Impact of Skills Acquired Through Judo Training on Risk Factors for Falling in Elderly Men and Women
Condition: Aging Problems; Frailty; Fall Injury; Accidental Fall; Fear of Falling
MeSH terms: Frailty
Study type: Interventional

Summary: 
      Falls and injuries from falls are one of the greatest threats to public health. One of the
      risk factors for accidental falls is a low self-efficacy regarding the perceived capability
      to perform activities without the risk of falling. Judo is a sport which include "break fall"
      strategies where falls with correct landing strategies and rolling movements are in focus in
      order to avoid injuries. The investigators expect that a judo inspired training
      (Judo4Balance) will strengthen self-efficacy when it comes to the perceived ability to
      perform daily tasks without the risk of falling and thereby reduce the risk for falling. Judo
      based training also includes a well rounded training with focus on strength, balance,
      explosive power, stamina, proprioception and flexibility. These physical qualities are of
      importance for reducing the risk of falling. Therefore the investigators' hypothesis is that
      a 12 week long judo inspired training program could be a suitable tool for reducing falls.

      The aim of the project is to evaluate and document whether a 12 week standardized judo
      inspired exercise program including both the training of above mentioned physical qualities
      as well as "break fall" techniques can influence the risk of falling as well as reduce the
      negative consequences such as injuries from an accidental fall.

      For the evaluation of the 12 week intervention a validated test battery will be used which
      gives an indication of the risk for falling in the near future. Furthermore, a specifically
      designed "Falling Competence" Test has been developed by the investigators' M. Tonoknogi and
      K Strömqvist Bååthe to measure "break fall" technique.

      If it can be proven that the intervention group reaches the expected positive results then
      the control group will be offered the same type of Judo4Balance training after that they have
      been participating as a randomized control group.

      There is evidence that the risk of falling can be reduced by training, nevertheless judo
      based training has not to the investigator's knowledge been scientifically investigated among
      the elderly with the aim of reducing the risk of falls. Neither has it been studied if this
      type of group training is motivational for continuing physical activity after the
      intervention.

      Due to the Covid-19 pandemic and the Swedish Govt. recommendations (in mid March 2020) to
      avoid group exercises for older adults (to decrease the risk of the spread of Covid-19) the 9
      exercise intervention groups where put on hold/paused after 6-9 weeks into the exercise
      program.

      We applied for and received an approval for an addition to the ethical approval (2019-03048),
      in order to follow up with the study subject after 6-7 months of self-quarantine in the homes
      with a self rating of: Fall EfficacyScale (FES), EQ3D as well as questionnaire about the
      subjects perceived physical and mental health. These questionnaires were sent by post.
    

Detailed description: 
      The aim of this study is to evaluate and document whether a 12 week standardized judo based
      exercise program which include both the physical as well as "break fall" technique can
      influence the risk of falling as well as reduce the negative consequences of an accidental
      fall.

      Questions asked:

        -  Can a 12 week standardized judo based exercise program improve the physical status with
           regard to risks for falls among elderly ?

        -  Can a 12 week standardized judo based exercise program improve the balance among
           elderly.

        -  Can a 12 week standardized judo based exercise program improve the self-efficacy among
           elderly so they can perform their daily chores without the fear of falling

        -  Can a 12 week standardized judo based exercise program increase the level of physical
           activity among elderly?

        -  Can a 12 week standardized judo based exercise program decrease the risk of falls among
           elderly?

        -  Is there a difference between men and women regarding the effects on fall rate and on
           physical factors influencing fall injuries after the completed sixteen week standardized
           judo based training program

      The intervention study is conducted in cooperation with the Swedish Judo Federation who has
      developed as standardized exercise program for the elderly named Judo4Balance. The
      recommended training is well in accordance with the physical exercises that are intrinsic to
      a judo practice. Therefore the hypothesis is that a 12 week long judo inspired training
      program could be a suitable tool for reducing falls and injuries from falls.

      For the evaluation of the 12 week intervention a validated test battery which gives an
      indication of the risk of falling for an individual in the near future will be used. There
      will also be a specifically designed Falling Competence test to measure the effectiveness of
      the "break fall" training.

      Furthermore a follow up of the participants' physical status and break fall technique as well
      as their level of physical activity will be conducted with the same set of tests two years
      after the first intervention.

      The persons included in the study will where it is possible be followed up regarding fall
      incidents for several years.

      If it can be proven that the intervention group reaches the expected positive results such as
      improved physical status, higher self-efficacy with regards to falling and increased
      technical "break fall" skills then the control group will be offered the same type of
      Judo4Balance training one or two terms after that they have been participating as a
      randomized control group.

      There is evidence that the risk of falling can be reduced by training, nevertheless judo
      based training has not to the investigators's knowledge been scientifically investigated
      among the elderly with the aim of reducing the risk of falls. Neither has it been studied if
      this type of group training is motivational for continuing physical activity after the
      intervention.

      A randomized control study consisting of an intervention study and a control group that is
      carried out between 2019 - 2022 at different places throughout Sweden.

      Recruitment will be made at local health centers, judo clubs, and through cooperation with
      clubs and activity centers for retired people.

      Older adults interested in the intervention will be informed about the study both in written
      form and verbally and are signing a consent form. Independent research assistants perform the
      tests. After the tests are made the participants in the study will be randomized into one of
      two groups. One group will participate in the standardized judo inspired 12 week practice and
      one group will not participate. Practical tests and questionnaires are repeated again after
      the 12 weeks regardless of group affiliation.

      The judo based exercise program (Judo4Balance)is divided into three blocks and is lead by
      experienced and especially trained judo teachers during 12 - 16 weeks (12 -16 sessions)

      Block 1) Good technique during break fall training and strength training, accustom the body
      to regular training, find the right level of training for the group, build up load resistance
      in muscles, tendons and bones, challenge the balance through new movements that are not used
      during daily living activities such as getting down and up from the floor, flexibility
      training för stiff joints such as neck, upper back and shoulders.

      Block 2) Improve "break fall" technique and strength exercises, increase the load in the
      strength exercises, challenge the balance and coordination, increase the range of motion,
      introduce "power" exercises when the participants master the technique, continue to build up
      the load resistance in muscles, tendons, and bones.

      Block 3) Train the skill of explosive power during strength exercises and break falls.
      Challenge the balance with increased complexity and difficulty.

      Before the intervention and after the 12 week of standardized judo training program and for
      the control group no specific program given the following tests will be made:

      The participants fill in a health declaration and a questionnaire that besides demographic
      information also includes questions about motivation through two questions regarding
      readiness for change and self-efficacy regarding performing daily tasks without fear of
      falling.

      Modified Falls-Efficacy Scale - Swedish version (FES(S)) is a validated questionnaire which
      measures the self confidence in performing an activity without falling on an 11 grade scale,
      where 0 is not sure at all and 10 is totally confident when performing the activity without
      falling. The participant rates oneself based on 13 described activities where maximum score
      is 130 points.

      The physical status with relevance to fall risk will be evaluated using the modified Short
      Physical Performance Battery (SPPB) where each physical function, balance, strength and
      walking is evaluated on a 4 grade scale. The test has a max points of 12 and has proven to
      have a good reliability according to test - retest.

      The Mini-Balance Evaluation System Test (Mini-BESTest) is used to measure balance. The test
      includes 14 different tasks on 4 sub-scales. All tasks are graded from 0 to 2 points, with a
      total maximum score of 28 points. The test has high reported test-retest reliability and
      inter rater reliability.

      Since there are no previously known tests for the evaluation of judo "break fall" techniques
      for adults or elderly people, two tests have been designed by Professor M. Tonkonogi &
      Research Assistant K. Strömqvist Bååthe at Dalarna University in cooperation with The Swedish
      Judo Federation to test the acquired skills for falling backwards as well as falling forwards
      in a safe setting, with progressive difficulty. The judo fall techniques are graded on a 0-4
      scale. Where 0 represents the minimum score and 4 the maximum score. Four judo puzzle mats
      are needed for the exercises.

      Frändin/Grimby Activity Scale will be used to measure the level of physical activity. The
      scales range from 1 to 6, with 1 representing 'hardly active at all' and 6 representing
      'intensive exercise regularly and several times per week.' The scale has been evaluated and
      shown to have good validity.

      European Quality of Life Questionnaire (EQ-5D or EQ3D) will be used to measure quality of
      life in five dimensions, hygiene, main activities, pain, worry and mood/depression.
      Furthermore an evaluation of the participant's health status is made on a vertical analogue
      scale (VAS) graded 0-100. EQ-5D is proven to have a good test-retest reliability and a high
      validity.

      The pattern of movement will be analyzed before, and after the intervention with the help of
      "surface - electromyograph electrodes placed bilaterally on the participant's back muscles
      and accelerometer based mobility sensors placed on the perons's wrists, ankles and chest.

      Change over time will be calculated with paired non-parametric statistics for nominal and
      original data. Change over time for interval and quote data is calculated with parametric
      statistics. Uni-variate data and multivariate data analysis will be used for calculating
      change and outcome variables between the groups over time A p-Value <0.05 is needed to show a
      significant difference.

      The study had to be temporarily suspended because of the Covid pandemic after 6-9 sessions.
      However, in the fall of 2021 we were able to restart the training with both the exercise
      group as well as the control group. Both groups trained for 12 weeks. The test battery was
      performed both before and after the 12 week intervention.
    

Intervention name(s): Judo4Balance - 12 week judo inspired exercise program
Intervention type(s): Other
Intervention description(s): 12 weeks x 45 minute judo inspired exercise in lead by instructor in a group setting.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention
Keywords: Fall prevention; Physical training; judo; exercise; Judo4Balance; Break falls; Preventive Exercise