INTRODUCTION
Globally, the old people population continues to increase, and their health problems become a big issue as a result (Choi et al., 2011). The old people gradually weaken their muscle strength and muscle tone due to aging, and their muscle mass and basal metabolic rate decrease (Bechshøft et al., 2016; Brown et al., 2000). In addition, due to the decrease in the flexibility of the spine and the range of motion of the joint, the posture becomes bent, and a problem occurs in the posture alignment (Kado et al., 2004).
The scapula is an intermediate segment that connects the upper limb and the trunk, and the position and stability of the scapula influence the alignment of the spine (Magarey and Jones, 2003) and the antigravity activity of the trunk (Hazar Kanik et al., 2017). Weakness and dysfunction of the muscles around the scapula affect posture changes in the trunk, cervical and thoracic vertebrae (Moezy et al., 2014), reducing balance ability and affecting functional mobility (Granacher et al., 2013). A recent study reported that kypotic posture, a typical posture in the old people, increased the risk of falls (Choi et al., 2011; Kado et al., 2004). Therefore, posture change through scapular movement can have a positive effect on body function and balance (Shiravi et al., 2019).
Balance is the control and maintenance of posture against stimuli from the external environment (Cheng et al., 2001). For the old people, balance is the most basic and essential factor for leading independent daily life (Kaufman et al., 2001). As aging progresses, sensory functions (vision, vestibular organs, and proprioceptive sensations) decrease and balance ability is lost, increasing the risk of falls and consequently lowering the quality of life (Rogers et al., 2003). Therefore, balance ability is essential for improving the motor function of the old people (Prasertsakul et al., 2018).
The physical function (PH) of the old people is an important factor in determining the quality of life (Geirsdottir et al., 2012). Various interventions such as aerobic exercise, lower extremity resistance exercise, trunk strengthening exercise, and elastic band exercise have been applied to improve the PH of the old people (Granacher et al., 2013; Huang et al., 2017; Liao et al., 2018; Liberman et al., 2017). Among them, exercises using elastic band is more effective in increasing function of muscle strength and preventing damage than bare body resistance exercises, and can provide more advantages in improving muscle strength, endurance, flexibility, and balance (Huang et al., 2017; Liao et al., 2018). In addition, it is an effective intervention method for the old people because it is easy to control the strength of resistance and helps strengthen muscles (Liao et al., 2018).
Interventions for improving motor function in the old people have been reported, but the effect of scapular strengthening exercise using an elastic band on motor function in the old people is rare. Therefore, we determined the effect of scapular strengthening exercise using elastic band on the balance and quality of life in the old people.
MATERIALS AND METHODS
Participants
This study was conducted on the old people using the Senior Welfare Center located in Changwon. Inclusion criteria are: (a) those who have not had difficulty walking or fall within the last 3 months, (b) those who have no serious pain, musculoskeletal damage, or neurological damage, (c) those who have spinal disorders and related diseases, (d) those who understand the instructions of the examiner and can perform them. Exclusion criteria are (a) a person with acute inflammation, (b) a person with visual and hearing problems. All participants understood the content of the study and participated voluntarily. This study was organized after the approval of the Research Ethics Committee of Kyungnam University (104060-A-2020-021). The selected participants were randomly divided into two groups. Romberg’s test, Y-balance test, and quality of life (36-item Short Form health survey, SF-36) were applied in both groups before and after intervention, respectively.
Intervention
The control group applied general conditioning exercise and the experimental group applied scapular strengthening exercise using elastic band (Spiralista, Brno, Czech Republic) exercise. All groups exercised for 40 min per session, 5 times a week, for a total 4 weeks. The exercise was conducted as a group exercise. Exercise programs for experimental group are shown in Table 1.
Static balance
Romberg test was to measure the static balance ability, and the Balancia software program (Balancia software ver. 2.0, Mintosys, Seoul, Korea) was used for data collection. Participants looked straight ahead on the Wii balance board and stood with both feet together. Participants opened their eyes, closed their eyes, and held each for 1 min.
Y-balance
To measure the flexibility and balance of the lower limbs, a professional Y-balance test kit (Functional Movement System, Lynchburg, VA, USA) was used. The participants stood in the center of the Y-balance board and maintained the balance by extending one leg as far as possible in each direction of the anterior (ANT), posterior-medial (PM), and posterior-lateral (PL). It was measured based on the dominant foot, and the average value was used by measuring twice, and the unit is cm. For Y-balance, the interrater reliability is intraclass correlation (ICC)=0.85–0.91, and the intrarater reliability is ICC=0.99–1.00 (Plisky et al., 2009).
Quality of life
A Korean SF-36 is a questionnaire form that the subject fills out to evaluate the quality of life related to health, with a total of 36 questions, PH, vitality, body pain, general health (GH) perception, physical role function, social function, emotional role function, and mental health (MH) (Han et al., 2004). Each item was calculated according to the Likert scale, and was calculated by applying a weight based on the score from 1 to 6 according to the question. Each scored item was summed for each item, and the total score was converted into a 100-point perfect score.
Statistical analysis
IBM SPSS ver. 18.0 (IBM Co., Armonk, NY, USA) for window was used for statistical analysis. Shapiro–Wilks test was performed to test the normality of variables. The independent t-test was used for the difference between groups, and the paired t-test was used for the differences within the group. All statistical significance levels (α) were set to 0.05.
RESULTS
General characteristics of the participants
Table 2 shows the general characteristics of the participants.
Static balance
With the eyes open, there were significant differences within the experimental group in the path velocity, path length, and path area (P<0.05). There were significant differences between groups in the change (post-pre) in path velocity, path length, and path area (P<0.05). With the eyes closed, there were significant differences within the experimental group in the path velocity, path length, and path area (P<0.05). There were significant differences between groups in path area before, after intervention and change (post-pre) (P<0.05) (Table 3).
Dynamic balance
In the ANT and PM, it was significantly increased within the experimental group (P<0.05). There were significant differences between groups in ANT in change (post-pre) (P<0.05) (Table 4).
Quality of life
There was a significant difference in PH within the experimental group (P<0.05). There were significant differences between the groups in MH and GH (P<0.05) (Table 5).
DISCUSSION
Decreased PH in the old people causes secondary problems such as daily life restrictions, reduced range of activities, and falls, thereby lowering the quality of life and acting as a factor that hinders independent living (Hyndman et al., 2006; Regterschot et al., 2014). Therefore, the purpose of this study was to determine the effect of the scapular strengthening exercise using elastic band on balance and quality of life in the old people.
Balance ability is closely related to muscle strength (Granacher et al., 2013), the muscles around the scapula are related to lateral core muscle (Hazar Kanik et al., 2017), and stability of trunk muscle affects shoulder muscle activity (Biscarini et al., 2019). In addition, the position and shape of the scapula is an important factor affecting the trunk (Biscarini et al., 2019). In the old people, curvature of the spine occurs mainly due to weakening of the muscles around the scapula, which increases postural sway and increases the risk of falls (Sinaki et al., 2005). Markovic et al. (2015) found that feedback-based balance and core resistance training is effective for muscle function and balance in the old people. They reported that the sway distance (mediolateral) reduction through increasing trunk muscle strength eventually improved the balance ability. As a result of this study, path velocity, path length, and path area of the static balance significantly decreased after intervention when the eyes were opened and closed. It is thought that the resistance given to the muscles around the scapula through the band affected the improvement of the trunk and the overall strength of the body, thereby improving the static balance ability.
Dynamic balance is the ability to maintain postural control while a person’s center of mass moves out of the support surface (Freund et al., 2019). With age, flexibility and range of joint motion decrease, resulting in poor dynamic balance of the old people (Kim et al., 2018). Lee et al. (2015) reported that the old people had a decreased balance using Y-balance compared to middle-aged women. This can be attributed to the various factors affecting balance, i.e., range of motion, muscle strength, posture, deformation, function, and psychological states (Menz et al., 2005; Spink et al., 2011). Bouillon et al. (2011) reported that the PM performed better than the anteromedial when measuring balance using star excursion balance test in the young adult and the old people. Gribble et al. (2012) and Hoch et al. (2016) reported that patients with chronic ankle instability received the highest score in the PM direction among the three directions of ANT, PM, and PL when applying the Y-balance. In this study, we found that the ANT and PM significantly increased in the experimental group. In particular, the ANT of the experimental group showed the highest value after intervention, which is a result of creating more knee flexion to maintain balance (Lee et al., 2015). In the control group, ANT, PM, and PL were all increased. It is thought that the intervention applied to the control group increased the flexibility of the ankle.
Exercise is essential for active healthy aging without functional impairment (Van Roie et al., 2010) and contributes to improving quality of life (Acree et al., 2006; Atlantis et al., 2004; Daskapan et al., 2005). Fraga et al. (2011) reported that the walking program for old women over the age of 60 is effective in improving the quality of life. Liu and So (2008) reported that when 12 weeks of Tai Chi exercise was applied to the old people, PH and GH were improved. In this study, the PH, GH, and MH were improved after applying the scapular strengthening exercise program using an elastic band. These results are consistent with the results of previous studies, and it is thought that the improvement of PH through exercise had a positive effect on health perception and thus the quality of life. This study is thought to have helped to improve the physical and MH areas of the quality of life through regular exercise and active communication of participants through group exercise.
In summary, the scapular strengthening exercise program using the elastic band improved the balance and quality of life of the old people. This is thought to be the result of the improvement of kyphotic posture through scapular strengthening exercise. Therefore, it could be suggested as an intervention program for improving the balance ability of the old people. As a limitation of this study, it is difficult to generalize the contents because the number of subjects is small, and the intervention period is short. In addition, there was a limitation in applying the same strength by applying the elasticity of the elastic band according to the physical condition of the old people. Therefore, in future studies, studies in which these limitations are supplemented should be conducted.
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