Strength training and falls among older adults: a community-based TR intervention.
Ample evidence has existed for more than a decade to support the use of strength training to improve the functional fitness of older adults. For example, Fiatrone and her colleagues (Fiatrone et al., 1990, 1993, 1994) demonstrated that strength training in markedly de-conditioned older adults improved lower extremity strength, walking speed, and stair climbing ability. With specific reference to the use of strength training for older adults as a therapeutic recreation (TR) intervention, Mobily, Mobily, Lane, and Semerjian (1998) showed that a community-based strength training program delivered by therapeutic recreation specialists was effective in improving the functional fitness of senior subjects. Subjects improved in arm strength, agility, coordination, flexibility and dynamic balance following participation in a community-based strength training program delivered at a senior citizens center.
However effective community-based TR may be at improving functional fitness among older adults, another challenge remains. While improvement in functional fitness is laudable as a health objective, the question that remains is whether strength training and the resulting functional improvements can be linked to the support of functional independence and avoidance of hazards that are associated with increased risk of institutionalization. If functional fitness gains cannot be translated into a convincing relationship with a variable that correlates with remaining independent in the community, then the efficacy of strength training as a TR technique will continue to be questioned.
Although several markers of functional independence appear in the literature, reducing the incidence of falls among the elderly may have the most impact on remaining independent. Functional fitness improvements resulting from strength training are meaningful to the extent that they, in turn, are associated with a reduction in fall risk and incidence.
Another question concerns whether the effectiveness of strength training relates to the seriousness of injury if the older adult does fall. Effectiveness of a community-based, TR led, strength training initiative may be further judged based on whether participation helps subjects avoid serious injury. For example, strength training may enhance the person's ability to extend the hands and arms in a protective manner and avoid or minimize injury during a fall.
Lastly, further verification is needed to determine whether recreational level strength training programs are effective as a TR modality. Only one study (Mobily et al., 1998) within the TR literature was identified. Replication of the effectiveness of strength training as a TR modality is timely because of the gradual transition of many allied health services from inpatient, acute rehabilitation to outpatient, preventive intervention. This is a vital concern for TR because of the escalating incidence of chronic conditions (Jette, 1996) associated with the aging of the US population. Persons with chronic conditions need on-going, health promotion programs in the community to avoid the loss of functional independence and development of co-morbid conditions.
Falls are a significant health problem for older adults. Estimates of the incidence of falls vary somewhat, but between 33% (Fuller, 2000; Sattin, 1992; Tinetti, Speechley, & Ginter, 1988) and 30% (Nourhashemi, Rolland, & Vellas, 2000) of adults 65 and older fall at least once each year. Furthermore, 60% of nursing home residents fall each year (Fuller, 2000). Not only do older adults fall more often than middle-aged and younger adults, they are more likely to sustain a serious injury or die as a result.
Falls are the leading cause of death from accidents in seniors (Hoyert, Kochanek, & Murphy, 1999), exceeding those caused by vehicular accidents. The danger to those 75 and older is even more pronounced, with 70% of accidental deaths in the 75+ cohort resulting from falls (Fuller, 2000). Twenty percent of hip fracture cases among older adults die within a year of injury (Jacobson, 2002).
Serious injury may also result from a fall. Over 85% of fractures among older adults are caused by falls (Baker, O'Neill, Ginsburg, & Goohua, 1992; Carter, Kannus, & Khan, 2001; Kraus, Black, & Hessol, 1984). Ninety percent of hip fractures are caused by falls (Fuller, 2000) and 10 % of falls among those 85+ years cause a hip fracture (Prudham & Evans, 1981). And the impact of a hip fracture on lifestyle is significant because of the development of functional dependence. For instance, about 50% of those sustaining hip fractures do not return to independent living in their own homes (Melton & Riggs, 1983; Scott, 1990).
With the serious consequences resulting from falls, researchers have turned their attention to identification of risk factors that are associated with falls in older adults. In his review, Fuller (2000) chronicled risk factors associated with falls into several categories: demographic factors (e.g., race, homebound, etc.), historical factors (e.g., previous falls, chronic conditions, etc.), physical deficits (e.g., cognitive impairment, reduced vision, etc.), and other factors (e.g., risky behaviors).
Careful inspection of risk factors associated with falls reveals that only some are modifiable. Non-pathological deconditioning (sarcopenia) that results from disuse is both a significant cause of falls (Lord & Clark, 1996; Tinetti, Speechley, & Ginter, 1988) in the elderly and a risk factor most responsive to modification in a favorable manner.
Disuse causes deterioration of fast-twitch muscle fibers, thought to be most responsible for strength, and leads to an increased risk for falls (Lacour, Kostka, & Bonnefoy, 2002). More broadly, Chandler, Duncan, Kochersberger, and Studenski (1998) found that strength loss led to all manner of functional decline among seniors in their study.
Fortunately, because muscle tissue responds quickly to exercise, the prospects for reversing sarcopenia are good in most frail older adults, thereby reducing the risk of sustaining a fall. Exercise has been effective in reducing the risk of falls in the elderly (Carter et al., 2001; Gardner, Robertson, & Campbell, 2000). Walking, Tai Chi, sport participation, and stretching and toning number among the types of exercise associated with a reduction in falls in older adults.
However, the most frequent and effective type of exercise employed in risk reduction trials has been strength training. Muscle tissue is especially responsive to overload associated with strength training. Using light to moderate resistance, significant gains in muscle mass and power have been recorded in older subjects (Hurley & Roth, 2000). Strength training with older subjects has led to improvements in fall risk in general (Hurley & Roth, 2000) and specific tasks and skills associated with functional mobility in particular, such as rising from a seated position, gait speed, transfers, stooping, stair climbing, balance, and lower extremity strength gain (Chandler et al., 1998; Fiatrone et al., 199,; 1993, 1994; Gregg, Pereira, & Caspersen, 2000). Upon completion of the literature review, the present authors concluded that falls present a serious threat to older adults. With the continued aging of society, falls will likely become a more significant health problem for the foreseeable future. The literature also supported the conclusion that exercise, and particularly strength training, is effective in reducing the risk and incidence of falls. What remains is to determine whether strength training delivered in a field setting by TR leads to fewer falls.
This study sought to answer three research questions.
1) Can a community-based, TR-led strength training program improve the functional fitness of asymptomatic older adults? The first matter to establish is that recreational level strength training using light to moderate resistance results in improvement in functional fitness measures of strength, coordination, and balance. In this respect, the present study seeks to replicate the results of Mobily et al. (1998).
2) Does participation in strength training reduce the reported incidence of falls in older adults relative to an age and gender matched comparison group of elders? This was the central question of the study. We especially wanted to learn if strength training and the resulting functional fitness improvements were associated with a reduction in the reported incidence of falls.
3) Does participation in strength training reduce the incidence of serious injury among older adults relative to an age and gender matched comparison group? If an older adult does fall, we hypothesized that the functional fitness benefits of strength training would lead to better use of protective responses (e.g., extending the arms for protection, rolling with the fall, etc.).
Ultimately, the main purpose of this study was to determine whether elderly subjects who participated in a strength training program fell less and sustained less serious injuries over a one year follow-up period. As a necessary prerequisite to the main purpose, a secondary purpose of this study was to confirm that subjects who participated in the strength training program demonstrated improvements in functional fitness measures as a result of participation.
Strength training subjects were solicited from those who participated in a strength training program for older adults within the preceding year. Twenty-one of 34 participants in the strength training program agreed to respond to a follow-up questionnaire pertaining to falls and injuries over the preceding year. Of those who did not participate in the follow-up, five could not be located at the phone number on their initial registration for the program. Another six did not return repeated phone calls. One phone number was disconnected and one refused to participate.
The comparison group was solicited from individuals who visited the same senior center where the strength training program met but did not participate in the strength training program. The researchers sought to recruit subjects in the comparison group who were "active" older adults in the sense that they continued to be involved in activities in their community. Accordingly, members of the comparison group visited the senior center to participate in other activities (e.g., cards, music, crafts, etc.) and/or to eat at the congregate meals program located at the same facility. Recruitment of comparison group members focused on obtaining an age and gender match to subjects in the strength training group who had agreed to participate. A total of 22 older adults volunteered to participate as members of the comparison group. One extra individual was recruited into the comparison group because the researchers were waiting on a promise to return a call from one additional strength training participant at the time the comparison group was recruited.
Strength Training Program
Subjects who participated in the strength training program within the preceding year completed the Revised Physical Activity Readiness Questionnaire (rPAR-Q; Shephard, Thomas, & Weller, 1991) prior to participation. The questionnaire asks subjects about seven different symptoms (e.g., "Have you developed chest pain in the last month?") they may be experiencing. An affirmative response to any of the seven items indicates that the person is not ready to participate in a moderate intensity exercise program without consultation with his/her physician. The rPAR-Q is a widely used health screening device for community-based exercise programs. Physicians were contacted for permission to participate whenever any subject in the present study answered one or more items on the rPAR-Q in the affirmative. In all cases, physicians did not hesitate to give their permission for participation.
Cardinal (1997) examined the usefulness of the rPAR-Q as a screening device by comparing responses to physiologic measure of fitness (e.g., maximum oxygen consumption estimates). He found that rPARQ responses were significantly associated with three of the five measures of health, and concluded that the rPAR-Q was a conservative screening measure useful in identifying elderly subjects eligible for participation in moderate intensity exercise programs.
The program itself was led by a Certified Therapeutic Recreation Specialist [TM] (1) (CTRS[R]) who was trained in delivering strength training programs to older adults and had previous experience with such programs. Strength training classes met three times per week for six weeks at a time. A typical session lasted 45 minutes, including a five minute warm-up interval (stretching), 30-35 minutes of strength training using light weights (typically one to five pound hand weights), and ending with a five to ten minute cool down and relaxation interval. Balance exercises (e.g., one foot balance with a chair for support as needed) were included in the closing ten-minute period of the classes as well. The average compliance of the strength training subjects was 82.6% sessions attended.
Dependent variable data for functional fitness measures, balance, and leg strength were collected before and after completion of the strength training program. Only subjects in the strength training program completed the functional fitness measures and assessments of balance and lower extremity strength. All subjects responded to the follow-up questionnaire pertaining to fall events, health, and physical activity over the past year.
Functional fitness measures
The hand-eye coordination and arm strength assessments were taken from the functional fitness test battery for adults over 60 years (Osness et al., 1990). For the coordination task, the subject is seated at a table and instructed to move each of three pop cans from a beginning position to an adjacent position, flipping each can upside down in the process. The process is then reversed to return each can to its original starting position. The time it takes to perform this task twice is recorded. For this, three trials were given and the times were then averaged. The arm strength task requires the subject to assume a seated position with a hand weight (four pounds for women, eight pounds for men) held to the side in the preferred hand. Upon receiving a signal to begin, the subject curls the weight up to a 90 degree angle by flexing at the elbow. The task is repeated as many times as possible during a 30 second time interval. Only one trial is administered (because of fatigue) and the dependent measure is the number of repetitions the person can perform in 30 seconds.
Bravo et al. (1994) found that the Functional Fitness Test Battery as well as individual items demonstrated sound test-retest reliability. Likewise, Shaulis, Golding, and Tandy (1994) discovered good reliability for the items on the functional fitness tests using an intra-class coefficient for stability. Coefficients for all items on the battery were 0.90 or higher.
Dynamic balance was assessed using the timed up-and-go test (Podsiadlo & Richardson, 1991). The test requires the subject to begin in a seated position in a chair with arms. Upon receiving a signal to begin, the subject stands and walks past a line three meters away, turns, walk back to the chair, and returns to a seated position. The measure is the amount of time (in seconds) that it takes to complete the task. Subjects repeated the task three times; the dependent measure was the average performance across three trails. Dynamic balance (balance while the person is moving) was preferred over static balance insofar as falls usually occur during ambulation instead of a stationary position. The assessment was judged reliable based on inter-rater consistency and valid based on significant correlations with functional measures, such as balance, gait speed, and functional capacity. The developers also found that the measure predicted ability to move around outside safely.
Lower extremity strength is implicated in falls, in cases of sarcopenia, and in avoiding falls in fit older adults. The timed stand test was used to estimate subjects' lower extremity strength in the present study. The test was developed by Csuka and McCarty (1985) as a simple, field method of evaluating leg strength. The subject is asked to stand up and sit down ten times beginning from a seated position. Time to complete the task serves as the dependent measure. Because of fatigue, the timed stands test was administered only once. Test-retest reliability of the test when administered ten weeks apart has been reported at 0.88 (Newcomer, Krug, & Mahowald, 1993). Evidence of timed stands test validity was demonstrated by its correlation with several functional performance measures--time to walk 50', lower extremity manual strength, and reported physical activity (Newcomer et al., 1993).
Subjects in both the strength training group and the comparison group answered items on the follow-up questionnaire pertaining to falls, health, and physical activity over the past year.
The researchers adopted the conventional standard for determining a fall. All subjects were read the following definition for a fall: "A fall is defined as an event which results in a person coming to rest unintentionally on the ground or other lower level, not as a result of a major intrinsic event (such as a stroke), or overwhelming hazard" (Tinetti et al., p. 1702). The subject was then asked to report the number of falls they had experienced in the past year, where each fall occurred, what they believed caused each fall, and whether they sustained an injury as a result of the fall.
The same follow-up questionnaire included questions adopted from the work of Magnus, Matroos, and Strackee (1979) on health and physical activity over the past year. Responses to the three questions predicted acute coronary events in Magnus et al.'s original work. Subjects were asked if they had changed to a more sedentary way of life in the past year, participated in regular light to moderate exercise, regularly lifted heavy objects, did heavy work (e.g., mowing lawn manually), or participated in sports (e.g. jogging).
Subjects who had participated in a strength training program especially designed for senior citizens within the last year were contacted through class rosters. Initial contact was made by the first author advising each subject of the intent of the study and the importance of the work in addressing falls in older adults. During the initial contact, the subject was advised that he/she would receive a call from one of the other members of the research team to ask questions about exercise and falls. The number and percent of subjects responding is reported above in the "subjects" section. Upon nearing completion of questioning of the strength training group subjects, the researchers identified an age and gender matched group of older adults for comparison purposes. These subjects were solicited at the same senior center where the strength training program took place. Upon volunteering to participate in the study, each subject was read the same questionnaire items and answers were recorded by one of the researchers.
Exact p-values for small sample sizes were generated by exact non-parametric methods. Specifically, Fischer's Exact test was used to analyze categorical variables, and the Wilcoxin Exact test was employed with continuous variables. Whenever significant differences in control variables were identified, the control variables were included in analyses of dependent variables. Descriptive statistics were employed to report a profile of each group's age, gender, and exercise habits over the past year. A frequency distribution table was developed to display location, cause, and type of injury.
The attributes for each group are reported in Table 1. Average age and gender distribution for each group was approximately the same. A considerably higher percentage of strength training group members reported heavy exercise, as would be expected because of their participation in the strength training program. A high percentage (73%) of comparison group subjects reported regular light to moderate exercise over the last year, even though more than half of them also stated that they had become more sedentary in the last year. This finding suggests that many (nearly 60%) of the comparison group subjects had been more active in the recent past.
Table 2 displays data analyses for control (i.e. gender, age, becoming more sedentary, light to moderate exercise, heavy exercise) and outcome variables (i.e. number of falls, hand-eye coordination, arm strength, leg strength, balance). No gender or age differences were observed for the control variables. Further analysis of control variables revealed that the strength training group and comparison group were not significantly different in most respects (i.e. gender, age, light to moderate exercise). However, two control variables differed based on group membership.
As expected, a significant difference was observed for reports of regularly lifting heavy objects. Fifty-seven percent of the strength training group said that they regularly lifted heavy things during the past year; whereas, only 23% of those in the comparison group reported regularly lifting heavy objects. This finding validates that the subjects in the strength training group were more likely to believe they were participating in regular, heavy exercise than subjects in the comparison group. In addition, a significantly greater number of comparison group subjects (59%) said they became more sedentary in the last year than the strength training group (19%).
Analyses of functional outcomes in the strength training group are also found in Table 2. The results replicated earlier findings from Mobily et al. (1998). Subjects who participated in the strength training program demonstrated significant improvements in hand-eye coordination, arm strength, leg strength, and balance. The hand-eye coordination task was completed almost two seconds faster after six weeks of strength training (M before=12.28 [+ or -] 2.67, M after =10.54 [+ or -] 1.96).
Likewise, arm strength, reflected by number of arm curls performed, improved by more than five repetitions (M before=21.94 [+ or -] 6.92, M after =27.17 [+ or -] 6.39), and leg strength improvement was indicted by a three and one-half second decrease in the amount of time it took to stand and sit ten times (M before=22.53 [+ or -] 3.84, M after =19.00 [+ or -] 3.36). Lastly, the time it took to rise, walk three meters, and return to a seated position (dynamic balance) was decreased by almost a second (M before=6.47 [+ or -] 0.99, M after =5.74 [+ or -] 0.83).
For the most part, gender and age did not influence the performance of the strength training group on functional measures (see Table 2). The exception was a gender difference for balance. Men improved their balance more than women. However, this was primarily attributable to the slower performance of the men before beginning the strength training program (men before M =8.16, women before M =6.41) because performance of the task after completion of the strength training program was about the same for men and women (men after M =5.85, women after M =5.72) A gender difference (see Table 2) in falls was discovered (p=0.044), with men more likely to fall than women (62.5% of men fell at least once, 31.4% of women fell at least once). Accordingly, gender was controlled for in the analysis of falls by group (strength training vs. comparison). The data indicated that group membership (strength training vs. comparison) was significantly (p=0.049) associated with reported falls, while controlling for gender. The strength training group reported 10 falls, while the comparison group reported 19 falls. Eleven (50%) of the comparison group subjects reported falling at least once in the past year, while only five members (24%) of the strength training group fell at least once in the past year.
Table 3 displays the qualitative characteristics of the falls reported. Serious injuries were not appreciably more frequent in either group, with three fractures reported (one in the strength training group, two in the comparison group) in the same proportion as the overall rate of falls (i.e. about half the frequency of serious injury in the strength training group). Interestingly, all of the falls reported by the strength training subjects occurred outside the home; whereas, about one-half of the falls reported by the comparison group happened in the home (home, steps, bathroom). About one-half of the falls in each group could not be attributed to a specific cause. Otherwise, trips, slips, and steps accounted for most of the explainable falls in both groups.
The results of this investigation led us to conclude that:
* Strength training was successful in improving functional fitness of participants;
* Those who completed the strength training program were significantly less likely to fall; and
* Strength training can be delivered effectively by TR in a community-based setting.
Improvements in functional fitness measures on the part of the subjects who participated in the strength training program replicated earlier results by the investigators (Mobily et al., 1998). Specifically, improvements were found in functional abilities related to avoiding falls and maintaining an independent lifestyle in the community. Hand-eye coordination serves as a window into the nervous system, indicating the extent of sensory-motor coordination and processing capability. Of course, leg strength has a rather direct connection with falls insofar as lower extremity strength has been reliably identified as a risk factor for falls (Chandler et al., 1998; Hurley & Roth, 2000). Likewise, balance is highly correlated with falls; poor balance is also regularly identified as a risk factor for falls (Chandler et al., 1998). Although arm strength does not have the immediate and intuitive appeal of leg strength as a risk factor for falls, it has been identified as a risk factor for the loss of independence among older adults (Chandler et al., 1998; Ostwald, Snowdon, Rysavy, Keenan, & Kane, 1989; Williams & Hornberger, 1984).
The main finding of this study was that strength training subjects were significantly less likely to fall in the preceding year than comparison group subjects. The protective effect of the intervention meant that strength training subjects decreased their risk of a fall by about 50%. Strength training subjects reported an average of 0.48 falls per person, while the comparison group subjects fell at a rate of 0.86 times per person. The fact that the comparison group was relatively active (73% said they participated regularly in light to moderate exercise) makes difference in fall rate even more remarkable. Clearly, the comparison group could hardly be considered sedentary. Hence, the significant difference in falls may reflect a value-added effect of strength training, above and beyond that of a regular light to moderate exercise program. Certainly, the beneficial effects of strength training found here urge use of strength training as part of a complete functional fitness program for older adults.
Severe injuries were not proportionately lower in the strength training group. However, because the absolute number of falls was larger in the comparison group, the risk exposure (for a serious injury) was greater in the comparison group.
The location of the reported falls did attract our attention, too. None of the falls reported by strength training subjects occurred in the home. In contrast, half of the falls in the comparison group took place in the home. This means that the comparison group fell half of the time in an environment that was known and predictable--their own home. This pattern of falls may be interpreted in two ways. Strength training subjects may have been more confident in their functional abilities and were more likely to hazard a trip outside their homes (and accordingly 100% of their falls were outside the home). Conversely, comparison group subjects may have been less willing to venture outside of their homes. Even after they attempted to avoid falls by staying home, comparison group subjects still fell twice as often and half of their falls were in their own homes.
Importantly for TR practice, the findings of this study demonstrated that strength training for an at-risk group of older adults was feasible. Strength training as a programmatic offering has several desirable attributes that should attract the attention of TR practitioners. It is safe insofar as the amount of resistance does not have to be excessive and stressful (subjects in this study typically used one to five pound hand weights). Simple and effective screening devices such as the rPAR-Q are accessible and available for field use. The program is "low tech" in the sense that only a small amount of simple equipment (e.g., light hand weights, mats, folding chairs, etc.) is needed. Because the equipment is inexpensive the program is low cost. Offering strength training in a group setting (as was the case here) increases the efficiency of the program and keeps per capita overhead costs to a minimum. The group setting typical of our strength training program is also conducive to enjoyment by way of social interaction and mutual support between participants. Dishman (1994) has noted that enjoyment is an important factor in determining compliance with exercise programs among older adults. The findings were very encouraging, but not conclusive because of methodological shortcomings. Ideally, in future studies both the strength training group and the comparison (control) group would be tested for functional abilities. Also, a completely randomized trial would strengthen the internal validity (cause-effect relationship) of a follow-up study.
The present study demonstrated that strength training by older adult subjects was not only effective in improving functional abilities, but also showed that those very same functional improvements translated into an improved quality of life, i.e., avoiding falls. In addition, this study showed that strength training is a viable program option for community-based TR because of its effectiveness, safety, and ease of implementation. With the aging of US society and the increase in the incidence of chronic conditions, TR programs designed to enhance functional abilities and thereby improve quality of life among at-risk groups should prove to be more in demand.
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(1) The trademarks 'CTRS[R]' and 'Certified Therapeutic Recreation Specialist[TM], are property of the National Council for Therapeutic Recreation Certification[R], all rights reserved."
K. E. Mobily is with the Program in Leisure Studies and the Department of Exercise Science; P. R. Mobily is with the College of Nursing; Raimondi is an undergraduate student with the Program in Leisure Studies; Walter is a graduate student with the Program in Leisure Studies; and Rubenstein is with the Department of Epidemiology. All authors are at the University of Iowa.
Kenneth E. Mobily, Paula R. Mobily, Robyn M. Raimondi, Kathy L. Walter, & Linda M. Rubenstein University of Iowa
Table 1. Summary of Characteristics for Strength Training and Comparison Groups Strength Comparison Variable Training Group Group Gender (% female) 81% * 82% Average age 72.8 74.5 Have you changed to a more sedentary 19% 59% way of life in the last year? (% "yes") Do you regularly participate in 95% 73% light to moderate exercise ...? (% "yes") During the last year, did you 57% 23% regularly lift or carry heavy things ...? (% "yes") Table 2 Exact p-values for Characteristics, Falls and Functional Ftness * Gender Age Variable Group p-value p-value p-value Gender 0.999 Average age 0.361 0.403 Sedentary lifestyle 0.012 0.205 0.999 Light to moderate exercise 0.095 0.446 0.999 Lift or carry heavy things 0.031 0.315 0.946 Number of falls (4 0.049 0.005 0.626 categories): 0, 1, 2, 3 Before-After Hand-eye coordination 0.001 0.303 0.503 Arm strength 0.004 0.587 0.351 Leg strength 0.001 0.140 0.999 Dynamic balance 0.001 0.044 0.536 * Note: Fischer's Exact test used for categorical variables, Wilcoxin Exact test used for continuous variables. Table 3 Nature of Falls: Strength Training versus Comparison Group * Strength Comparison Description Training Group Group Injuries: No reply 3 4 No injury 4 7 Cut foot 0 1 Bruise/sore 2 5 Fractured wrist 1 0 Fractured ankle 0 1 Fractured arm 0 1 Location of fall: Home 0 6 Steps 0 2 Bathroom 0 2 Street 2 2 Sidewalk 3 4 Hill/uneven terrain 3 0 Indoor public facility/store 1 1 Other 1 2 Reported cause: Don't know 6 10 Trip 3 3 Sip 1 2 Steps 0 3 Vertigo 0 1 * Note: In the strength-training group, a total of five people fell 10 times. In the comparison group, a total of 11 people fell 19 times.
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|Author:||Mobily, Kenneth E.; Mobily, Paula R.; Raimondi, Robyn M.; Walter, Kathy L.; Rubenstein, Linda M.|
|Publication:||Annual in Therapeutic Recreation|
|Date:||Jan 1, 2004|
|Next Article:||Effects of a computerized therapeutic recreation program on knowledge of social skills of male youth with emotional and behavioral disorders.|