EARLY MOBILIZATION AND EXERCISE IN ELDERLY PATIENTS AFTER CORONARY ARTERY BYPASS GRAFTING
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According to the Portuguese Ministry of Health there are in Portugal more than 9,500 femoral neck fractures each year, which reached hospital expenses of around 52 million euros. The same source estimates the mortality from 20% to 30% over a year after fracture; referring to severe disability it reaches a prevalence of 40% in the same period. Objective: To know the effect on the functional capacity of the elderly falling victim, which results in femoral neck fracture. Method: This research is a descriptive, longitudinal, prospective correlational study with a quantitative methodology. The sample consisted of 35 elderly patients at the first assessment and thirty in the second, all admitted to the trauma service of the Bragança Hospital Unit, Portugal. Data collection took place between February and June 2014 and the second evaluation was conducted between August and December, 2014. It was intended to assess the degree of recovery of functional ability after fracture of the proximal end of the femur, the fear of falling and characterize the falls. The instrument used for calculating the degree of functional recovery was the Katz index. Results: Of the sample studied 33.3% had femoral neck fracture and the remaining 66.6% had trochanteric, subtrochanteric and intertrochanteric fractures. Surgical treatment was instituted in 93.3%. The values of the Katz index decreased from 15.53 to 12.93 points. The degree of recovery of functional independence is significantly higher in patients who underwent osteosynthesis with hip prosthesis, whether it was partial or total. Conclusion: The variables that most influenced the functional recovery were the type of fracture and the type of osteosynthesis. There was a decline in functional capacity and in parallel an increase in the fear of falling.
According to the Portuguese Ministry of Health there are in Portugal more than 9500 femoral neck fractures each year, which reached hospital expenses of around 52 million euros. The same source estimates the mortality from 20% to 30% over a year after fracture; referring to severe disability it reaches a prevalence of 40% in the same period.
To know the effect on the functional capacity of the elderly falling victim, which results in femoral neck fracture.This research is a descriptive, longitudinal, prospective correlational study with a quantitative methodology. The sample consisted of 35 elderly patients at the first assessment and thirty in the second, all admitted to the trauma service of the Bragança Hospital Unit, Portugal. Data collection took place between February and June 2014 and the second evaluation was conducted between August and December 2014. It was intended to assess the degree of recovery of functional ability after fracture of the proximal end of the femur, the fear of falling and characterize the falls. The instrument used for calculating the degree of functional recovery was the Katz index
Of the sample studied 33.3% had femoral neck fracture and the remaining 66.6% had trochanteric, subtrochanteric and intertrochanteric fractures. Surgical treatment was instituted in 93.3%. The values of the Katz index decreased from 15.53 to 12.93 points. The degree of recovery of functional independence is significantly higher in patients who went under osteosynthesis with hip prosthesis, whether it was partial or total.
The variables that most influenced the functional recovery were: the type of fracture and the type of osteosynthesis. There was a decline in functional capacity and in parallel an increase in the fear of falling.
Ageing is associated with a decrease in the functionality of all organic systems. One factor that affects the quality of life in the elderly is the decrease of balance that sometimes leads to falls and consequently the fear of falling. In this sense, it is essential to try to mitigate this progressive degeneration. Wii is a platform technology and method that can be used to improve balance in elderly and thus enable them a better quality of life and well-being. Objective: To investigate whether an exercise program using Wii games, improve balance in a group of institutionalized elderly. Method: A quasi-experimental study was design in which it was used a sociodemographic questionnaire, nine of the ten tests of Fullerton Balance Advanced Scale to assess balance and the Falls Efficacy Scale (FES) to assess fear of falling. The exercises program where performed on the Wii platform, and applied in 10 minutes session three times a week for two months. Results: Twenty elderly were included, 70% women, with an average age of 82.20±4.92 years, 55% were widowed, 35% single and 10% married. The results of the Fullerton Balance Advanced Scale evaluation showed that 17 elderly improved balance and 3 elderly decreased. The Fear of falling results showed a statistically significant increase (Z=–2.875; p=0.004) from the first to the second assessment moment (67.20±12.07 vs 70.25±12.94). Conclusions: The exercise program set up with the Wii platform improved balance ability and decreased fear of falling in the elderly who participated in this study. Wii games can be used in rehabilitation of elderly to improve balance and reduce fear of falling.
Chronic kidney disease (CKD) is characterized by a progressive and irreversible decline in kidney function and that affects all other organs and systems (Bastos, Bregman & Kirsztajn, 2010). Patients with CKD on hemodialysis have reduced functional capacity and sedentary behavior, which results in increased morbidity and mortality. (Johansen et al., 2012). Over the past few years have been developed and implemented programs to maximize functionality with demonstrated beneficial effects, in this specific population (Segura-Ortí, 2010). Changes in the blood profile, resulting from these intervention programs, are not yet sufficiently studied (Henrique, Reboredo, Chaoubah & Paula, 2010). The scientific literature on the modification of the hemodialysis patient's anemia markers by physical exercise remains quite limited. Research efforts are few and those that exist do not always present clearly the values of these analytical parameters.
The objective of this study is to analyze the changes in the blood profile of the hemodialyzed patients after the implementation of a training program to maximize functionality.
To achieve this objective was drawn a causal comparative research at a hemodialysis clinic of monitored during 4 months. 24 individuals (intervention group) were included in a program of aerobic training (stationary bicycle and treadmill) during the 2nd and the 3rd months, before hemodialysis and 27 maintained their usual routine (control group). Functional capacity (sit-to-stand test and up and go test) was evaluated before and after the exercise program; the blood profile was monitored (hemoglobin, hematocrit and iron) monthly throughout 4 months. The duration of hemodialysis and the administered dosage of darbepoetin were assessed.
The exercise program proved to be decisive on improving the functional capacity of these patients which translates into clear gains in autonomy to performing activities of daily living. In the intervention group the darbepoetin administration dosage has decreased, keeping the anemia parameters unchanged, which is an advantage for patients and reduces treatment costs. Hemodialyzed patients will benefit of rehabilitation care, with programs to maximize functionality, in daily treatment, therefore rehabilitation professionals must take part on multidisciplinary teams in hemodialysis clinics.
Coronary Artery Bypass Grafting (CABG) is one of the most commonly performed surgical procedures. During the postoperative period, the prolonged bed rest increases the possible occurrence of systemic complications, resulting from immobilization. Aim: This quasi-experimental study aims to analyze the hemodynamic variables and the peak expiratory flow (peak flow) during the application of two different exercise protocols (with and without passive exercise peddler) compared with the traditional intervention (non-invasive ventilation) in elderly patients after Coronary Artery Bypass Grafting. Methods and material: Thirty elderly patients, in postoperative care of CABG, were organized into three groups: Group A – which performed the exercise in a passive exercise peddler; Group B – which performed motor physical therapy without using the exercise peddler; and Group C – with non-invasive ventilation. Considering a 5% significance level (p<0.05) the Shapiro Wilk’s test for normality analysis was performed and then a descriptive analysis of the sample was made. To analyze the variation of the results in each group before and after test Wilcoxon’s test was performed. Finally, to analyze and to compare the three groups before and after test, the Kruskal Wallis test was performed. Results: The results showed a significant increase in Peak Flow values in the three groups (before and after test), a significant reduction of systolic blood pressure in group A, and increase of cardiac frequency and respiratory frequency in group B. In the analysis between groups, it was observed a significant reduction of diastolic blood pressure in group C. It is concluded that early mobilization and exercise, with or without the exercise peddler, can be safe and performed in elderly patients after CABG in the Intensive Care Unit (ICU). Careful use of positive pressure in the non-invasive ventilation is needed due the effects on blood pressure and cardiac debit.
Coronary Artery Bypass Grafting (CABG) is one of the most commonly performed surgical procedures. During the postoperative period, the prolonged bed rest increases the possible occurrence of systemic complications, resulting from immobilization. Knowing that physical exercise balances the blood pressure and taking into account its benefits, we tried to analyze the hemodynamic behavior of the patient in PO after exercise sessions in the ICU. Check the effect of using an interval protocol with cycle ergometer; the use of physical therapy without the cycle ergometer and NIV, in hemodynamic variables (Blood Pressure, Heart Rate, Respiratory Rate and Oxygen peripheral saturation) in elderly patients, postoperative myocardial revascularization surgery in the Intensive Care Unit (ICU).
30 elderly patients undergoing coronary artery bypass graft surgery, with postoperative in ICU selected randomly thus constituting three different groups.
Cycloergometer brand - MASTER HOME, model ASK 901
A multi-parametric monitor brand Drager Medical, Model Infinity Vista XL for the collection of HR, RR, BP and SpO2
Mechanical ventilator brand Newport Medical Model: E360Br
Masks of Noninvasive Ventilation, Newport Medical brand
Peak Flow brand Cardinal Health to analyze the peak expiratory flow
Casio stopwatch manual of 8 memories with milesimal precision 1/1000
Procedure for collecting data
Before the application of protocols will be carried out the measurement of peak expiratory flow values (Peak Flow) before and after application of each protocol. Results showed a significant increase in Peak Flow values in the three groups (before and after test), significant reduction of systolic blood pressure in group A and increase of respiratory frequency in group B.
Disuse syndrome is a disorder that is most often associated with acute or chronic disease complications. Despite disuse syndrome may affect all organs and systems, the impact of range of motion limitations caused by immobility on functional capacity to perform activities of daily living is often very severe. Mobilization and active exercise have beneficial effects that counteract the impact of immobility on the body. Objective: This study aims to assess the effect of a mobilization and active exercise program on the range of motion of bedridden patients with disuse syndrome. Method: A quasi-experimental pre-post study was developed. The sample consisted of 26 persons that have been bedridden for more than six months at home. A mobilization and active exercise program was designed, fitting patients’ individual needs and implemented 2 times/ week for 2 months. Caregivers where trained to transfer the patient from bed to chair and to repeat active exercise every day. Data collection was performed before and after intervention, using the Barthel Index and a goniometer for range of motion evaluation. Results: 26 study participants, aged 77.19 ± 11.67 and bedridden for 18 months (18.73 ± 15.25) were enrolled, but only 24 completed the intervention program. There was a minimal difference in the sex distribution with 7.6% more women than men. The results showed a statistically significant increase on range of motion of the shoulder, elbow, wrist, hip and knee. There was statistical significance in plantar flexion but not on the dorsiflexion. Barthel Index score increased significantly (28.65±21.28vs31.46±23.28; p=0,035) after the mobilization and active exercise program. Conclusion: A mobilization and active exercise program implemented regularly may contribute to improve range of motion of bedridden patients with disuse syndrome.
Heart failure is characterized, from a functional point of view, as a pathology that causes limitations in carrying out the activities of daily living and consequent loss of functional and instrumental autonomy due to its classic symptoms such as: dyspnea, edema, easy tiredness and intolerance to activity. These symptoms make the patient become increasingly dependent and searching for inactivity as a way to preserve energy and avoid those symptoms. It is known that exercise is beneficial and safe when applied according to the characteristics of the patient and his medical condition, even in the process of stabilization of the acute phase of its pathology. Identify the variables that enhance a better response to exercise in patients with heart failure in acute phase. Realize that the performance of structured and supervised exercise in acute phase allows the patient to improve the resistance to exercise and improve functional capacity and performance of Daily Living Activities. Identify health gains indicators arising from a rehabilitation program. Through the exploratory method, clinic and physiologic variables have been identified that could change with exercise and which allow a better response to exercise in the acute phase of the disease. Patients with decompensated heart failure of a cardiology ward were selected to comply with a minimum of 3 sessions of a program of physical exercise with increasing levels of intensity. Vital signs, Borg scale to subjective perception of effort and the London Chest Activity Daily Living (LCADL) scale for dyspnea associated with activities of daily living were assessed before and after the implementation of the program. Intensity and progression on the program were also evaluated by exercise parameters such as number of laps on the exercise peddler, number of meters walked and number of steps climbed. 20 patients were assessed, with mean age of 64.05±9.97 years. Data obtained showed a positive variation, meaning that patients improved their functional capacity along the program, despite being in acute phase of heart failure.Descriptive and inferential statistics analysis of the data allows us to conclude that patients with previous practice of exercise, lower basal heart rate, higher oxygen saturation, lower number of associated cardiovascular risk factors presented a better response to the exercise and with a better evolution throughout the program.
Heart failure is characterized, from a functional point of view, as a pathology that causes limitations in carrying out the activities of daily living and consequent loss of functional and instrumental autonomy due to its classic symptoms such as: dyspnea, edema, easy tiredness and intolerance to activity. These symptoms make the patient become increasingly dependent and searching for inactivity as a way to preserve energy and avoid those symptoms. It is known that exercise is beneficial and safe when applied according to the characteristics of the patient and his medical condition, even in the process of stabilization of the acute phase of its pathology. Through the exploratory method, clinic and physiologic variables have been identified that could change with exercise and which allow a better response to exercise in the acute phase of the disease. Patients with decompensated heart failure of a cardiology ward were selected to comply with a minimum of 3 sessions of a program of physical exercise with increasing levels of intensity. Vital signs, Borg scale to subjective perception of effort and the London Chest Activity Daily Living (LCADL) scale for dyspnea associated with activities of daily living were assessed before and after the implementation of the program. Intensity and progression on the program were also evaluated by exercise parameters such as number of laps on the exercise peddler, number of meters walked and number of steps climbed. The study involved 20 patients with 64±9.9 years, 80% men, with a length of stay of 18.6 days on cardiology ward, between September 2013 and April 2014, with an average of 4.4 program sessions. Data obtained in LCADL (29.9±8.9 vs 20.9±6.8), exercise parameters and Borg score after the exercise showed a positive variation, meaning that patients improved their functional capacity along the program, despite being in acute phase of heart failure. Descriptive and inferential statistics analysis of the data allows us to conclude that patients with previous practice of exercise, lower basal heart rate, higher oxygen saturation, lower number of associated cardiovascular risk factors presented a better response to the exercise and with a better evolution throughout the program.
Hemodialysis is a technique that effectively replaces some functions of the human kidney, allowing the survival of such patients, since loss of kidney function is incompatible with life. In most patients with chronic kidney disease, the level of renal function tends to gradually decrease over time. The most serious outcome of chronic kidney disease is renal failure. The vascular access is vital in patients with chronic renal failure undergoing dialysis and their dysfunction is a major cause of morbidity and hospitalization. Adequate vascular access for hemodialysis defines not only a better therapeutic outcome and patient survival. The flow of arteriovenous fistula (AVF) is an important factor in the successful execution of the hemodialysis.
Were studied 27 patients, 20 males and 7 females, with ages between 39 and 94 years old. The diameter and the flow of the draining vein were evaluated by ultrasound flow. Were also carried out the Hand Grip Test, the Pinch Gauge Test and it was done an anthropometric evaluation using a bioimpedance scale. This study aimed to identify the relationship between vascular perfusion, body composition and muscle strength in chronic kidney disease patients on regular hemodialysis program. The average flow of the arteriovenous fistula was 1340.096±304.615ml/min and the diameter of the arteriovenous fistula was, on average, 0.57±0.06mm. To check for significant differences between the variables we used the Spearman correlation coefficient test. When correlated left handgrip strength and average flow (r = -0.576, p = 0.01), pinch gauge test of the opposite side of the fistula and average flow (r = -0.450, p = 0.059) and visceral fat and average flow (r = -0.444, p = 0.05), there were statistically significant negative correlations. Individuals with higher results in the pinch gauge test in left finger showed lower flow, lower diameter and lower area of the draining vein. Taking into account the results obtained, we can see that the sample is relatively small, which means that the conclusions of this study are not extrapolated to the Portuguese population in regular hemodialysis program, but just be confined to the group of patients evaluated. The results suggest that there is a negative relationship between the flow of the arteriovenous fistula and muscle strength and body composition. For higher values of muscle strength correspond lower flow values of the draining vein.
Physical activity is important for healthy ageing and may help to maintain good function in older age. Institutionalization is often due to functional decline and institutions frequently do not provide activities to maintain or regain functionality. Exercise therapy is an important component of rehabilitation programs for elderly and helps reduce pain, improve joint stability, functional ability, muscle strength and endurance, and aerobic capacity; preventing bone loss and fractures, and improving or maintaining quality of life. This study aims to investigate if a physical exercise program improves self-perception of health status, physical fitness, muscle strength and body composition in a group of institutionalized elderly. A quasi experimental study was conducted using the Portuguese version of the Short Form-36 Health Survey (SF-36v2), the Rikli Jones Senior Fitness Test, hand dynamometry and bioelectrical impedance before and after a physical exercise program. A total of 20 elderly aged 76.1±8.7 years with 18.3±13.3 months of institutionalization, participated in a two-month of physical exercise program. Results show that scores of SF-36v2 after the program had significantly increased in physical and mental components. They also increased significantly in scales such as physical functioning, bodily pain, vitality, social functioning, general health and mental health. Physical fitness results show that all components improve after the intervention. Noteworthy are aerobic endurance, lower flexibility, superior flexibility and agility, speed and dynamic balance all with statistical significance. An increase in muscle mass and a decrease in body fat, metabolic age, visceral fat and body water was observed, but without statistical significance. Bone mass had no changes. Physical exercise programs can contribute to improve physical status and self-perception of well-being leading to autonomy and confidence in performing daily living activities. In institutionalized elderly population this is a very important step towards independent life.
Pulmonary rehabilitation in COPD exacerbation has several advantages such as reduction of hospital readmission and mortality, the considerable increase of quality of life and functional improvement translated into a better outcome in the 6 min walking test. Upper limbs exercise is recommended in pulmonary rehabilitation guidelines because it reduces stress, decreases dyspnea and dynamic hyperinflation and improves functional capacity with impact on daily living activities. This study aimed to evaluate the functional changes that occur in COPD patients with exacerbation, after a program of resistance exercises of the upper limbs. A multi-case study was developed on seven patients with COPD, GOLD III and IV (diagnosed by FEV) in exacerbation. Data collection included an initial interview for clinical history, functional assessment using the London Chest Activity of Daily Living (LCADL), the 6 min Pegboard and Ring Test (6min PBRT), handgrip strength and the Saint George Questionnaire for quality of life assessment.
A program of upper limbs exercise training was implemented. Vital signs (blood pressure, respiratory rate, heart rate and pain, dyspnea (Borg Dyspnea Scale) and peripheral oxygen saturation were assessed before and after exercise training and during if the patient presented any symptom. After 7 days of treatment, assessment instruments were applied. RESULTS: All 7 participants (2 women, 5 men), aged between 50 and 85 years, had as risk factor being ex-smokers. The entire group has several comorbidities (diabetes, heart problems, anxiety/depression, osteoporosis) and low inclusion in rehabilitation or exercise programs.
Upper limbs exercise during an exacerbation period appeared to be safe and beneficial in all of the cases studied. Vital signs, dyspnea and peripheral oxygen saturation remain on normal range during exercise training sessions. Data obtained in 6min Pegboard and Ring Test (6PBRT), London Chest Activity of Daily Living (LCADL) and handgrip strength showed a positive evolution between assessments in all participants resulting in an improvement of exercise capacity of the upper limbs and in an increase of their functionality. There was no significant changes in quality of life. CONCLUSION: Results may indicate that the inclusion of resistance active exercises in rehabilitation programs tend to improve skeletal muscle strength and performance in ADL.
Pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) exacerbation has several advantages such as reduction of hospital readmission and mortality, the considerable increase of quality of life and functional improvement translated into a better outcome in the 6 min walking test. Upper limbs exercise is recommended in pulmonary rehabilitation guidelines because it reduces stress, decreases dyspnea and dynamic hyperinflation and improves functional capacity with impact on daily living activities. This study aimed to evaluate the functional changes that occur in COPD patients with exacerbation, after a program of resistance exercises of the upper limbs. A multi-case study was developed on seven patients with COPD, GOLD III and IV (diagnosed by FEV) in exacerbation. Data collection included an initial interview for clinical history, functional assessment using the London Chest Activity of Daily Living (LCADL), the 6 min Pegboard and Ring Test (6min PBRT), handgrip strength and the Saint George Questionnaire for quality of life assessment. A program of upper limbs exercise training was implemented. Vital signs (blood pressure, respiratory rate, heart rate and pain, dyspnea (Borg Dyspnea Scale) and peripheral oxygen saturation were assessed before and after exercise training and during if the patient presented any symptom. After 7 days of treatment, assessment instruments were applied. All 7 participants (2 women, 5 men), aged between 50 and 85 years, had as risk factor being exsmokers. The entire group has several comorbidities (diabetes, heart problems, anxiety/depression and osteoporosis) and low inclusion in rehabilitation or exercise programs. Upper limbs exercise during an exacerbation period appeared to be safe and beneficial in all of the cases studied. Vital signs, dyspnea and peripheral oxygen saturation remain on normal range during exercise training sessions. Data obtained in 6min PBRT, LCADL and handgrip strength showed a positive evolution between assessments in all participants resulting in an improvement of exercise capacity of the upper limbs and in an increase of their functionality. There was no significant changes in quality of life. The results may indicate that the inclusion of resistance active exercises in rehabilitation programs tend to improve skeletal muscle strength and performance in ADL.
This study aimed to identify the relationship between vascular perfusion, body composition and muscle strength in chronic kidney disease patients on regular hemodialysis program. Method: 27 patients were studied, 20 males and 7 females, with ages between 39 and 94 years old. The diameter and the flow of the draining vein were evaluated by ultrasound flow. A Hand Grip Test, Pinch Gauge Test and an anthropometric evaluation using a bioimpedance scale were done. Results: The average flow of the arterio-venous fistula was 1,340.096±304.615 ml/min and the diameter of the arterio-venous fistula was, on average, 0.57±0.06 mm. To check for significant differences between the variables the Spearman correlation coefficient test we used. There were statistically significant negative correlations between left handgrip strength and average flow (r=–0.576, p=0.01), pinch gauge test of the opposite side of the fistula and average flow (r=–0.450, p=0.059) and visceral fat and average flow (r=–0.444, p=0.05). Individuals with higher results in the pinch gauge test of the left finger showed lower flow, lower diameter and lower area of the draining vein. Conclusions: The results suggest that there may be a negative relationship between the flow of the arteriovenous fistula and muscle strength and body composition. Higher values of muscle strength correspond to lower flow values of the draining vein.
With aging, the human body goes through a period of transformation that generate decline of some physical capacities, such as decreased flexibility, agility, coordination, joint mobility and balance, compromising the functional capacity of older people, which is essential for carrying out Activities of Daily Living. The physical exercise is key to improving the functional capacity of the elderly, in particular with proprioceptive exercises, which have been used in recent studies with elderly.
The aim of our study is to evaluate the effects of a proprioceptive exercise program on functional capacity in the elderly group.
To achieve this objective, we designed a quasi-experimental study with pre- and post-intervention. In all participants were evaluated hand grip strength, finger pinch force, the Tinetti Gait and Balance Test , single leg balance test, evaluation of senior fitness test by the "arm curl test", "sit to stand test" "timed up and go test", "back scratch test" and "chair, sit and reach test " by Rikli & Jones. The program was conducted 2 times a week for 12 weeks.
The sample was consisted of 24 elderly, 12 of them in the intervention group (67.25 ± 2.01 years) and the other 12 in control group (68.08 ± 1.73 years). According to the results, the intervention group showed a statistically significant improvement in all evaluations performed after the program. In the control group, there was no significant improvement in functional capacity component evaluated after 12 weeks.
Our proprioceptive exercise program proved to be decisive in improving the functional capacity of the elderly. This proprioceptive training program is one of the pioneers in this specific area with great potential for future use.
With aging, the human body goes through a period of transformation that generates decline of some physical capacities, such as decreased flexibility, agility, coordination, joint mobility and balance, compromising the functional capacity of older people, which is essential for carrying out Activities of Daily Living. The physical exercise is key to improving the functional capacity of the elderly, in particular with proprioceptive exercises, which have been used in recent studies with elderly. Objective: The aim of our study is to evaluate the effects of a proprioceptive exercise program on functional capacity in the elderly group. Method: To achieve this objective, we designed a quasi-experimental study with pre- and post-intervention measurements. All participants were evaluated with hand grip strength, finger pinch force, the Tinetti Gait and Balance Test, single leg balance test, evaluation of senior fitness test by the “arm curl test”, “sit to stand test” “timed up and go test”, “back scratch test” and “chair, sit and reach test “ by Rikli & Jones. The program was conducted 2 times a week for 12 weeks. Results: The sample consisted of 24 elderly, 12 of them in the intervention group (67.25 ± 2.01 years) and the other 12 in a control group (68.08 ± 1.73 years). According to the results, the intervention group showed a statistically significant improvement in all evaluations performed after the program. In the control group, there was no significant improvement in functional capacity components evaluated after 12 weeks. Conclusion: Our proprioceptive exercise program proved to be improving the functional capacity of the elderly. This proprioceptive training program is one of the pioneers in this specific area with great potential for future use.
