The effect of proprioceptive neuromuscular facilitation techniques compared to aerobic exercise on balance, fear of falling, and quality of life in older adults: a randomized controlled trial

doi:10.21203/rs.3.rs-4962703/v1

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The effect of proprioceptive neuromuscular facilitation techniques compared to aerobic exercise on balance, fear of falling, and quality of life in older adults: a randomized controlled trial

https://doi.org/10.21203/rs.3.rs-4962703/v1

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Background

Aging is a long-term and unalterable phenomenon with changes in various systems such as cardiovascular, respiratory, neuromusculoskeletal, and vestibular. Exercise and physical activity reduce the progression of aging complications. Therefore, we examined the effect of proprioceptive neuromuscular facilitation techniques compared to aerobic exercise on balance, fear of falling, and quality of life in older adults.

Methods

Fifty-two older adults aged over 60 years (31 males, 21 females) were included. After initial evaluation, individuals were randomly assigned into two treatment groups (PNF techniques and aerobic exercise). Both treatment groups received 12 treatment sessions over 4 weeks. Balance, fear of falling, and quality of life were assessed at baseline and after a 4-week intervention. Analysis of covariance (ANCOVA) and paired samples t-test were utilized to between and within-group changes of variables.

Results

The results showed no significant differences in balance, fear of falling, and quality of life between groups after the intervention (P > 0.05). In within-group comparison, only the berg balance scale (BBS) significantly improved after the intervention (P < 0.05).

Conclusion

The findings suggest that PNF techniques in comparison with aerobic exercise could not contribute to improvement in balance, fear of falling, and quality of life. Therefore, more clinical trial studies with a control group are needed to determine the exact effects of these techniques.

Trial Registration Number (TRN) and date of registration:

The trial was registered at the (https://www.irct.ir), (IRCT20210505051181N4) on 9/2/2023.

Proprioceptive neuromuscular facilitation

Aerobic exercise

Balance

Fear of falling

Quality of life

aging

Aging is defined as a continuous and irreversible process characterized by numerous neurophysiological changes leading to decreased functional capacity and physical activity levels. Currently, we are witnessing a growing trend of aging in the world. Over the last decade, human lifespans have increased significantly, and by 2050, the population over 65 years old will reach from 550 million to 1.4 billion people (1–4). Decreased muscle strength, coordination, and impaired proprioception in older adults may be associated with alterations in balance and physical function (5–7) and are an important predictive factor for fear of falling (FOF) and reduced quality of life (QOL) (1, 3–5, 8–10). Moreover, falls have multiple physical and psychological consequences (11–14).

Low levels of physical exercise are associated with poor postural control and impaired balance. Therefore, using therapeutic physical exercises were recommended to improve physical function is older people (7, 11, 15–18). Aerobic exercise is a common physical exercise, as it increases endurance and cardiopulmonary fitness, aerobic capacity, balance, and QOL in older adults. In addition, it could diminish FOF. Swimming, running, and stairs as aerobic exercises that could improve balance in older adults by increasing the flexibility and strength of the lower limb muscles (7, 18, 19). Several studies have investigated the effect of aerobic exercises on improving physical function (20–22). According to a systematic review and meta-analysis, exercises including an aerobic component could be effective for balance improvement and fall prevention in older adults (7). Walking, as another aerobic exercise could improve postural balance in older adults by increasing muscle strength and proprioception (23). Vafaeenasab et al. in a randomized controlled trial study, investigated the effects of Frenkel balance exercise and aerobic exercise in older adults. The results demonstrated a significant increase in static and dynamic balance in both groups (18). The results of the study by Mei and Chang showed that aerobic exercise could effectively improve the body performance of older adults in activities of daily living (ADL) (22). In the systematic review by Bai et al. the benefits of aerobic exercise for older adults extended beyond cardiovascular changes. This type of exercise could reduce the inactivity-induced loss of strength, mobility, balance, and endurance which is vital for the safe performance of ADL in older adults (20).

Physical function and balance depends upon physiological parameters including muscle strength, sensory input from proprioception, and visual and vestibular systems (24). Decline in proprioceptive function as a factor associated with aging, is considered essential for the normal functioning of the body during movements and in maintaining balance (25). Proprioceptive exercises are specifically designed to stimulate mechanoreceptors which are embedded in the skin, joint capsule. and surrounding connective tissue, that all of them lead to improvement in proprioception (26).

Proprioceptive neuromuscular facilitation (PNF) technique is a therapeutic approach for improving balance through proprioception (5, 6, 17, 27, 28). Areeudomwong et al. in a randomized controlled trial study, assessed the effects of PNF training and general trunk exercises on pain intensity, disability, and static balance in working-age patients with chronic low back pain. The results demonstrated more improvement in static balance provided by PNF techniques compared to the general trunk exercises (29). Rhythmic stabilization (RS) and stabilizing reversal (SR) as PNF techniques could improve balance through increasing stability, muscle strength, and coordination between agonist/ antagonist muscles (27). In addition, they could play an important role in decreasing FOF and increasing QOL in older adults (11, 15, 30).

The high prevalence of proprioceptive deficits as the main basis of physical function and balance disorders, as well as the relationship between balance disorders and fear of falling and consequently decrement in QOL in older adults, make it necessary to plan an effective treatment approach (6, 11, 15, 30–33). The underlying assumption of this study was that neuromuscular stimulation using proprioception could provide an effective treatment strategy for balance disorders and its consequences in older adults (17, 34).

To the best of the authors’ knowledge, study on effect of PNF techniques on balance, fear of falling and quality of life in older adults has not yet been investigated. Findings of this specific protocol are needed to provide scientific knowledge for the appropriate treatment strategies in this population in the clinical setting.

The main aim of this randomized controlled trial is to compare the effect of proprioceptive neuromuscular facilitation techniques to aerobic exercise on balance, fear of falling, and quality of life in older adults.

Trial design

The current study is an assessor-blind 1:1 randomized controlled trial with a parallel group of 52 patients designed to investigate the effect of PNF techniques compared to aerobic exercise on balance, fear of falling, and quality of life in older adults. This study followed the CONSORT guideline. The study protocol was registered in the Iranian Registry of Clinical Trials (IRCT20210505051181N4)

Participants

Fifty-two older adults were recruited through nursing homes by using convenience samples. Figure 1 shows a flowchart of participant recruitment. Demographic variables, including age, gender, weight, height, body mass index (BMI), and Mini-Mental State Examination (MMSE) score were recorded. BMI was captured from height and weight measurements (weight divided by height squared). Data was collected from several nursing homes in Tehran, Iran, from March 2023 to November 2023. Participants were included if they met the inclusion and exclusion criteria. Table 1 summarizes the eligibility criteria of the study. Ethical approval for the study (IR.IUMS.REC.1401.914) was obtained from the Iran University of Medical Sciences. All eligible participants were informed about the interventions before signing the consent form.

Table 1

Inclusion and Exclusion criteria of the study
Inclusion criteria	Exclusion criteria
1-Age over 60 years old 2- MMSE score greater than or equal to 24 3- BBS score between 21 to 48	1-Inability to stand without assistive device 2- Use assistive devices during walking 3- Inability to walk 30 meters or more without assistance 4- Any physical and movement restrictions in pelvic, hip and knee joints 5- Inability to exercise for 30 minutes 6- Having neuromusculoskeletal, neurological, neuropathy, psychological diseases 7- Vestibular disease 8- unstable or ongoing cardiovascular/respiratory disorders 9- History of hearing and visual impairment
MMSE: Mini-Mental State Examination; BBS: Berg Balance Scale

Initial assessment

The initial assessment consisted of evaluating balance disorders and cognitive status in older adults. At first, to check the presence of balance disorders, the Berg Balance score (BBS) test was taken, if the acquired score was between 21–48, they were included in the study. In addition, the Persian version of the MMSE questionnaire was used to evaluate the cognitive status of older adults. A score of 24 or higher, was eligible (14, 35, 36). The assessor examined all outcome measures before and after treatment sessions.

Randomization

Before beginning the intervention, a clinic secretory, outside the research team, performed the randomization process. All participants were assigned to either the experimental (PNF techniques) or control group (aerobic exercise) with an allocation ratio of 1;1, using block balanced randomization method.

Blinding

The study followed an assessor-blind design, with the examiner unaware of the specific allocation and treatment group assignments. Participants were not blinded to the intervention groups.

Interventions

The experimental group received PNF techniques (n = 26) and the control group received aerobic exercise (n = 26). The trial was conducted over 4 weeks, 3 sessions a week, with a total of 12 sessions intervention period (37–39). Each treatment session included 5 to 7 min of warm-up followed by 40 min of exercise protocol and concluded with 6 min of cool-down. The duration of entire treatment session lasted approximately 50 min. The interventions were supervised by a physiotherapist, with more than 3 years of clinical experience with older adults.

Warm-up and cool-down exercises

Active warm-up exercises for both groups included lunge, whole body stretch, upper trapezius, wrist extensors, and wrist flexors muscle stretch (Fig. 2). All these warm-up exercises were done 3 times with a hold time duration of 15 sec (40). Cool-down exercises for both groups included A. knee to chest in the supine position (2 repetitions, 20–30 sec hold time) (41) B. shavasana relaxation; subjects were asked to lie in the supine position with eyes closed and relax the body for 5 min (40) (Fig. 3).

Aerobic exercises (Control group)

Participants in the control group performed outdoor supervised walking for 40 min (39). Accupedo Pedometer software was used during walking and the participant was encouraged to increase the number of steps in each session compared to the previous one (39, 42, 43).

PNF techniques (Experimental group)

Participants in the experimental group performed PNF techniques. PNF techniques including rhythmic stabilization and stabilizing reversal that were conducted on the lower trunk (flexor and extensor muscles) (Fig. 4, 5). A rest period of 2 minutes was allowed between the two parts of the techniques. Each technique consisted of 3 sets (37, 39) and 10 repetitions with a duration time of 10 seconds in each set (37, 39, 44). Among the sets, 1 minute was given for rest and 30 sec between repetitions. Specific details of the PNF techniques are provided in Supplementary 1.

Outcomes

All outcomes were measured by an assessor (FPK) on two measurement time points: 24 hours before the commencement of the first treatment session and 24 hours after the end of the twelfth session (45).

Primary outcome measures

Balance

In the current study, balance was the primary outcome. Berg Balance Scale (BBS), Functional Reach test (FRT), and Timed Up and Go test (TUG) were used to evaluate balance. The test order was randomized for each participant (46). Before testing, a familiarization trial of all tests was performed (47). The BBS assesses both dynamic and static balance (48). The BBS is a sensitive tool for measuring functional balance in older adults. the test contains 14 self-report items describing functional activities of daily living such as sitting to stand, standing with eyes opened, sitting, stand to sit, standing with eyes closed, standing without support with paired feet, forward reach, etc. Higher scores indicate better functional balance (49). The BBS is a reliable and valid assessment tool (50). The TUG test is a single-item test for rapid screening of functional mobility. TUG has demonstrated acceptable reliability and validity in the older adults (49). To perform the test, participants were instructed to stand up from a chair, walk 3 m at their comfortable speed, turn, walk back toward the chair, and sit down. The duration of the test was measured in seconds using a chronometer (51). The participant performs 3 trials of the test with a 1 min rest between trials. The average is considered for analysis (49, 52). The FRT is a reliable and valid test for dynamic balance assessment (49). Participants were asked to stand next to the wall while keeping their arms straight at shoulder level and reach forward as far as possible, without stepping. The distance between the length of the arm and a maximal forward reach was recorded in the standing position. Longer reaching distances indicate better dynamic balance (53). The difference between the first and second measurements is obtained and the average of 3 trials of the test is used for analysis (49, 54).

Secondary outcome measures

Fear of Falling and quality of life

In the current study fear of falling and quality of life were the secondary outcomes. The FES-I and WHOQOL-OLD questionnaires were used to assess FOF and QOL, consequently. The FES-I questionnaire measures FOF, in which 16 items exist, 10 items are related to basic activities, and 6 items are related to more difficult social and physical activities. A higher score indicates more concern about falling (9). The WHOQOL-OLD questionnaire evaluates QOL. It consists of 24 items in 6 domains. Higher scores indicate better QOL (55). The Persian version of both questionnaires is reliable and valid (9, 55).

Sample size

The sample size was calculated with G*Power, version 3.1.9.2. From a priori analysis, with a power of 80%, α = 0.05, the effect size of 0.8, and considering 10% dropout, 52 older adults were included

Statistical analysis

All data were analyzed using SPSS, version 24. The Shapiro–Wilk test was used to evaluate the normality of the variables. Demographic information was compared by independent t-test between two groups. Levene's test was performed to determine variance homogeneity. Analysis of covariance (ANCOVA) was utilized to compare post-intervention values between groups, using baseline values as covariates. After checking all assumptions of ANCOVA, separate ANCOVA was conducted for each dependent variable (BBS, FRT, TUG, FES-1, WHOQOL-OLD scores). Within-group changes of variables with normal and non-normal distributions were analyzed with paired samples t-test and Wilcoxon test, respectively. Mean, SD, and effect sizes were calculated for each variable and 0.05 was considered the significance level.

The baseline demographic characteristics of the participants are demonstrated in Table 2. All data were disturbed normally (P > 0.05). There were no significant differences in baseline demographic characteristics between the two treatment groups (P > 0.05). There were no differences between groups (experimental vs. control group) in the outcome measures at baseline. All assumptions of ANCOVA were confirmed. As shown in Table 3, the main effect of intervention type (aerobic and PNF) is not significant in any of the tests and there were no differences in test scores between groups for each dependent variable (BBS, FRT, TUG, FES-I, WHOQOL-OLD score) (P > 0.05).

Table 2

Demographic characteristics of the subjects
Variable (Unit)	Control group (Aerobic) (n = 26)	Intervention group (PNF) (n = 26)
Age (y)	70.12 (1.49)	68.31 (1.18)
Sex Male Female	19 (73.08%) 7 (26.92%)	12 (46.16%) 14 (53.84%)
Weight (kg)	68.92 (1.77)	64.29 (2.25)
Height (cm)	165.80 (1.80)	162.70 (1.83)
BMI (kg/m2)	25.17 (0.68)	24.32 (0.82)
MMSE Score	26.85 (0.34)	27.50 (0.26)
MMSE: Mini-Mental State Examination; BMI: Body Mass Index

Table 3

Comparison of post intervention values between groups, using baseline values as covariates (ANCOVA) BBS: Berg Balance Scale; FRT: Functional Reach Test; TUG: Timed Up and Go; FES-1: Falls Efficacy Scale – International; WHOQOL-OLD: World Health Organization Quality of Life-Old module
Outcomes	Control group (Aerobic) (n = 26)	Intervention group (PNF) (n = 26)	Levene's Test	Between-Group Differences
Outcomes	Mean (SD)	Mean (SD)	P-value	P-Value	Effect Size
BBS Score	44.57 (6.10)	45.00 (6.03)	0.527	0.506	0.009
FRT Score (cm)	19.54 (7.35)	17.30 (7.33)	0.578	0.649	0.004
TUG Time (sec)	13.95 (3.59)	13.96 (3.19)	0.914	0.279	0.024
FES-I Score	26.96 (12.14)	30.30 (12.38)	0.343	0.479	0.010
WHOQOL-OLD Score	87.80 (16.20)	89.73 (19.26)	0.142	0.832	0.001

In the experimental group, within-group analyses showed no significant differences for FRT, TUG, FES-I, WHOQOL-OLD pre- and post-intervention (P > 0.05), but the BBS significantly increased post-intervention versus pre-intervention (Mean difference = 2.26, 95% CI = (-13.37 - -1.54), P < 0.05). However, in the control group, within-group differences were not achieved for all outcome measures (p > .05) (Table 4).

Table 4

Within-Group Differences for the Outcomes of balance, fear of falling and quality of life
Outcomes	Measurement time	Control group (Aerobic) (n = 26)			Intervention group (PNF) (n = 26)
		Mean difference	P-Value	Effect Size (95% CI)	Mean difference	P-Value	Effect Size (95% CI)
BBS	After intervention vs. Before intervention	1.26	0.214	0.248 ( -0.78–3.32)	2.26	0.021	0.478 (0.36–4.17)
FRT	After intervention vs. Before intervention	-1.66	0.285	-0.214 ( -4.79 -1.47)	-1.58	0.200	-0.178 (-3.78–1.45)
TUG	After intervention vs. Before intervention	0.49	0.350	0.186 (-0.57–1.56)	-0.60	0.256	-0.226 (-1.67–0.46)
FES-1	After intervention vs. Before intervention	0.00	0.259	0.308 ( -1.08–8.16)	0.50	0.938	-0.004 (-3.29–3.21)
WHOQOL-OLD	After intervention vs. Before intervention	-1.57	0.332	-0.193 (-4.86–1.70)	-1.00	0.746	-0.064 (-7.30–5.30)
BBS: Berg Balance Scale; FRT: Functional Reach Test; TUG: Timed Up and Go; FES-1: Falls Efficacy Scale – International; WHOQOL-OLD: World Health Organization Quality of Life-Old module

This study was a randomized controlled trial designed to evaluate the effect of PNF techniques compared to aerobic exercise on balance, FOF, and QOL in older adults. The findings showed non-significant differences in balance, FOF, and QOL between groups.

This study found no significant differences between the groups in the balance outcomes post-intervention. It was expected that PNF techniques would improve the balance due to increasing the stability and strength of the muscles, increasing the inter- and intra-muscular coordination, and by addressing sensorimotor components and processes involved in balance (27), But this hypothesis was only confirmed for the within-group comparison of BBS in the PNF techniques group. The BBS is often considered a gold standard for assessing balance (56), and it also examines 14 activities and gives a better overview of a person's abilities than the TUG outcome (57). This test is a multidimensional measurement tool for balance (58) and is used in people with multiple disabilities and it examines both static and dynamic balance (48). For this reason, in the current study, the positive effect of PNF techniques on the BBS is seen, but due to the lack of between-group differences, this result should be used with caution.

Studies have shown that muscle strength, ankle and upper limb range of motion, and trunk flexibility have effects on FRT and TUG results (59–62). There is a possible interpretation that due to the application of PNF techniques only in the lower trunk, this intervention could not affect the results of the FRT and TUG outcomes.

According to the results of Mesquita et al., the use of PNF techniques and patterns together led to the improvement of BBS, TUG, and FRT in healthy women (45). This inconsistency could be explained by the PNF pattern’s characteristics in which spiral and diagonal movements of the limbs activate deep abdominal muscles and increase trunk stability (5). Consequently, balance improvement could occur due to the importance of the role of trunk control in balance (63). Kim et al. showed balance improvement by using trunk PNF in people with stroke (64). In this study, the techniques were performed in both standing and sitting positions, but in the current study, only the sitting position was applied. In the standing compared to the sitting position, the activity of lower limb muscles is higher, that considered necessary to perform the FRT (64, 65). In addition, different studies’ samples can lead to apparently different results.

Additionally, it was expected that walking as a control group exercise would improve balance variables (23), but this within-group hypothesis was not confirmed. In the present study, 4 weeks of walking was considered a therapeutic intervention, which seems to be not enough to improve balance. Within 4 weeks, only neural adaptation occurs (66). Studies that designed at least 6 and 8 weeks of exercise, showed improvement in balance because of muscular adaptation and increased strength of lower limb muscles (23, 66). Regarding Rezola et al. balance exercises should be specially included in the exercise program to improve balance, and walking does not improve balance alone (67). Based on the evidence, aerobic exercises such as a treadmill, and a stationary bicycle because of the improvement of motor re-learning, activation of sensory afferents, and locomotor patterns could have positive effects on the balance of older adults (68, 69).

The authors hypothesized that the lack of difference in FES-I score as an outcome measure of FOF between and within groups could be related to the type of intervention. Considering the positive effect of physical exercises on the FOF (70), it was expected that PNF techniques would reduce FOF, but this hypothesis was not confirmed. The FOF depends on lower limb muscles strength and walking speed (15, 71). There is also a strong correlation between the TUG and the FES-I outcome measures (9). In addition, studies have shown that FOF is affected by physical and cognitive problems, therefore, to improve FOF, there should be a cognitive component in the interventions (72). The results of the present study are inconsistent with the study of Song et al. in which using the proprioceptive neuromuscular facilitation integration pattern (PIP) reduced the FOF in older adults (73). In Song's study, the recovery of the FOF can be followed by the improvement of walking speed, while in the current study, the walking speed was not increased. In addition, it was expected that due to the positive effect of physical exercises on FOF (70), walking as a physical exercise can improve FES-I score, but this hypothesis was not confirmed, too. There is a relationship between lower limb muscle strength and FOF (15). Regarding a study, 8 weeks are needed to recover muscle strength after walking (23). By considering 4 weeks of walking in the present study, the lack of recovery is justifiable. The results of the present study are inconsistent with the study of Sitthiracha et al., which showed that progressive step marching exercises reduce the FOF (74). In this study, an increase in the strength of the lower limb muscles was seen, which reduces the FOF (15), while in the present study, due to the short duration of the intervention (4 weeks), no improvement happened in lower limb muscles’ strength.

According to the results, the QOL did not significantly improve between and within groups. In general, exercise causes the release of serotonin, dopamine, and norepinephrine neurotransmitters and the regulation of endorphins, which increase the sense of vitality, well-being, and self-esteem, and finally could improve QOL (75–78). In the present study, it was expected that PNF techniques and walking as physical exercises would improve QOL, but this hypothesis was not confirmed. The reason could be the short time of the study. The QOL is reduced due to long-term problems and therefore improves only over time, and 4 weeks is a relatively short time to observe a definitive change in the QOL (40). Before this study, no study had investigated the effect of PNF techniques on older adults' QOL. The result of the present study in the aerobic exercise group is inconsistent with studies by Janyacharoen et al. (79) and Sitthiracha et al (74). In these studies, modified stepping and progressive step marching exercises improved the QOL in older adults. The reason for this discrepancy in the results could be the longer duration of the study (8 weeks) in these studies.

Limitations

The present study can be criticized for some limitations. First, this study was conducted on healthy older adults and the sampling method was improbably simple, so the results of this study cannot be generalized to all older adults. Second, in the current research, PNF techniques were performed only in the lower trunk and not in other areas. Third, most of the nursing homes did not have the necessary cooperation to enter the present study due to their low morale. Future studies should investigate the effect of other PNF techniques on older adults' balance.

The results of this study indicated that older adults had no improvement in balance, FOF, and QOL by receiving the PNF techniques compared to aerobic exercise. According to the study findings, only the BBS as an outcome measure of balance was improved in the PNF techniques group after intervention. The novelty of the study was using the PNF techniques and comparing it with aerobic exercise in older adults.

BBS: Berg balance scale

BMI: Body mass index

FES-I: Fall Efficacy Scale-International form

FRT: Functional reach test

FOF: Fear of falling

MMSE: Mini-mental state examination

PIP: Proprioceptive neuromuscular facilitation integration pattern

PNF: Proprioceptive neuromuscular facilitation

QOL: Quality of life

ROM: Range of motion

RS: Rhythmic stabilization

SR: Stabilizing reversal

TUG: Timed up and go test

WHOQOL-OLD: World health organization quality of life-old module

Acknowledgments: Not applicable

Author contributions: Concept and Design: MKV and SSA, Data collection: MA and FP. Data analysis and interpretation: AH and MKV. Manuscript preparation: MA and MKV. All

authors read and approved the final manuscript.

Funding: No funding was obtained for this study

Disclosure statement: The authors report there are no competing interests to declare.

Data Availability: The data presented in this study are available on reasonable request from the corresponding author.

Ethics approval and consent to participate: The trial was approved by the Ethics Committee of Iran University of Medical Sciences (Reference number: IR.IUMS.REC.1401.914). All the participants were informed about the intervention and possible adverse events before the commencement of the trial and signed an informed consent form.

Consent for publication: All the participants were informed of the protocol and the consent was then obtained. They give their consent for the publication of identifiable details, which can include photograph(s) and/or videos and/or case history and/or details within the text (“Material”) to be published in the above Journal and Article.

Competing interests: The authors declare that they have no competing interests.

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Additional files
1. Supplementary 1: DOXS, PNF techniques, Specific details of the PNF techniques
2. Additional file 1: DOXS, Figures, Figures 1,2,3,4,5
3. Additional file 2: DOXS, Tables, Tables 1,2,3,4,5

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The effect of proprioceptive neuromuscular facilitation techniques compared to aerobic exercise on balance, fear of falling, and quality of life in older adults: a randomized controlled trial

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Abstract

Background

Methods

Results

Conclusion

Trial Registration Number (TRN) and date of registration:

Figures

Introduction

Methods

Trial design

Participants

Initial assessment

Randomization

Blinding

Interventions

Warm-up and cool-down exercises

Aerobic exercises (Control group)

PNF techniques (Experimental group)

Outcomes

Primary outcome measures

Balance

Secondary outcome measures

Fear of Falling and quality of life

Sample size

Statistical analysis

Results

Discussion

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1