International Journal of Multidisciplinary Education and Research

International Journal of Multidisciplinary Education and Research

ISSN: 2455-4588
Impact Factor: RJIF 5.12
www.educationjournal.in
Volume 3; Issue 3; May 2018; Page No. 46-51

Effect of square stepping exercise versus Swiss ball exercise on balance in institutionalized
elderly population
Mona1, Dr. Bharti Arora2, Dr. Sheetal Kalra3
1
MPT Neurology, SGT University Budhera, Gurugram, Haryana, India
2, 3
PT, SGT University Budhera, Gurugram, Haryana, India

Abstract
Aim: To compare the effect of Square Stepping Exercise and Swiss Ball Exercise on Balance in Institutionalized elderly
population.
Material and Method: Experimental Study design. A total of 30 subjects was randomly assigned in to 2 groups. Each group had
15 subjects named as Group A and Group B. Group A: Square Stepping Exercises. Group B: Swiss Ball Exercises. Simple
Random Sampling was done. Source of Sample tau devi lal Old Age Home Sec-4 (Gurugram)
Variables: i) Dependent Variables: Balance. ii) Independent Variables: Square stepping exercises, Swiss ball exercises. Outcomes
measure- Berg Balance Scale (BBS)
Result: Data was analyzed using SPSS Version 21.00. The Balance Score were examined under Square Stepping Exercises and
Swiss ball Exercises Training by using Paired t- test within in the group and Independent sample t- test between the groups. The P-
value was set at a significant level of P< 00.5.
Conclusion: The study shows significant improvement in balance of elderly population following Swiss Ball Training. But
improvement is more marked under Square Stepping Exercises training.

Keywords: square stepping mat, swiss ball, berg balance scale

Introduction term care homes compared with women living in the

Elderly or old age consists of ages nearing or surpassing the community [9]. Balance is a complex process involving the
average life span of human being, the boundary of old age reception and integration of sensory input and the planning
cannot be defined exactly because it does not have the same and execution of movement to achieve a goal requiring
meaning in all societies. Numerous studies demonstrates that upright posture [10]. Every activity we carry out requires us to
impaired balance and decrease lower extremity strength are react to gravity and our body to adjust accordingly in order to
important risk factor for the loss of physical function, maintain balance [11]. There is a positive relationship between
occurrence of fall in older adults [1, 2]. Amongst elderly people balance control or motor and sensory system function in order
bone fractures in relation to falls are a frequent phenomenon. to understand the cause of falling and create a effective
These accidents are often associated with physical decline, strategies to prevent fall in the elderly population [12, 13].
negative impact on quality of life and reduced survival. Fall The number of elderly people is growing very fast in both
risk has been related to a number of factors such as history of developed and developing countries. The rapid change in the
falls, muscle weakness, gait deficit, balance deficit, use of social and cultural values had made a tremendous impact on
assistive device, visual impairment, mobility impairment, fear mental well being of elder. In the modern world elder are the
of falling, cognitive impairment, depression, sedentary mean of a burden on the family in all societies and culture and
behavior, age, number of medications, mistreatment with elderly is common everywhere14. Many
psychotropic/cardiovascular medications, nutritional deficits, families who lives in the urban localities tend to send the elder
urinary incontinence, arthritis, home hazards and footwear [3]. in the institutions. Institutionalization provokes the feeling of
Fall defined as an event which results in person coming to rest loneliness and neglect in elder. Such living arrangements may
inadvertently on the ground or other lower level [4, 5, 6]. have negative effect on mental health of its resident, because
Resulting from fall in older people can lead to severe placement is often accompanied by feeling of lack control
depression, malnutrition, and increased chance of infection over own life and inability to make decisions regarding daily
which can have more deleterious effects on physiological issue [15]. Sensory system deteriorates with age increase
structures and functions in older people than in younger attention in allocated to heighten the signal coming from this
people [7]. Falls are a leading cause of injury and death among system in order to gain necessary information for postural
older adults and a significant public health issue [8]. Although control [16, 17]. Balance become more impaired in elderly
falls are common among the elderly population, recent population who are residing in residential care facilities
research conducted in kerala state, in India, has found a because of sedentary life style, mental frailty, physical
greater increases in fall in elderly women residing in long weakness, physical damage that cause falling, experience of

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International Journal of Multidisciplinary Education and Research

suffering fall has an effect on status cause anxiety and self 4. Complaint of dizziness or blurred vision leading to
imposed mobility restriction [17]. This inhibition of mobility as difficulty in walking.
a result of fear decreases the physical fitness and activity level 5. Acute low back ache.
in the institutionalized elderly population and further increase 6. Lower extremity joint deformity.
the risk of fall [18]. The square stepping exercise or SSE is a 7. Uncontrolled diabetes.
low cost indoor program to improve fitness of the lower 8. Any cardiovascular disorders.
extremity developed through universities. It is an exercise
method based on solid scientific Evidence and its application Variables
include the improvement of mobility in children and the Dependent Variables- Balance
prevention of life-style disease [19]. There is a positive
relationship between balance control or motor and sensory Independent Variables- Square stepping exercises, Swiss
system function in order to understand the cause of falling and ball exercises
create a effective strategies to prevent fall in the elderly
population [12, 13]. Another recent advance in core stabilization Instruments and Tools Used- Square Stepping Mat, Swiss
training is use of the Swiss ball. These exercises are used to Ball, Arm rest chair Stopwatch.
strengthen the core abdominal muscles [20]. Abdominal
muscular endurance and strength are important for trunk Procedure
stability, appropriate posture and body movements. The core 30 subjects who fulfilled the inclusion criteria was divided
is important because it provides proximal stability for distal into two groups. Subjects in Groups A and B followed
mobility [21]. The central nervous system and body protocol 2 times in a week for 12 weeks. Written informed
proprioceptors work together to refine pattern of movement. consent was taken from subjects prior to study.
Performing exercises on Swiss ball may increase
proprioceptive demands and stress the core muscles that are Group A: Square Stepping Exercises (Experimental Group)
important. Therefore the purpose of this study was to The Square stepping exercises (SSE) group was participating
Compare the effect of square- stepping exercises and Swiss in the supervised group session 2 times a week for 12 weeks.
ball exercise on balance in institutionalized elderly population. Each session comprised of warm up exercises, square stepping
exercises and cool down exercises. SSE is performed on thin
Method felt mat (100x250cm) that is partitioned into 40 squares (25cm
Study Design- Experimental Study Design each).

Sample Size- A total of 30 subjects was randomly assigned in Instruction to the Subject
to 2 groups. Each group had 15 subjects named as Group A The subject was instructed to walk from one end of the mat to
and Group B. the other according to step pattern provided. When the persons
Group A – Square Stepping Exercises. reached the end of the mat, they were instructed to return to
Group B – Swiss Ball Exercises. their start position by walking normally off the mat and then
stand in line for the next stepping. The SSE includes forward,
Sampling- Simple Random Sampling backward, lateral, and oblique step patterns. After the person
become familiar with each pattern, they were instructed to
Source of Sample- Tau devilal old Age Home Sec-4 walk with heels lifted, that is, on their toes, without treading
(Gurugram) on the frames of square. Each step pattern is repeated 4-10
times to ensure that person could complete the pattern, and
Inclusion Criteria followed by introduction of more complex step pattern.
1. Institutionalized Elderly Population.
2. Age above 50 years
3. Both male and female.
4. Able to understand and follow verbal instruction.
5. Ambulate independently at least 10 meter.(10 meters walk
test)
6. Mini Mental Scale- above 24
7. Faller and non faller.
8. Geriatric Depression Score above 14
9. Berg Balance Score- above 30

Exclusion Criteria
1. Any Neurological condition (stroke, Parkinson’s disease
etc.)
2. Limited mobility.
3. Any orthopedic disorder (rheumatoid arthritis, fracture
etc.)

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International Journal of Multidisciplinary Education and Research

Group B: Swiss Ball Exercises (Experimental Group)

Swiss ball exercises program consisted of 12 types of
exercises for balance twice a week for 12 weeks: warm up,
Swiss ball exercise and cool down exercise. The ball used in
this program was 55 cm in diameter and it was selected with
the consideration of the height of the subject. For warm up
and cool down, stretching exercises were performed to
increased Flexibility of the joint and break time for 3 min was
inserted between each set in consideration of physical strength
of the subject. Each exercise was performed in 3 steps from
easy to difficult level: ball exercise in lying down position
(Bridging on the Ball, Knee Flexion, Hip Adduction), ball
exercise sitting in the ball (Trunk Flexion, Anterior, Posterior
and Lateral tilting), and ball using the wall(Ball pushing
Facing the Wall). The program lasted for 12 week and the
number of repetition and sets were gradually increased by
Fig 1 session.

Table 1
Exercises 1-3 week 4-6 week 7-9 week 10-12 week
1. Bridging on Ball 10×3 10×4 5×4 5×4
2. Hip Adduction 3×5 5×5 3×5 3×5
3. Leg Raised Holding the Ball Between the Feet 3×5 5×5 3×5 3×5
4. Knee Flexion 3×5 5×5 3×5 3×5
5. Sit up on the Ball: Trunk flexion 3×5 5×5 3×5 4×5
6. Back Extension on Ball: Trunk Extension 3×5 3×4 4×4
7. Bounce on Ball 3×3 3×4 4×4
8. Pelvic Rotation on Ball 3×3 3×4 4×4
9. Knee Extension on Ball 3×3 3×4 4×4
10. Pelvic ant. Post. And lateral tilting on Ball 2×3 3×3
11. Side Bridging: Trunk lateral bending 2×3 3×3
12. Ball push facing the wall 2×3 3×3

40 Subject were assessed from Tau-Devi Lal old age home

sec-4 (Gurugram). Five Subjects were excluded because they
did not follow the inclusion criteria. Five Subjects excluded
because of Complaint of musculoskeletal pain.
Total 30 Subject was selected who met all the inclusion
Criteria. Total 30 patient which included 16 female and 14
male. First we compared demographic and functional data of
the age matched subgroup. Analysis comparison was done
between both group first at base line, after 4 weeks, 8 weeks,
and then again comparison was done after 12 weeks
intervention and result was noted.

Group a (Square Stepping Exercises)

Balance Score showed significant balance improvement with
the mean BBS after 12 weeks was increased to 53.2 ±1.699
from a value of 34.87±3.314. Balance Score showed
Fig 2 improvement with the mean score of BBS from base line
(34.87±3.314) to after 4 weeks exercises (43.13 ±3.701). Then
Result there was significant improvement occurs after 4 weeks
Data was analyzed using SPSS Version 21.00. The Balance training to 8 weeks training with the mean score of BBS
Score were examined under Square Stepping Exercises and increased to 48.07 ±3.127 from value of43.13 ±3.701. There
Swiss ball Exercises Training by using Paired t- test within in was also significant improvement occurs after 8 weeks
the group and Independent sample t- test between the groups. training to 12 weeks training with the mean score of BBS
The P- value was set at a significant level of P< 00.5. increased to 53.2 ±1.699 from value of 48.07 ±3.127.

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International Journal of Multidisciplinary Education and Research

Table 2
Base line to 4th week 4th week to 8th week 8th week to 12th week
N 15 15 15
Group- A Mean 43.13 48.07 53.20
Square Stepping Exercises S.D 3.701 3.127 1.699
t-value 11.585 10.665 8.663
p-value 0.001 0.000 0.000

Table 4: Mean Comparison of Berg Balance Score (BBS) in Study

Population at Base line, After 4 week, 8 week and 12 week.
BBS Baseline 4th week 8th week 12th week
Mean ± 43.13 48.07 53.2
Group- 34.87±3.314
S.D ±3.701 ±3.127 ±1.699
A
p-value 0.001
Mean± 33.87 41.33 47.13 51.47
Group-
S.D ±2.615 ±2.743 ±2.356 ±1.995
B
p-value 0.005

Fig 3

Group B (Swiss Ball Exercises)

Balance Score showed significant improvement with the mean
score of BBS after 12 weeks was increased to 51.47 ±1.995
from the mean score of BBS at base line was 33.87 ±2.615.
There was mild improvement occurs in mean score of BBS
from baseline exercise to after 4 weeks as the mean score of
BBS at baseline was 33.87 ±2.615 and this score was
increased after 4 weeks to the value of 41.33 ±2.743. Then
there was improvement occurs in mean score of BBS from 4 Fig 5
weeks to 8 weeks and the score was increased to the value of
47.13 ±2.356 from the value of41.33 ±2.743 But there was Table 5: BBS Changes Baseline to After Twelve Week
significant improvement take place with the mean score of t- test for Equality of
BBS after 8 weeks exercise to 12 weeks exercise and that Means
score was increased to the value of 51.47 ±1.995 from the t-value Df P-value
value of 47.13 ±2.356 after 8 week to 12 week. Balance at baseline Equal variance assumed .971 28 .367
Balance after 4 week Equal variance assumed 1.513 28 .141
Table 3 Balance after 8 week Equal variance assumed .923 28 .364
Balance after 12
Base line to 4th week to 8th week to Equal variance assumed 2.562 28 .016
week
4th week 8th week 12th week
Group- B N 15 15 15
Swiss Ball Mean 41.33 47.13 51.47 This result showed that at Base line treatment both Groups
Exercises S.D 2.743 2.356 1.995 having not significant difference in Berg Balance Score. (t-
t-value 8.305 13.564 8.940 Value is. 971 and P- Value is. 367). After 12 weeks of
p-value 0.003 0.002 0.000 exercises Berg Balance Score was increased in Group – A as
the (t- Value is 2.562 and P- Value is. 016). So Result showed
that Group A was more significant as compared to Group B.
Discussion- The result of the study support our hypothesis that
there was significant improvement in balance of
institutionalized elderly Population in both group who
received square stepping exercises and Swiss Ball Exercises.
But Group A who received Square Stepping Exercises showed
more significant improvement as compared to Group B who
received Swiss Ball Exercises (p<0.016). There was
improvement in BBS score after 12 weeks training program in
both groups. Square Stepping Exercises (SSE) is a simple,
low-cost and feasible method that can be easily performed
indoors. The SSE program involves multidirectional
Fig 4 movements including forward, backward, lateral and oblique

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International Journal of Multidisciplinary Education and Research

step patterns on a thin mat. Falls are the public health is increasing "core stability" and balance. One should assume
epidemic of this decade. One out of three adults aged 65 and that "core stability" refers to the synergistic contraction of the
over falls each year4) [22]. Falls are the leading cause of muscles of the abdomen and lower back. In addition, exercise
traumatic brain injury, fractures, loss of independence, balls can be used to strengthen other muscles, including those
associated illness and early death in older adults. The results of the legs and help in improvement in balance [25].
of this study imply that SSE could be used as means of According to these explanations and results, the trunk
rehabilitation and public health promotion because it has stabilization exercise with a Swiss ball increased the muscle
number of advantages: First, it is possible for fewer staff activities of the elderly. Generally, the elderly are not
members (including physicians, public health nurses, and powerful enough to perform common resistance exercises and
exercise instructors) to simultaneously supervise several older provide evidence of the validity of trunk stabilization exercise
adults with high risk of falling as SSE can be performed but also suggest an alternative approach to improve the core
within a small indoor space. Second, outdoor walker can stability of the elderly and improvement in balance. So that
substitute walking with SSE when it rains. Third, SSE requires Swiss Ball exercises help in improvement in balance but SSE
minimum investment because it involves the use of low tech is more helpful to improve balance and strength.
equipment. Fourth, because of the significantly small reaction On the basis of above discussion and result of statically
time, which is a cognitive function, SSE may improve analysis showed that Square Stepping Exercises after
information processing speed and psychomotor prosesses [3]. completion of intervention improve Balance 5.25% faster as
Fifth there is visual feedback while performing Square compared to Swiss ball exercises.
Stepping Exercise on the Special mat, also while performing
the exercise [22]. Conclusion
According to Shigematsu et al., SSE is found to be effective in The study shows significant improvement in balance of
balance improvement from the meta-analysis done with three elderly population following Swiss Ball Training. But
studies with P=0.0015. The studies were found to be improvement is more marked under Square Stepping
heterogeneous which could be due to the exercises used for Exercises training.
comparing with SSE were different (trunk extension, trunk
flexion, bri etc.), for instance one study used balance and Acknowledgement
strengthening exercises but the other two studies used walking It is my immense honour to present this dissertation. I am full
as a treatment for the controlled groups. of gratitude towards the almighty, my family and each one of
A study by Pijnappels and colleagues (2005) revealed that you who helped me throughout the journey of completion of
during a trip, when the balance of one leg is lost, the other leg this work.
is immediately lifted off the floor, in a manner similar to I thank Dr. Bharti Arora for her constant guidance and
hopping, in order to prevent a fall. This mechanism can support. Her inputs for improvement in every aspect of this
explain the reason for the lower number of falls observed in work helped me immensely.
the SSE group as the former appears to have adequate I also thank all the faculty members of my institute, especially
functional ability to prevent falls [23]. Dr. Sheetal Kalra, my co guide for her constant guidance,
Shigematsu and Okura et al. (2006) found improved support and encouragement.
locomotion speed (walking around 2 cones) using the same My special and whole hearted gratitude to all the subjects for
SSE program of intervention, better neuromuscular function their co-operation, patience and their valuable time which they
and coordination as a protective response to falls. Another spend for the collection of data required for the study purpose.
research in this field indicated that SSE was as effective as a Also, a very special thank you Dr. Garima dhankar without
specific training to strength and balance to prevent falls in whose support this work would not have been possible.
older people (Shigematsu et al., 2008) [23]. I would like to thank all my friends specially Prajjwal Arora
Subjects who received Swiss ball training also showed for their encouragement.
improvement in balance. Anderson and Behm (2005) suggest, Last, but not the least, I would like to thank all my batch
the proprioceptive system relies on information from the joints mates, especially who helped me throughout and were a
and muscles to coordinate unconscious reflexes to maintain constant source of encouragement.
balance [24]. According to Lehman et al. (2005) local muscles Once again a heartfelt thank you to all!
have a greater proprioceptive function, and if the Swiss-ball
stresses these muscles to a greater extent, this may form the Reference
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