Understanding of Balance Exercises - Research Paper Example

RESULTS AND ANALYSIS The results of this research project have to be viewed as specific to one gym with demographics particular to it. Insight is more generally possible, however, into the activities performed at an established gym with a wide range of facilities and exercise classes. Other gyms in the area are less well equipped and provide fewer balance classes, general classes or have no areas for mat work or specific balance exercises. The presence of these resources informed the choice of this specific gym. Graphical and table representations of the results can be found in the appendices to this paper. 110 people were asked to complete the questionnaire. Most participants were pleased to be involved and many were keen to discuss the research. On completion of the questionnaire there was time to explore participants’ understanding of balance exercise, the benefits thereof and to opportunistically encourage participation in such exercise. The survey was analysed using Microsoft EXCEL and PASW Statistics package. In total 110 people responded to the questionnaire. Slightly more than half of the respondents were women (55%). Respondents were classified into age groups with the divisions between the age groups chosen to fit important life boundaries. The largest single group were aged between 36 and 50 years of age (41%) with just 8% aged over 65. The detail of the age-sex demographics of the respondents is shown in figure 1 below. There were no statistically significant differences in the age distributions of men and women. See Table 1, Page 45 Retention of respondents at the gym was high with almost half the respondents (47%) having attended for 5 years, or more. No significant differences were found in the retention times for men and women, or between respondents in different age groups. Respondents were also frequent attendees at the gym with over half (59%) attending three times per week and almost 90% attending at least twice a week. Again there were no significant differences in attendance rates between men and women, or for different age groups.  The vast majority of the respondents had been given an induction session when they joined the gym (83%, n= 91). Women were more likely than men to have undergone induction with only 5 women having had no induction at all, (8%) compared to 14 men (29%). This difference is statistically significant (Chi-squared = 7.89 1df p=0.005). This might suggest either that gym staff are more willing to offer an induction session to women than men, or that women are more willing to accept induction. A cross tabulation of whether an induction session had been received, with the duration of regular attendance at the gym suggested that the proportion receiving induction had remained constant over time. Just over one third of those who were given an induction session had balance exercises explained and discussed during the induction (33 out of 91). There is no evidence to suggest that women were more likely to have been offered balance exercises than were men, nor that there was any difference in emphasis on balance activity among those in the various age groups. 30% of respondents had been advised to perform balance activity by parties other than gym instructors. 54% (18 participants) of these were advised by a health professional and all advice was received after consultation relating to previous injuries. There was no statistical difference in gender or age group discernible within the aforementioned group. Of the 18 participants, 11 had not continued balance activity. This suggests that despite people being aware of prevention and re-injury they still experience barriers to performing such beneficial activity. 60% of respondents performed balance activity with a mean number of balance sessions per week of 1.7. The distribution of results is skewed with a small number of respondents undertaking many sessions while the majority undertook very few. (see boxplot- to add in). Women seem to undertake more balance sessions than men with the median woman completing 1 session per week compared with no sessions for the median man. This difference is significant p=0.003 (Mann Whitney U test). The mean number of sessions per week is also higher for female respondents at 2.2 than the mean of 1.1 for male respondents. Of the respondents performing balance sessions 74.5% perform 1 session twice a week and 25.5% 1 session 3 or more times per week. Current guidelines advocate activity levels of three or more times a week. Lack of knowledge of a particular activity is often a barrier to those who perform little exercise, and barriers may be different not only for different genders, but also for different ages, and levels of fitness (Newson, 2007). This and the gender differences observed in the engagement in balance activity are considered in the discussion section. 56% of respondents performed sports (34 male, 28 female). This corresponds to 69% of males and 46% of females. The distribution of the results was skewed with a significant gender difference (Mann-Whitney test mean rank males =66.1, females =46.9) and was seen in the average number of sports performed per week: for males =2.63 and for females =1.56. Stem & leaf plot Significant differences were also noted within male age groups between 20-35 years of age and within those 66-80 years old. Means of 2.45 and 3.33 are seen for these groups, in comparison to 1.58 and 1.92 for the two age groups between the two mentioned. “Higher risk sports” (to exclude cycling, bowling and swimming and to include football, tennis, squash, racquetball, running, cricket, climbing, golf and hockey) were considered to be activities using lower limb function/ twisting/change of direction with potential for increased risk of lower limb injury. ‘”Higher risk sports” activity mirrored the results of all sports with significant gender and age differences (Male mean 1.85, Female mean 0.54, and Mann-Whitney Test mean rank: male 71.6, female 42.6) and the peaks of activity in the upper and lower male groups were evident again. Men appear to participate in all sports more often than women, with age differences of significance. Women, however, appear to do more balance activity. Review of research in this field supports the notion that sports participation is higher in males and looks further at reasons for this within the discussion. Sport is considered to be a large component of cultural identity and that sporting involvement within females still remains low in comparison to males, particularly in non-English-speaking countries (Taylor+Toohey, 1998). A cross tabulation of respondents who do sports shows 42% do not perform balance exercise and as a result have potential increased risk of injuries. 64% of respondents did comment on their reasons for lack of uptake of balance sessions and many respondents made multiple comments. There is a discrepancy in the number of comments: 26 of these respondents did actually do balance sessions. This in itself reveals a lack of understanding of either the specific question or the questionnaires’ covering information sheets or of what constitutes balance activity. This fact, though, does highlight a lack of understanding of balance training and the confusion as to whether it is, or is not, being performed. This section of the results is therefore difficult to interpret but some analysis and comment is offered, nonetheless. See Table 9, Page 53 - 54 Following analysis there were 3 areas of note relating to gender differences. 42.9% males and 23.0% females were unaware of the benefits of performing balance activities or exercises. A descending mean analysis confirmed that females are more aware of the benefits of balance training and that this was of significance (Chi- square p=0.026). Males also have a preference for concentrating on strength and aerobic activity (20 males, 4 females) rather than performing balance exercises. More females than males experience an induction process. A cross tabulation of induction, balance discussion and performance of balance showed that of those who received induction, males and females were equally likely to have balance mentioned. From this you would anticipate that males and females would perform balance activity equally, but the results indicate that females are more likely to participate in such activity than men. Additional “other” comments related to gender and barriers to balance performance: Male (20-35 years): “No men do mat work and there are no male gym instructors who do balance classes. It’s all women and during the day. Even with circuit or body attack/tone you feel outnumbered by women. I’m not sure what to do. I’ve seen people doing plank but don’t know what the benefits are or why you do it.” Male (20-35 years): “They took the small room off us (males in weights section) and put rowing machines in it. Some of us used it to do some mat and plank work but now you can only do that in the open gym. It doesn’t look cool doing that sort of exercise so nobody does it. If the room was still there I’m sure it would be used. It would be better if someone could show us how to do it as we don’t really know what to do or how often.” Male (20-35 years): “Our footy coach said we should do some but I’ve no idea what to do and don’t want to look a jerk by asking him.” Male (20-35 years): “Maybe a poster on the wall showing us what to do and why. I’ve never been shown and I’ve never asked.” Male (20-35 years): “Further information would be useful. I know it is good for you but I’m not really sure why. You can’t see the benefit like you can with aerobic or strength training so it’s easy not to do it.” Female (51-65 years): “Word spreads when you are older, you have more time to read and are aware of the benefits and have time to do exercise that will help flexibility and stop you falling. It’s more sociable doing classes and enjoyable.” Female (51-65 years): “The classes are good fun and it punctuates the day. I wouldn’t do half of what I do in a class if I did my own thing” Incidental comments, such as these quoted, have value in that they have highlighted the relative lack of knowledge gym-goers have, relating to the importance of, as well as the characteristics of balance exercise. While they are allegorical, and represent purely subjective opinions, they have strengthened the conclusions reached in this paper. It is the contention of the paper that many gym attendees may be participating in balance activity, unaware of its benefits, at levels below those recommended by the literature in the field. There are also significant differences between males and females in uptake of sport and balance activities – this is explored further in the discussion. Summary relating to study aims and research questions 1. Frequency with which gym users attend. 11% once a week; 30% twice a week; 59% three times or more a week. 2. Proportion of gym users who were advised during induction programmes that balance activity was a necessary component of their exercise regime. 83% of respondents had induction. 36% had balance activity discussed at induction. 64% did not have balance activity discussions. 3. Proportion of gym users that perform balance activity and the frequency with which it is performed. 60% of respondents perform balance activity. Of the 66/110 participants who performed balance exercise, 74.5% performed it less than 3 times a week, 25.5% performed it 3 or more times a week. In total 17% (19/110) of respondents perform balance activity 3 or more times a week. 4. Proportion of gym users who perform sports activities and the frequency with which they are performed. 56% of respondents perform other sports activities once per week (69% of males and 46% of females) 39% take part in sports less than 3 times a week, 17% take part in sports more than 3 times a week. Of the 62 participants who do participate in sports, 58% also perform weekly balance activity. 5. Qualitative elements of the questionnaire. Reasons for lack of engagement in balance activity were considered and reported on. Such comments, along with additional comments made by researchers in papers used in the literature review, inform the discussion section which will examine and provide writer’s comments on the findings of the survey as reported. RESULTS AND ANALYSIS RESULTS AND ANALYSIS DISCUSSION Superficially this writer’s assumption that the majority of recreational gym users do not perform specific balance exercise has, to a degree, been revised owing to the results of this survey. 60% of the participants do participate to varying degrees in such activity, whether they are aware that they are partaking in specific balance exercise or not. However, set against this only 19/110 (17%) perform balance activity at the current evidence based level, as informed by the studies reflected in the literature review and much contemporary advice. The literature review also reveals that balance activity of once a week for 1 hour could be as effective on outcomes as the current guidelines of shorter durations 3 times a week (Li 2005). 47/110 participants do balance activity at a frequency of less than thrice a week and 19/110 more than thrice a week. Although the survey did not look specifically at the time spent in minutes per week performing balance exercise, it is possible that those performing activity once a week may experience some beneficial effect, even if their exercise is not of 1 hours’ duration (see: Nitz, 2004 : once a week for 40 minutes). This could be an area to explore further, perhaps in subsequent larger studies, with a different focus. Literature in the field supports the positive effects of balance training on falls in people of older ages and injury and re-injury rates in all ages (see for example: Voukelatous, 2007, and Hume, 2008). The survey participants are a highly selected group of gym users who are motivated to attend the gym regularly and more generally sports orientated. All attend weekly with 98/110 attending twice a week or more. Over 50% of the gym users had been members of this gym for more than 5 years. There are no significant demographic differences between males and females. This finding is despite evidence in the literature to suggest that women still frequently have very different attitudes to sport than those of men. But women continue to redefine themselves in a changing world. Many barriers to their entry into sport have been lowered but there remains a challenge to question dominant norms without the view /label of “feminism”. (Hanis-Martin, 2006) The research could be used for comparison with other gyms’ attendees and also form a backdrop of evidence to be used within the general population, where it seems women are changing in their approach and attitudes to sport, generally. (ibid.) The results of the quantitative questions are as described. The qualitative questions should be viewed in the context that the questionnaire does not account for all participants’ views. They concentrate on those who do not perform balance activity and are used to explore the reasons for this. All results are analysed and processed to provide broad themes for discussion. Patterns and key issues making comparisons and looking at possible explanations are explored using the theory of planned behaviour (Ajzen, 1991). This is a validated model that proposes that an individual’s intentions and behaviour are predicted by beliefs about the positive and negative consequences of carrying out the behaviour. Gaining insight into reasons for non-participation in interventions is explored through attitudes and beliefs about balance training, reasons for not engaging, importance of balance exercise within their gym regime, engagement supported by someone other than a gym instructor and if they had continued to adhere to the exercise programme. Comparisons and interpretation of the data are used to develop explanations for non-participation. A very clear lack of perceived benefit of balance training is in evidence. 44 comments are explored and related to lack of benefit, lack of awareness of benefit and no perception of the training’s importance. Almost 1/3 of the comments state that the individual’s gym time is limited and because of this they do not perform balance training. 22 have time constraints and concentrated on exercise they feel most beneficial – “a good sweat out” or an hour’s swim. These behaviours could be explained by a lower perceived benefit of balance training in comparison to aerobic or strength training. 4 don’t feel there is any benefit and 3 that it is for the elderly only. It appears physical and psychological health or wellbeing is not in isolation strong enough reasons for regular exercise. (Koivula, 1999) Such aspects as physical health, weight control, appearance, stress/mood management, competition, enjoyment, fun, excitement and social interaction may result in variance of behaviour – the uptake of exercise. Older adults and females value competition less, while social incentives are less valued by younger adults and males. (ibid.) 4 respondents attended balance classes previously but no longer did so, with no explanation for this. Perceived benefit for a specific goal of aerobic or strength training is noted in 40 participants and relates to the concentration on strength or aerobic activity. A distinct lack of knowledge or limited knowledge regarding aspects of exercise routines emerges from the study. 108 comments on reasons for non-participation in balance exercise are recorded from 70 of those surveyed. Balance activity is not performed in 44 of those participants. The discrepancy in numbers arises from comments being made by 26 participants who are unaware that their gym regime contains balance activity. Despite the questionnaire information sheet, and advice when handing out the literature, confusion appears to be present regarding gym class components. Understanding of balance activities, and exercise to improve balance, seems to be an issue. There are 31 comments on being unaware of balance activity benefits. Some comments centre on received advice to perform balance training but without further explanation or reasons given, hence a subsequent lack of engagement. 33/110 participants had been advised by parties outside the gym to perform balance activities. 18/33 of these were advised by a health professional. 11 of these participants state that they had not continued to do so despite being aware of the benefits for preventing injury or re-injury. All gym users should undergo some form of induction when joining a gym and the majority of the participants in the survey had. In the writer’s view, this is an ideal time for imparting knowledge and improving understanding of balance exercise in isolation and within a multi-modal setting. Of the 91/110 participants who experienced induction 54 (59%) had no discussion of balance activity. Some participants were inducted with balance discussed as part of the introduction and still do not perform balance exercise. Important evidence regarding the motivations and barriers to exercise emerge from the survey. Comments made by male participants explore barriers to balance exercise uptake with specific issues. Only one male instructor ran a balance class. There is a perceived lack of encouragement by gym instructors to educate and advocate the importance of balance exercise. There is a dislike of performing mat work and balance activity in the open gym. One male made a request for more advice and information and it was thought this may encourage engagement. Poor uptake of balance training is an issue specifically in 20-35 year old males where 13/18 of that group do not engage in the activity (total males- yes 23, no 26). In comparison there is double the engagement of balance training in females (total females - yes 43, no 18). Motivation to exercise by improving stamina through aerobic activity, fitness for other sports and, to build upper body strength and muscle bulk, are mentioned by participants and could account for the attitudes of those who are not performing balance activity. The concepts of masculinity and femininity as well as an athletic competence may influence such preferences among males. (Miller+Levy, 1996) Two females made additional comments, stating that many retired people are aware of the benefits on falls reduction and that there are positive psycho-social and progressive aspects to gym classes. Those people who participated in other sports influence the results fairly significantly. 56% (62/110) perform other sports with an even distribution in under and over 50 year olds (58% vs. 53%). There is a high proportion of male under 50s who perform sports (70%). Many of the sports undertaken have a high incidence of injury due to strain and twisting. 26/62 (42%) of the participants who engaged in other sports do not perform balance exercise as part of their weekly regime, despite evidence that they are at increased risk of injuries. Further exploration of the attitudes towards balance training in this group and the appropriate educational interventions to improve the said attitudes could have an impact on falls and injury prevention. As recognized by Koivula (1999) and referred to earlier in this paper, older adults and females value competition less and this may give some initial direction to the formulation of strategies to increase their participation. CONCLUSIONS AND RECOMMENDATIONS While guidelines available at the gym, scientific literature and reviews provide data on the effectiveness of balance training, only 60% of the surveyed gym users perform balance training. A significant 40% do no balance activity. This is despite good facilities at this gym and many being encouraged to do so at induction. 42% perform regular sport activities but do no balance training and, as such, have increased risk of subsequent injury. Only 17% do balance training at the current evidence based level. There are many factors that relate to initiation and continuation of balance training. These may reflect patterns recognizable in the uptake of other exercise. Sports become stereotyped as gender–neutral, feminine or masculine based on conceptions regarding gender, gender differences and beliefs regarding perceived appropriateness of participation in certain sports due to gender. Sports that seek to provide beauty and aesthetic pleasure, that are graceful and non-aggressive are accepted by females more and are in line with the stereotyped expectations of femininity. (Koivula, 2001) In the study the main reasons for non-participation are a low perceived need, time limitations and a lack of understanding of balance and the benefits of this type of training. It would seem logical to increase awareness of the risks from falling and injury related to sports activities, in an attempt to improve participation, especially among sports coaches and sportspeople. Personal invitation is believed to be an important factor to take part in intervention especially from a health professional (Yardley 2006) but evidence from the questionnaire suggests that despite advice to continue balance training post-injury, over a half of the people surveyed do not. A theory of planned behaviour proposes that the relation between personality and behaviour is mediated by social-cognitive constructs contained within the planned behaviour. (Ajzen, 1991). A person’s intention to exercise is central determinant to exercise and is defined within attitude, subjective norm and perceived behavioural control. Attitudes play an important role and are reflected in a positive/negative evaluation of performing the behaviour. (ibid.) The perceived ease or difficulty of performing the behaviour may also have both direct and indirect effects on uptake of exercise activity. (ibid.) This raises the question of motivational aspects and whether more detailed assessments, that emphasize the multiple benefits of balance activity, the ease and enjoyment of balance exercises, and regular review, would improve uptake and adherence. Comments from participants in the survey mirror themes that appear in the literature review papers. Exercise education, facilities and exploration of individual or group programmes are thought to be relevant. Education would encapsulate all age groups and could promote a regime that might encourage engagement. Increased participation in multi-modal programmes, across ages and genders, would strengthen the social acceptability of this type of exercise. Following the results of the survey, evidence relating to the literature review, and previous literature, conclusions and recommendations could be considered and explored as they may apply to the population more generally. Exercise programmes for falls prevention should become a lifetime habit. Unfortunately there is poor uptake of balance activity in the general population (Gardner 2001). Lack of understanding and knowledge are factors that should be explored within both users and providers of falls, injury and rehabilitation services as well as within primary care and gym settings. Increased health expectations should be population wide, with a positive exercise ethos encouraged in both young and old. Changes in current service provision to look at “Exercise for all” in the community would be ideal. Any changes in the awareness of and the participation in balance activity exercise would be hard to achieve without full support from central and local government. Development and improvement of facilities for young and old, transport issues and the provision of quality balance exercise services have obvious cost implications. Encouraging the uptake of balance exercise is important for people of all ages and there is no exception to this, even among motivated recreational gym users – a group allegorically likely to be enthusiastic about new, beneficial exercise knowledge. This is especially important at induction as it was shown that the majority of this gym’s members did undergo induction. Gym instructors should be proactive and encourage balance exercise. Given that a high proportion of the participants were members for more than 5 years it would be useful to invite them for “review induction” and explore ideas and knowledge. Advice on which classes have balance components should be clear. For this to occur, the gym instructors should also be empowered to speak qualitatively about balance exercise and its benefits. Males in the weights section could be specifically targeted to encourage balance training and more male instructors should run classes with balance components which would not be perceived negatively by males, specifically, such as circuit and body attack. “Health classes” advocating health promotion could be encouraged with monthly topics using the foyer or café areas for posters/information boards. Encouraging family activities and group exercise could be explored with more information about the benefits of exercise, physiology and diet. The reality of gender differences should not be discounted, although there is encouraging evidence that these can be overcome. Although gender differences are discernible in leisure time physical activity, and in health promotion, and women tend to exhibit a lower rate of uptake of sport, they do enjoy the same level of strenuous activity as men do. Additionally, independent variables of perceived importance of sport achievement, sport and exercise related instruction, physical education experiences and social modelling were the same for both genders. (Vilhjalmsson+Kristjandottir, 2003) Current classes should encourage and educate gym users to incorporate balance exercise into their regime and advise as to why certain aspects are performed in the classes: “we are doing bumps on the bikes to improve core stability”, or “this exercise – standing on one leg with arm weights – is to increase your balance.” Advice on the “silent benefits” of balance training should also be incorporated at induction and throughout interactions between gym staff and clients. Information and educational material in the gym’s recreational areas could promote balance exercise and posters displayed in the gym areas with advice on balance and proprioceptive benefits would be a simple informative tool. Within the gym setting these are achievable recommendations and could have a positive effect on balance exercise uptake and engagement, which in turn will impact on falls and injury prevention and psycho-social behaviour. Finally, although many gym users do perform balance exercise, the question remains how many people in the general population do? This writer proposes that very few people in the general population are aware of the benefits of, or even the nature of balance activity. How can that be changed? Further study is certainly required and should include wider population surveys to establish accurate data. Methods are essential by which to encourage multi-modal activities, as well as balance exercise in isolation, if there is to be any major impact on falls and injury prevention. Read More