Intr oduction
F alls in elderly ext ends far beyond min or injury t o significant loss of fun ctional independence an d ev en death (Chan dler an d Duncun , 1993). F alling account s for th e m ajority of death s r elat ed t o injury , the sixth leading cau se of death am ong th e
elderly . An estim at ed 30 per cent t o 50 per cent of adult , 65 year s of age an d older and 40 per cent of adult s ov er the age of 80 experience one or m or e falls annually (Lor d et al, 1991). T he fall cau ses th e admission to a nur sin g home for people who ar e 65 y ear s old ar e about 45 per cent for w om en and 28 per cent for m en
Co m pari s on o f S pin e an d L o w e r E x tre m it ie s R an g e o f M o t ion B e t w e e n in E lde rly F alle r s an d
N on f alle rs
P ar k H y u n - k ee, M .A ., R .P .T .
Dept . of P hy sical T h er apy , S eou l H ealth Colleg e
국 문 요 약
넘 어 지 는 노 인 과 안 넘 어 지 는 노 인 의 척 추 와 하 지 의 관 절 가 동 범 위 의 비 교
박 현 기
서울보건대학 물리치료과
이 연구의 목적은 노인들 중, 넘어지는 사람들(faller s)과 안 넘어지는 사람들 (nonfaller s)의 경부, 체간, 하지의 관절가동범위를 측정하여 비교하는 것이다. 본 연구 대상은 남자 6명, 여자 22명, 나이 65세에서 88세의 노인으로 독립적으로 활동할 수 있 는 사람들을 두 개의 집단으로 한 사람씩 면접을 통해 분류하였다. 대상자 선정 이전 일년 동안 한번 이상 넘어진 경험이 있는 사람들을 넘어진 사람들로 규정, 그리고 넘어 진 경험이 없는 사람들을 안 넘어진 사람들로 정의하였다. 관절가동범위는 각도기로 측 정하였고 미국 정형외과 학회(American Academy of Orthopaedic Surgeons)의 표준화 된 가동 범위 측정방법을 사용하였다. 넘어진 사람들과 안 넘어진 사람들의 연구 결과 의 차이를 알아보기 위하여 양측 독립성 t - 검정을 사용했다. 연구결과, 넘어진 사람들 과 안 넘어진 사람들간의 관절가동범위 중 흉요부의 굴곡, 신전, 우측굴곡, 좌측굴곡, 그리고 우측회전과 좌측회전, 고관절부의 신전, 내전, 외측회전과 내측회전, 그리고 족 관절의 배굴에서 유의한 차이가 있었다. 이와 같은 결과는 체간, 고관절부 그리고 발목 의 유연성이 노인들의 균형을 유지하는데 영향을 준다고 말할 수 있다.
핵 심 단 어 : 노인; 균형; 관절가동범위.
(Mathia s et al, 1988; T inetti et al, 1988;
T in etti and William s, 1997; Whitney et al, 1998).
A fall ev ent occur s when the postur al contr ol sy stem fails t o m aint ain equi- librium . T o achiev e an d m aint ain equi- librium , an individu al mu st contr ol and r egulat e specific postur al output during v olunt ary , inv olunt ary , or ext ernally im - posed m ov em ent s of the cent er of gr avity (O ' Brien et al, 1997). Postur al r espon ses ar e ex ecut ed thr ough the mu sculoskelet al sy st em and changes to any part of the mu sculoskelet al sy stem may lead t o in - cr eased difficulty in m aint aining equilibrium (O ' Brien et al, 1997). A dequat e postur al contr ol r equir es keeping the cent er of gr avity ov er the ba se of support during st atic and dyn amic situation s . T h e com - pon ent s of the postur al contr ol sy stem ar e str ength , r ange of m otion , pr oprioception and centr al pr ocessing (Chan dler and Duncun , 1993).
T he fall in elderly is r elat ed t o phy siologic and biom echanic chan ges that ar e associat ed with aging . T he potential r anges of joint motion v ary thr ou ghout the life span becau se of age r elat ed chan ges in the m echanical pr operties an d m orphology of joint stru ctur es (Jam es an d P arker , 1989). Decr ease in r ange of m otion is associat ed with n orm al aging in both m en and w om en . T his decr ease in j oint m ov e- m ent ex ist s ev en in th e ab sence of pa - thology (Gajdosik et al, 1999). Loss of spinal and peripher al j oint r ange of motion is associat ed with decr eased postur al contr ol (O ' Brien et al, 1997). F lexibility in joint m ov em ent is r equir ed for a per son t o accomm odat e v ariou s perturbation s by al- lowing body t o perform v ariou s postur al
contr ol str at egies .
T her e ar e no compr ehen siv e analy sis of joint r ange of m otion other th an low er extr emities seem r eadily av ailable an d ev en then m any of these pr eviou s studies only hav e ex amin ed the r ange of m otion in ant erior and post erior dir ection . F or ex - ample, knee flexion an d ext en sion , ankle dor siflex ion and plant arflexion , and so forth . In n orm al adult s, the ant er opost erior and lat er al st ability is r equir ed t o m aint ain balance. T he obj ectiv e of the pr esent study is t o det ermine an d compar e the differ en ce of cervical, trunk and low er extr emity r ange of m otion in thr ee dim en sional dir ection s bet w een faller s and nonfaller s.
Phy sical ther apist s ar e inv olv ed in fall pr ev ention an d post fall r ehabilit ation in elderly population . Comparison of these dat a m ay be u seful in un der st an ding the joint flexibility differ ences bet w een t w o gr oup s and the r elation ship of j oint flex ibility at each joint t o falls in elderly . T his study m ay pr ovide dir ection for int erv ention an d ar ea of r ange of m otion assessment in elderly .
M e t h o d s
P ro c e dure
Six males and 22 females , aged 65 t o 88
year s, independently r esiding in social
service facilities and in the community ,
w er e classified int o t w o gr oups as faller s
or nonfaller s . F aller s gr oup con sist ed of 14
females with m ean age of 77 an d non -
faller s gr oup con sist ed of 6 m ales and 8
females with m ean age of 73. T h e
permission t o participate in the study w as
obt ained fr om each subject . In this study , a
fall w as defin ed as an ev ent during which a subject com es to r est on the gr oun d or at som e low lev el, n ot a s the r esult of m ajor intrin sic ev ent or ov er whelming hazar d (Lee an d Kerrigan , 1991; Lor d et al, 1992; O' Brien et al, 1997). T he clas - sification of t w o gr oups w as m ade thr ou gh int erview pr ocess. A subj ect who r eported hist ory of one or m or e falls during on e year period prior t o dat e of r ecruitm ent w as classified a s faller s. A subject who denied any hist ory of fall during sam e period w a s clas sified as n onfaller s. All subject s w er e fr ee fr om u sin g assistiv e devices for ambulation and ex hibit ed no pathology of centr al and peripher al nerv ou s sy st em , activ e orthopedic pr oblem s, and uncontr olled car diov ascular pr oblem s.
A goniom etric m easur em ent w as u sed t o determin e joint r ange of m otion . Mea s - ur em ent s w er e t aken at cervical and thor acolumbar spine, hip, kn ee, and ankle joint s. T he r an ge of motion v ariables m easur ed at cervical an d thor acolumbar spin e w er e flexion , ext en sion , side bendin g right and left , an d r ot ation right an d left . T he r ange of motion v ariables mea sur ed at hip joint w er e flexion , ex t en sion , adduction , abduction , an d int ernal and ext ernal r o- t ation . T h e r an ge of m otion v ariable m easur ed at kn ee joint w er e flexion and ext en sion . T he r ange of motion v ariable m easur ed at ankle w er e dor siflexion , plant - arflexion , inv er sion , an d ev er sion . T h e r eli- ability of g oniomet er for m easurin g low er extr emity j oint r an ge of motion has been w ell docum ent ed (Boone et al, 1978; Smith an d W alker , 1983; W alker et al, 1984). T he r an ge of motion w as det ermined u sing st an dar d for joint r ange of motion est ab - lished by the Am erican A cademy of Or -
thopaedics Sur geon s (Norkin and Whit e, 1985).
D at a A n aly s i s
T he m ean v alues for all r ange of m otion m easur ed at cervical, thor acolumbar , hip, knee, and ankle joint s w er e obt ained an d compar ed betw een faller s an d nonfaller s . T he av er age of bilat er al low er extr emities r ange of motion w er e u sed t o calculat e the m ean v alues for low er extr emity . T w o t ailed student t - t est s w er e perform ed u sing Micr osoft Ex cel pr ogr am t o det ermine dif - fer ences bet w een in j oint r an ge of motion v ariables the faller s and n onfaller s. T he crit erion u sed for st atistical significance w as α=.05.
R e s u lt s
T he m ean v alues and st an dar d deviation
cervical, thor acolumbar , hip, knee, and
ankle r ange of m otion w er e pr esent ed in
t ables below . T he r ang e of m otion m ean
v alues at all j oint s mentioned abov e for
nonfaller s w er e gr eat er than faller s ex cept
ev er sion at ankle j oint . How ev er , only
m ean v alues for all thor acolumbar spine
r ange of m otion , hip ex ten sion , abdu ction ,
int ernal and ext ernal r otation , and ankle
dor siflex ion w er e foun d st atistically sig -
nificantly differ ent betw een tw o gr oups .
T able 1. Cervical joint r an ge of m otion
Variables F aller s Nonfaller s p
F lex ion 38.7±5.7
*40.6±6.4 .5
Ext en sion 33.6±8.4 35.3±7.8 .6
Side Bending Right 13.7±7.0 15.1±6.1 .6
Side Bending Left 12.1±9.3 15.6±7.6 .3
Rotation Right 30.9±5.4 31.9±6.1 .6
Rotation Left 29.8±6.4 30.4±7.8 .8
*
m ean±SD
T able 2. T hor acolumbar joint r ange of motion
Variables F aller s Nonfaller s p
F lex ion 2.6±1.0
*3.5± .9 .02
Ext en sion 2.4±1.2 3.3± .5 .02
Side Bending Right 6.4±3.1 10.1± 3.5 .01
Side Bending Left 6.7±2.9 10.0± 3.5 .01
Rotation Right 7.8±4.3 18.6±10.4 .003
Rotation Left 7.1±4.6 15.8± 8.4 .004
*
m ean±SD
T able 3 . Hip j oint r ang e of m otion
Variables F aller s Nonfaller s p
F lex ion 101.6±12.2
*101.8± 9.7 0.9
Ext en sion 3.1± 2.3 5.1± 3.0 0.006
A dduction 4.1± 2.3 5.2± 2.8 0.1
Ab du ction 18.4± 5.3 25.2± 6.8 0.0001
Intern al Rot ation 19.1± 8.8 29.1±10.8 0.0005
Ext ernal Rotation 36.3± 5.9 39.7± 4.6 0.01
*
m ean±SD
T able 4 . Knee joint r ange of motion
Variables F aller s Nonfaller s p
F lex ion 137.5±8.7
*138.4±4.8 .6
Ext en sion - 6.6±5.5 - 1.0±1.8 1.1
*
m ean±SD
D i s c u s s i o n
F alls ar e a major cau se of decr eased m obility and independen ce in th e elderly and hav e been cited as an independent pr edictor v ariable leading t o nur sing hom e admission and hospit al admission (Lee an d Kerrigan , 1999). Mor eov er , falls ar e a leadin g perpetr at or of accident al death s am ong adult s older than age 65 y ear s.
Balance impairm ent s w er e found t o be a significant risk fact or associat ed with in - cr eased risk for falling in elderly . Balance oft en becom es impair ed as one gr ow s older (Hu ghes et al, 1996). A number of phy si- ological changes accompany the norm al aging pr ocess. Decr ea se in j oint flexibility is one of the chan ges that ar e found in elderly .
F lexibility is a foundation for a fr ee m ov em ent at ev ery joint . F lex ibility in joint m ov em ent allow s for a per son to accom - m odate v ariou s postur al r espon ses. In norm al adult s, the ant er oposterior and lat - er al st ability is r equir ed t o m aint ain bal- ance. While dist al to pr ox imal sequen cing in r espon se t o platform perturbation appear s t o be the pr edominant patt ern , a higher in ciden ce of pr oxim al t o dist al sequencin g in the older adult has been ob serv ed. T he differ en ce in postur al contr ol
m echanism with aging m ay be due t o the chan ge in their joint flex ibility . T he sev er e limit ation of joint m otion will be con - str ained by the biom echanical appar atu s thr ough which postur al r espon se mu st be expr essed (Ch andler and Duncun , 1993).
T he r esult of the r ange of m otion com - parison bet w een tw o gr oups in dicat es th at flex ibility of th e thor acolumbar spin e, hip and ankle j oint s may be r elated t o fall in the elderly . T h ese r esult s ten d t o support Sh ephar d ' s (1984) ob serv ation that th e declin e in joint flexibility is accompanied by decr ease in st ability and m obility , and by an in cr ease in deformity . Gu an d a sso- ciat es (1996) su ggest ed that ther e ar e lar ger ant er opost erior shear for ces at th e hip joint an d upper body segment r otation in the elderly for m aint enance of balance.
Alex an der an d associat es (1992) also sug - gest ed that ther e is incr ea sed u se of trunk m otion for m aint enance of balance in the elderly . T he con clu sion of these t w o stu d- ies m ay explain the r esult of this study that th er e is a significant differ en ce in r ange of m otion bet w een the faller s and nonfaller s . Since elderly u ses hip an d trunk for postur al contr ol t o m aint ain balance, flex ibility at these joint s may be neces sary for elderly t o m aint ain balan ce.
T he dor siflex ion of ankle joint m otion
T able 5 . Ankle joint r an ge of m otionVariables F aller s Nonfaller s p
Dor siflex ion 11.4±5.7
*18.5±3.5 0.002
Plant arflex ion 35.6±7.4 36.1±4.4 0.7
Inv er sion 22.1±6.2 22.8±7.8 0.7
Ev er sion 13.0±4.9 11.4±2.8 0.17
*
