian Postgraduate Award Scholarship
FM Alexander Trust –United Kingdom
AUSTAT – Australian Society of Teachers of the Alexander Technique
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29. References
Verdú E, Ceballos D, Vilches J J, Navarro, X.(2000). Influence of aging on peripheral nerve function and regeneration. Journal of the Peripheral Nervous System 5(4):
Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, Sharp DM, Hale LA. (2005). Randomised controlled trial of prevention of falls in people aged >=75 with severe visual impairment: the VIP trial. BMJ 331(7520):
Kovács É, Tóth K, Dénes L, Valasek T, Hazafi K, Molnár G, Fehér-Kiss, A.(2012). Effects of exercise programs on balance in older women with age-related visual problems: A pilot study. Archives of Gerontology and Geriatrics 55(2):
Cheung KKW, Au KY, Lam WWS, Jones AYM.(2008). Effects of a Structured Exercise Programme on Functional Balance in Visually Impaired Elderly Living in a Residential Setting. Hong Kong Physiotherapy Journal 26: 45-50
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30. References Australia | China | India | UK
Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. (1994). A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. Journal of Gerontology: MEDICAL SCIENCES 49(2): M85-M94.
Lord SR, Ward JA and Williams P. (1996). Exercise effect on dynamic stability in older women: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation 77(3):
Lord SR, Menz HB and Tiedemann A. (2003). A Physiological Profile Approach to Falls Risk Assessment and Prevention. Physical Therapy 83(3):
Perera S, Mody SH, Woodman RC, Studenski SA.(2006). Meaningful Change and Responsiveness in Common Physical Performance Measures in Older Adults. Journal of the American Geriatrics Society 54(5):
Sherrington, C., Tiedemann, A. et al. (2011). Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 22(4):
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