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Exerc Sci > Volume 32(3); 2023 > Article
Salsabila, Rahman, and Lindoyo: Different Effects of Single-leg Stance Exercise and Bridging Exercise with Core Stability Exercise on Older Adults Balance

Abstract

PURPOSE

Older adults experience a degenerative process that causes several health problems such as an increased risk of falling due to poor balance. However, to reduce the risk of falling exercise is used as an early intervention. The study aimed to understand the differences in the effect of single-leg stance exercises and bridging exercises with core stability exercises on increasing balance in older adults.

METHODS

A quasi-experimental study was conducted at the Salus Medica Physical Medicine and Rehabilitation Clinic using a sample of 30 individuals divided into two groups. The interventions were conducted twice weekly for one month. The evaluation included first, middle, and final evaluations using the Berg Balance Scale. Moreover, the statistical test was used to determine the effect of intergroup administration on increasing the balance of older adults, whereas the independent t-test was used to determine the effects of intergroup administration on increasing balance among older adults.

RESULTS

The results of the repeated-measures analysis of variance revealed that the p-value assumed sphericity in both groups (p=.000), which implies that the two groups improved the balance of the older adults. The independent t-test identified that the p-value equal variances were assumed (p=.572), which indicated no difference in the effect between the two groups in increasing the balance of older adults.

CONCLUSIONS

No significant difference between single-leg stance exercises with core stability exercises and bridging exercises with core stability exercises in improving balance among older adults was observed.

INTRODUCTION

The older adults or someone who is over 60 years old experiences degenerative processes such as a decreased function of the musculoskeletal system, which increases the risk of falling, which results in limitations in daily life and even death [1]. Research has found that 3.6% of the older adults risk falling [2]. Risk factors for falling in the older adults include an unsafe environment, history of falls, urinary incontinence, decreased leg muscle strength, decreased vision ability, and impaired walking and balance [3,4].
Single-leg stance exercise is an exercise that can optimally activate the muscles on the side of the body that is used as a pedestal. Bridging exercise increases trunk stability and muscle strength. Core stability exercise is an exercise that can activate the muscles without burdening the tissues so that it can stabilize the spine. This research chooses the straight leg raise exercise as a core stability exercise. Given that many older adults have knee complaints, straight leg raise exercises can help reduce knee pain by increasing the strength of the genu flexor muscles [5,6].
Balance training and fall prevention have traditionally concentrated on lower extremity strength management while ignoring other components of balance tactics. The addition of core training as one of the balance training methods has not been frequently recognised or imple-mented in patients. Research conducted by Wahyundari et al., shows that core stability exercises and bridging exercises are considered appropriate exercises for the older adults because they are designed to prevent falls. This exercise can restore the body,s postural control function, increase the range of motion of the joints and maintain body balance [7]. Meanwhile, research by Aksay states that single-leg stance exercise for four minutes a day has positive results in increasing the balance of the older adults [8].
These two exercises are more effective than others in improving balance in the older adults. This is because bridging exercise is important position that develops coordination in balance especially static balance. Furthermore, bridging exercises can be used as low intensity weight bearing which is safe for the older adults. Meanwhile, core stability exercise in the older adults was significantly increase balance and gait by improves the control of body [9-11].

METHODS

1. Participants

A quasi-experimental approach was used in this study which was carried out to find cause and effect through a pre and post-test research de-sign with a control group. The sample was taken using a purposive sam-pling technique with single blind, which means that only the researcher conducted the research and knew what interventions were received by the respondent to completion.
This research was conducted 4 weeks. The older adults population is 50 people, with 30 people as the selected sample. Participants were selected based on inclusion criteria; (1) aged 60-85 years, (2) can be invited to communicate, (3) willing to become research subjects, and (4) has no sensory, attentional, or cognitive impairments. Participants who had the following exclusion criteria were not included in this study; (1) respondents use walking aids, (2) BMI>30, (3) has injuries to the upper and lower extremities and vertebrae in the past six months, and (4) currently or have a history of stroke and Parkinsonʼ s. This study was approved by ethical committee RS Tk. II 04.05.01 dr. Soedjono, approval by number 182/EC/I/2023.

2. Older adults balance

Balance is the basis of the ability to stand upright and move, which can be improved effectively with various exercises [12]. The research instrument used in this study is the Berg Balance Scale (BBS). The results of the BBS can be interpreted with a ratio scale, namely 0 to 20: likely to need wheelchair assistance to move safely, 21 to 40: will need some type of walking assistance, and 41 to 56: independent in daily activities without walking aids [13].

3. Single-leg stance exercise

Single-leg stance exercise is an exercise that will stimulate sensory input and strength of the lower extremity. This exercise also requires full muscle activity on the sides of the body that are used as a pedestal [14]. The single-leg stance exercise intervention procedure includes: (a) have the respondent stand up straight holding the back of a chair, (b) give an example of the single-leg stance exercise first to respondents, (c) instruct the respondent to lift one leg forward around 75˚-90˚, (d) the other leg is supported in a straight state, (e) the dosage for single-leg stance exercise can be seen in Table 1, and (f) do it on the other leg [15].
Table 1.
Exercise prescription for single-leg stance exercise (4 weeks program)
Session Intervention Purpose Table content
I-IV Single-leg stance exercise Increases lower extremity muscle strength and postural control F: 2x/week
I: 8 secs and 8 reps with RPE scale 4-6
t: 2 sets with interval rest 2 min
T: strengthening, coordination, proprioceptive, and neuromuscular control exercise
V-VIII Single-leg stance exercise Increases lower extremity muscle strength and postural control F: 2x/week
I: 8 secs and 8 reps with RPE scale 4-6
t: 3 sets with interval rest 2-3 min
T: strengthening, coordination, proprioceptive, and neuromuscular control exercise

F, frequency; I, intensity; t, times; T, type.

4. Core stability exercise

Core stability exercise aims to improve the body's skills to minimize pressure and burden on the spine [16]. This study chose the straight leg raise exercise as a core stability exercise. The straight leg raise exercise intervention procedure includes: (a) the respondent is supine and relaxed on a mat/bed with a pillow above his head (optional). Trunk and pelvic in the neutral position, (b) give an example of the straight leg raise exercise first to respondents, (c) instruct the respondent to lift one leg as high as 40˚-60˚. Make sure your knees are straight, (d) the dosage for straight leg raise exercise can be seen in Table 2, and (e) do it on the other leg [15].
Table 2.
Exercise prescription for core stability exercise (4 weeks program)
Session Intervention Purpose Table content
I-IV Straight leg raise exercise Improve core stability F: 2x/week
I: 8 secs and 8 reps with RPE scale 4-6
t: 2 sets with interval rest 2 min
T: strengthening, coordination, proprioceptive, and neuromuscular control exercise
V-VIII Straight leg raise exercise Improve core stability F: 2x/week
I: 8 secs and 8 reps with RPE scale 4-6
t: 3 sets with interval rest 2-3 min
T: strengthening, coordination, proprioceptive, and neuromuscular control exercise

F, frequency; I, intensity; t, times; T, type.

5. Bridging exercise

Bridging exercise is a closed-chain and weight-bearing exercise that can increase the strength of the hip joint extensor muscles, thereby activating the trunk stability muscles to maintain posture [17]. The bridging exercise intervention procedure includes: (a) the respondent is supine with arm resting beside the body, (b) demonstrate the bridging exercise first to the respondent, (c) instruct the respondent to bend both legs and be given a distance shoulder width, (d) instruct respondent to lift both buttocks by pressing both feet onto the mat/bed so that the positions of the shoulders, pelvic, and knees make a straight line, (e) make sure your shoulders stay on the mat/bed and your neck stays relaxed, and (f) the dosage for bridging exercise can be seen in Table 3 [15].
Table 3.
Exercise prescription for bridging exercise (4 weeks program)
Session Intervention Purpose Table content
I-IV Bridging exercise Improves trunk, pelvic, gluteus, and hamstring muscle strength F: 2x/week
I: 8 secs and 8 reps with RPE scale 4-6
t: 2 sets with interval rest 2 min
T: strengthening, coordination, proprioceptive, and neuromuscular control exercise
V-VIII Bridging exercise Improves trunk, pelvic, gluteus, and hamstring muscle strength F: 2x/week
I: 8 secs and 8 reps
t: 3 sets with interval rest 2-3 min
T: strengthening, coordination, proprioceptive, and neuromuscular control exercise

F, frequency; I, intensity; t, times; T, type.

6. Data analysis and interpretation

1) Univariate analysis

To present the data, descriptive statistics are used, which can provide information about the parameters of each variable. Parameters that are usually used in descriptive statistics include median values such as mean (average), median (middle value), mode (a value that occurs most often), dispersion values (variance, standard deviation, range, frequency, and value of N). They also measured the total score to add to the characteristics of the data.

2) Bivariate and multivariate analysis

The data normality test uses the Shapiro-Wilk test with a value (p>.05) to normally distribute the data. Then test the data's homogenity using Mauchlyʼ s sphericity test with a value (p>.05) so the data is homogeneous. The effect test uses repeated measure ANOVA because the data is normally distributed and homogeneous. Using assumed sphericity with a value (p <.05) means there is a difference in the effect of single-leg stance exercise with core stability exercise and bridging exercise with core stability exercise on older adults balance.
Different effect tests with independent t-tests conducted on O1, X1 - O2, X2; O2, X2 - O3, X3; and O1, X1 - O3, X3 provided that the data are normally distributed according to the Shapiro-Wilk test with a value (p> .05), and the data is homogeneous according to Levene's test with a value (p >.05). If the value of the independent t-test (p <.05), it is proven that there is a difference in the effect of single-leg stance exercise with core stability exercise and bridging exercise with core stability exercise on the balance of the older adults.
In order to interpret the research results correctly, this study has the following objectives; (a) to know the effect of single-leg stance exercise with core stability exercise on increasing the balance of the older adults, (b) to know the effect of bridging exercise with core stability exercise on increasing the balance of the older adults, (c) to know the effect of single-leg stance exercise with core stability exercise on increasing balance in the older adults in the first and middle evaluations, (d) to know the effect of bridging exercise with core stability exercise on increasing the balance of the older adults in the first and middle evaluations, (e) to know the effect of single-leg stance exercise with core stability exercise on increasing balance in the older adults in the middle and final evaluations, (f) to know the effect of bridging exercise with core stability exercise on increasing the balance of the older adults in the middle and final evaluations, (g) to know the effect of single-leg stance exercise with core stability exercise on improving older adults balance in the first and final evaluations, (h) to know the effect of bridging exercise with core stability exercise on increasing the balance of the older adults in the first and final evaluations, and (i) to know difference in the effect of single-leg stance exercise with core stability exercise and bridging exercise with core stability exercise on increasing the balance of the older adults.

RESULTS

Collecting data on the characteristics of the research sample became the beginning of the implementation of this research. Data were obtained through the Berg Balance Scale in the first evaluation before the intervention was carried out on a sample of respondents who had met the inclusion and exclusion criteria. 100% of the allocated respondents suc-ceeded in following the entire research process. The characteristics of this research data are as follows:

1. Univariate analysis

The results of the data characteristics can be seen in Table 4. Based on primary data sources, the BBS examination results for the two groups in the first evaluation obtained an average value of 2.63, a mean value of 3; and the frequently appearing value is 3. In the middle evaluation, the average value is 2.96; the mean value is 3, and the frequently appearing value is 3. In the final evaluation, the average value is 3; the mean value is 3, and the most frequently occurring value is 3.
Table 4.
Characteristics data
Characteristics N F % Mean±STDEV Range Median Variance Mode
Gender 30
  Women 23 76.7
  Men 7 23.3
Age 30 2.4±1.45 4 2 2.11 1
  60-65 years old 12 40
  66-70 years old 6 20
  71-75 years old 3 10
  76-80 years old 6 20
  81-85 years old 3 10
BMI 30 2.53±1.07 3 2 1.15 2
  Underweight (<18.5) 5 16.7
  Normal (18.5-22.9) 12 40
  Overweight (23-24.9) 5 16.7
  Obesity I (25-29.9) 8 26.7
BBS first evaluation 30 2.63±0.49 1 3 0.24 3
  Need some type of walking assistance 11 36.7
  Independent 19 63.3
BBS middle evaluation 30 2.96±0.18
  Need some type of walking assistance 1 3.3
  Independent 29 96.7
BBS final evaluation 30 3±0.00 0.00 3 0.00 3
  Independent 30 100

BMI, body mass index; BBS, berg balance scale.

2. Bivariate and multivariate analysis

All data were found to be normally distributed using the Shapiro-Wilk test and homogeneous using Mauchly's test of sphericity and Levene's test. Test the effect of each group with repeated measure ANOVA and test the difference in effect between the two groups using the independent t-test. The results of bivariate and multivariate analysis can be seen in Table 5.
Table 5.
Bivariate and multivariate analysis
Mean Mean Difference p-value Conclusion
Shapiro-Wilk test*
  First evaluation .361 a Normally distributed data
.212 b Normally distributed data
  Middle evaluation .177 a Normally distributed data
.072 b Normally distributed data
  Final evaluation .105 a Normally distributed data
.296 b Normally distributed data
Mauchly's test of sphericity* .061 a Homogeneous data
.206 b Homogeneous data
Shapiro-Wilk test** .169 a Normally distributed data
.921 b Normally distributed data
Levene's test** .317 Homogeneous data
Sphericity assumed .000 a H0 is rejected
.000 b H0 is rejected
Pairwise comparisons
  SLSE+CSE O1-O2 3.8 .000 H0 is rejected
  BE+CSE X1-X2 5.133 .000 H0 is rejected
  SLSE+CSE O2-O3 4.2 .000 H0 is rejected
  BE+CSE X2-X3 3.533 .000 H0 is rejected
  SLSE+CSE O1-O3 8 .000 H0 is rejected
  BE+CSE X1-X3 8.667 .000 H0 is rejected
Equal Variances Assumed
  SLSE+CSE & BE+CSE 8 a 0.666 .572 H0 is accepted
8.666 b

SLSE, single-leg stance exercise; BE, bridging exercise; CSE, core stability exercise.

* repeated measure ANOVA

** independent t-test.

a SLSE+CSE;

b BE+CSE; O1 first evaluation SLSE+CSE; O2 middle evaluation SLSE+CSE; O3 final evaluation SLSE+CSE; X1 first evaluation BE+CSE; X2 middle evaluation BE+CSE; X3 final evaluation BE+CSE.

Test the first and second hypotheses using sphericity assumed to see whether there is an influence between the two groups on increasing the balance of the older adults. Test the three to eight hypotheses using pairwise comparisons to see whether there is an effect between the two groups on increasing the balance of the older adults at certain evaluation stages. Test the nine hypotheses using equal variances assumed to see whether there is a difference in influence between the two groups on increasing the balance of the older adults.
Based on the results of the Shapiro-Wilk test for both groups at each evaluation stage, the data were normally distributed. The results of Mauchly's test of sphericity for the two groups at each evaluation stage obtained homogeneous data. Because all data are normally distributed and homogeneous, the test can be continued with repeated measure ANOVA. The repeated measure ANOVA test results for both groups have the same value (p =.000) on sphericity assumed, which means that the two groups influence increasing the balance of the older adults.
The results of the repeated measure ANOVA test of the single-leg stance exercise group with the core stability exercise in the first and middle evaluation on pairwise comparisons had a value (p =.000) with a mean difference of 3.8. In the middle and the final evaluation, it has a value (p =.000) with a mean difference of 4.2. In the first and final evaluations, it has a value (p =.000) with a mean difference of 8. This means that there is an effect of single-leg stance exercise with core stability exercise on increasing the balance of the older adults with an increase of 3.8% in the first and middle evaluations. 4.2% in the middle and final evaluations and 8% in the first and final evaluations.
The repeated measure ANOVA test results for the bridging exercise group with the core stability exercise for the first and middle evaluation for pairwise comparisons had a value (p =.000) with a mean difference of 5.13. In the middle and final evaluation, it has a value (p =.000) with a mean difference of 3.53. In the first and final evaluation, it has a value (p =.000) with a mean difference of 8.6. This means there is an effect of bridging exercise with core stability exercise on increasing the balance of the older adults with an increase of 5.13% in the first and middle evaluations, 3.53% in the middle and final evaluations, and 8.6% in the first evaluation and final evaluation.
The results of the Shapiro-Wilk test for the single-leg stance exercise group with core stability exercise had a value (p =.169), and the bridging exercise group with core stability exercise had a value (p =.921) which means that the data is normally distributed. Leveneʼ s test results for both groups have a value (p =.317), meaning the data is homogeneous. Therefore, the data meets the requirements for the independent t-test. The results of the independent t-test obtained equal variances assumed (p =.572), which means that there is no difference in the effect of single-leg stance exercise with core stability exercise and bridging exercise with core stability exercise on increasing the balance of the older adults.

DISCUSSION

Based on the statistical test results for the single-leg stance exercise group with core stability exercise, the value of sphericity assumed (p =.000) means that single-leg stance exercise with core stability exercise influences increasing the balance of the older adults. This statement is supported by Blodgett et al., and Victor et al., which states exercise con-tributed to the balance performance of the body in older adults that decrease risk of fall [18,19].
This is because one leg receives a load which activates the leg, pelvic and trunk muscles increasing muscle strength. In addition, these exercises can activate nerves to improve proprioception so that they are considered effective in improving balance and functional walking. Leg muscles are important in maintaining postural balance and joint stability in addition to core muscles [20,21]. This statement is supported by Kusnan-to et al., in Malasari et al., who stated that balance training could increase muscle fibre (hypertrophy). This hypertrophy will experience components of the phosphagen metabolic system, including ATP and phosphocreatine, increasing muscle strength [22].
The bridging exercise and core stability exercise groups had statistical test results of assumed sphericity (p =.000), which means that bridging exercise and core stability exercise influenced increasing the balance of the older adults. This is in line with research by Azkia et al., which states that bridging exercise can reduce the risk of falling. The dose used in the study was 20 minutes per session, three times per week for more than three weeks [23]. When doing a bridging exercise, the body must maintain a position by pressing the legs down so that will dominate the contraction to the stabilisation centre and increase the pressure on the joint through the contraction of the psoas, hip, thigh, gluteal and abdominal muscles. This will help to improve joint stability and proprioception [10,15,17].
The components of balance are the vestibular system, the visual system, the somatosensory system, the cognitive system and the musculoskeletal system [24]. According to Table 4, the findings obtained for BMI were 5 people in the underweight group, 12 people in the normal category, 5 people in the overweight category, and 8 people in the obesity category I. Research from Lee et al., found that older adults BMIs in the obese range have poor balancing abilities, increasing their risk of falling. This is occured because there was a decrease in isokinetic knee extensor muscle strength and had a greater total sway distance [25].
Based on research by Ponde et al., states that core stability exercise is important for maintaining balance in the older adults. Early intervention, such as providing balance exercises, is recommended to reduce the risk of falling [26]. In line with the systematic review study by Sherrington et al., explaining that exercise is effective as a preventative measure for the risk of falling in the older adults [27]. Besides getting stron-ger, exercise also changes muscle structure, increasing storing nutrient reserves to support physical performance [2,28].
Core stability exercise is designed to increase the function of the core muscles, which control and maintain trunk stability so that it will stimulate the motor region of the brain and the ability to maintain body balance [29,30]. In line with research by Ge et al., Shi and Zhou et al., and Szafraniec et al., which state that core stability exercise is effective in increasing motor balance and endurance in the trunk muscles [31-33].
Core muscles are important in stabilizing every body movement, including the balance strategy. Balance strategy is divided into three stages namely stepping strategy exercise, ankle strategy exercise, and hip strategy exercise. Ankle strategy exercise aims to train the plantar flexor and dorsiflexor muscles by activating these muscles to stabilize the body. Hip strategy exercise aims to train the hip flexor and trunk muscles as the centre of body mass. Meanwhile, the stepping strategy exercise aims to train in moving forward or backwards by improving the base of support so that the centre of body mass is at the base of support [34,35].
Based on the statistical test results for the single-leg stance exercise group with core stability exercise and the bridging exercise group with core stability exercise using independent t-test, the value of equal variances assumed (p =.572) means that there is no difference in the effect of single-leg stance exercise and core stability exercise and bridging exercise with core stability exercise on older adults balance.
This can be because the single-leg stance exercise with core stability exercise and bridging exercise with core stability exercise have the same mechanism, namely loading the legs and using postural control, which can stimulate proprioception. The body will react optimally when there is a change in the position of the body's weight so that the balance is maintained. One of the important factors affecting balance is visual, vestibular, and proprioception sensory input [20,36].
Single-leg stance and bridging exercises are closed chain weight-bearing exercises that improve balance by involving the hip, knee, ankle and trunk stability muscles. These exercises will produce joint compression, which activates the neuromuscular of several muscle groups and is proprioceptive [17]. In research by Kwon et al., stated that closed kinetic chain exercise is more effective than open kinetic chain exercise in improving balance, especially dynamic balance [37]. Other research conducted by Mohsen et al., with Morris and Schoo states that weight-bearing exercise significantly increases lower limb muscle strength and balance [38,39]. This is supported by Lord et al., [40] in their book which concluded that an effective exercise program in reducing the risk of falling must consist of challenging balance exercises and weight-bearings.
The researchers did not include variants of the single-leg stance exercise, core stability exercise, or bridging exercise, which is one of the study's shortcomings. Only 30 people completed a 4-week exercise course, hence the number of participants was limited. Furthermore, this study did not categories older persons based on the severity of specific balance difficul-ties, such as moderate to severe reliance on walking aids. The core stability exercises were not tailored to individual muscle groups.

CONCLUSIONS

This study found that single-leg stance exercise with core stability exercise and bridging exercise with core stability exercise both influenced the balance of the older adults both in the first and middle evaluations, middle and final evaluations, first and final evaluations. In addition, there is no difference in the effect of single-leg stance exercise with core stability exercise and bridging exercise with core stability exercise with increasing older adults balance.
Future researchers could benefit from developing research variables such as one-legged stance with eyes closed, bridging exercise with a ball, straight leg raising with a band, and dynamic balance training. It is planned to improve the percentage of responders who have completed a 6-week fitness programme and to categorise older adults based on specific balance levels, such as moderate to heavy reliance on walking aids. A gold standard balance measurement instrument is likely to be em-ployed for future studies.

ACKNOWLEDGMENTS

We thank the Universitas Muhammadiyah Surakarta especially Department of Physiotherapy for the direction and knowledge shared so that this article can be completed. Not forgetting the respondents, be-loved family, and other parties that the authors cannot mention in full.

Conflict of Interest

The authors declare no conflict of interest.

AUTHOR CONTRIBUTIONS

Conceptualization: BI Salsabila, F Rahman; Data curation: BI Salsabila; Formal analysis: BI Salsabila; Funding acquisition: BI Salsabila; Meth-odology: BI Salsabila, F Rahman; Project administration: BI Salsabila, Y Lindoyo; Visualization: BI Salsabila; Writing - original draft: BI Salsabila; Writing - review & editing: F Rahman, Y Lindoyo.

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