Scientific Papers

The effect of corrective exercises on musculoskeletal disorders among the older adults residing in a nursing home in Rasht, Guilan, Iran | BMC Musculoskeletal Disorders

This is a randomized controlled clinical trial study with pre-test and post-test design that was performed on older adults residing in a nursing home, in 2020.

Study design and participants

The statistical population included all older adults residing in a nursing home (n = 397) in Rasht, the capital of Guilan province, located in the north of Iran. This city has only one non-profit, public nursing home that operates round the clock. This care center is located in a space of 17,000 square meters, to care for the older adults and disabled, in Suleiman Darab of Rasht. The main conditions for the clients’ admission are old age, lack of physical, motor, and spinal ability and, the inability of the family to take care of them. This center has wards 1, 2, and 3 for men and women, child and adolescent ward, and spinal cord lesion ward. In this research, the samples were selected from men’s and women’s wards.

Based on inclusion criteria, only the eligible older people were selected and randomly divided into intervention and control groups. A total of 70 eligible older people were selected and randomly divided into intervention (n = 35) and control (n = 35). In both groups (intervention and control), 6 subjects withdrew from cooperation due to unwillingness to continue cooperation. Finally, 29 samples remained in each group. The research flow is shown in Fig. 1.

Fig. 1
figure 1

Flowchart of the allocation of participants to the study groups

Inclusion criteria included individuals aged 60 years and older, appropriate general health status (independence in daily activities and ability to perform training protocol), having a good state of cognition, vision and hearing, no history of orthopedic surgery in the past year, no musculoskeletal fractures in the last six months, no congenital anomalies and specific skeletal diseases such as rheumatoid arthritis and no cardiovascular disease or acute illnesses, lack of regular exercise and non-drug addiction and lack of painkiller and sedative use. Exclusion criteria also included mobility problems during exercise, not attending all training sessions, and the older adult’s unwillingness to participate in the study.

Sampling method

A simple randomization method was used to select the subjects in the intervention and control groups. To this end, first, the names of the older were written on separate sheets, and then they were placed in an envelope. The participants were randomly placed in the intervention and control groups by taking them out of it one by one. At baseline, the researcher completed the questionnaires by asking questions about the samples. After training corrective exercises, the musculoskeletal status of the samples was checked again by the researcher. The pre-test was performed one week before and the post-test one week after the 8-week intervention (corrective exercise).

The sample size was calculated by considering the test power of 0.9 and the significance level of 0.05, 26 people for each group based on the following formula. Taking into account the probability of attrition, the final sample size of 35 people for each group was considered.

$$n=\frac{{\left({Z}_{1-\frac{\alpha }{2}}+{Z}_{1-\beta }\right)}^{2}({\delta }_{1}^{2}+{\delta }_{2}^{2})}{{({\mu }_{1}-{\mu }_{2})}^{2}}$$

$$n=\frac{{(1.96+1.28)}^{2}{(4.45}^{2}+{4.38}^{2})}{{\left(7-11\right)}^{2}}=25.57\cong 26$$

Research instruments

Research instruments included a demographic information questionnaire (age, sex, marital status, number of children, number of grandchildren, previous place of residence, years of work history, income, medical history, body mass index (BMI), blood pressure, and pulse and respiration rate before and after the intervention), the Nordic Musculoskeletal Questionnaire (NMQ) and the pain Visual Analog Scale (VAS), which were completed by the researcher by asking relevant questions from the samples.

The Nordic Musculoskeletal Questionnaire is one of the most common questionnaires for determining musculoskeletal symptoms, presented by Kuorinka et al. at the Institute of Occupational Health in Nordic countries in 1987 [26]. It assesses only three areas of the body. Dawson later modified the instrument in 2009 and evaluated nine body parts [27, 28]. It is used to assess the patterns and prevalence of MSDs for the different parts of the body regions in the last 12 months [29]. This questionnaire consisted of general questions on the history of having trouble in any of the nine body regions: neck, upper back, lower back, shoulder, elbow, hand/wrist, hip, knee, and ankle/foot. This questionnaire was accompanied by a body map diagram, which facilitated the subjects to locate the pain or discomfort sites in their bodies. In addition, questions were also asked regarding the subject’s lifetime experiences, followed by the prevalent questions, and, lastly, on the items related to consequences of pain in the whole year. The response categories were restricted to “yes” and “no”. It is reliable for collecting information about the onset, prevalence, and consequences of musculoskeletal pain in the nine body regions [29]. This instrument has been used many times in epidemiological studies in Iran. The psychometric properties of this instrument were evaluated by Mokhtarinia et al. (2015). The range of the kappa coefficient was calculated between 0.78 and 1 [28].

In the present study, the pain Visual Analog Scale (VAS) was used to assess pain intensity. This scale is one of the oldest, easiest, and best-validated measures to assess pain [30]. The VAS is a 10 cm line with anchor statements ranging from zero (no pain) on the left to 10 (the most severe) on the right. Mild, moderate, and severe pain are indicated by scores 1–3, 4–7, and 8–10, respectively [31, 32]. Its validity and reliability are excellent and its reliability was confirmed in Iran with a correlation coefficient of r = .88 [32].


The exercise class started with 10-min warm-up exercises (including stretching and balance exercises), and then continued for 30–40 min performing corrective exercises after the researcher in groups and individually, according to the conditions of each sample. At the end of the training class, cooling exercises and returning to the initial state were carried out for about 10 min. The intervention group performed corrective exercises for 8 weeks and 3 sessions per week and each session lasted for one hour. Exercises were designed based on each person’s ability and the principles governing the exercise, including the exercise intensity, gradual increase in exercise intensity, exercise duration, the principle of load progression, and the movement pattern of the exercise [12]. No special exercises were considered for the control group, and they performed daily and routine activities. Each stretching exercise was performed slowly and in a controlled manner. Increased resistance training was used to increase muscle strength. According to the principle of load progression, each session was added to the number of repetitions so that as subjects continued the exercises, they performed them more frequently, within a shorter rest time, and without feeling tired. The exercises started with 10 repetitions and reached 30 times at the end of the eighth week. Exercises include eight types of physical activity (exercises for the back, neck, shoulders, knees, ankles and feet, pelvis and abdomen, elbows, wrists, and hands). The exercises were designed from simple to complex. Special exercises were considered for each of the above-mentioned organs separately. The training program for the neck was of the type of isometric exercises. The special exercise program for the lower back was flexion exercises with an emphasis on strengthening the abdominal muscles and back extensors. The shoulder training program emphasized muscle strengthening and flexibility. Strengthening and flexibility exercises were also considered for the hands. More details about the intervention protocol are presented in Appendix 1.

All the exercises were done by one of the researchers and under the supervision of a physiotherapy specialist. Participants were asked not to perform any additional exercise. The control group was asked to do their normal daily activities and not participate in any exercise program. After completing the study, the control group will undergo the exercise intervention protocol.

Treatment fidelity

Treatment fidelity refers to the methodological strategies used to monitor and enhance the reliability and validity of behavioral interventions [33]. The US National Institute of Health (NIH) Behaviour Change Consortium has proposed a model of fidelity which identifies 5 areas in which fidelity should be addressed in behaviour change research: study design, the training of intervention providers, and treatment delivery, receipt, and enactment [34].

To comply with treatment fidelity, in designing the study, the intervention (corrective exercises) was designed by the research team based on the book by Hertling et al. [35]. One of the researchers (Master of Geriatric Nursing) was trained under the supervision of a physiotherapy specialist, and he provided the intervention. He was present at the nursing home at specific times during the weekdays and performed exercises for the sample under the supervision of an ergo therapist at a nursing home. He taught the exercises to the participants under his supervision. He had full control over how the samples performed the intervention and how the participants performed the exercises. After training the samples in the researcher’s presence according to the location of the disorder, corrective exercises were performed. Educational pamphlets were also used by older adults to better understand exercises. Thus, using training pamphlets, how to do the exercises was taught visually for the samples. The training was performed on the bed of each older adult individually or in groups according to the musculoskeletal symptoms of each sample. Older adults with the same musculoskeletal symptoms were grouped and trained. For example, older adults with musculoskeletal symptoms in the neck were grouped and performed corrective exercises as a group. The educational content and intervention method were the same for all samples with similar musculoskeletal symptoms. Furthermore, the number of exercises and the duration of the intervention were the same for all samples with similar musculoskeletal symptoms. The frequency and timing of interventions were monitored continuously using auxiliary tools such as an hourglass and counting tools such as line markers and finger counting.

Data Analysis

Data analysis was performed using descriptive and inferential statistics by Statistical Package for the Social Sciences version 19 (SPSS; IBM, Armonk, NY, USA). Normality was measured by the Kolmogorov-Smirnov test. The data were not normally distributed, so non-parametric tests were used for data analysis. To evaluate the effect of the intervention on MSDs, the post-intervention results were evaluated using the Chi-square test. To evaluate the effect of the intervention on pain intensity, the post-intervention results and the mean score of pain intensity of musculoskeletal disorders were compared between the two groups compared using the Mann-Whitney test. To compare pain variables before and after the intervention, the Wilcoxon test was used. The McNemar’s test was used for the presence or absence of MSDs.

The percentage of change pre- and post-test was calculated as.

Percentage change from pretest to posttest =\(\frac{\text{p}\text{o}\text{s}\text{t}\text{t}\text{e}\text{s}\text{t}\ \text{s}\text{c}\text{o}\text{r}\text{e}-\text{p}\text{r}\text{e}\text{t}\text{e}\text{s}\text{t}\ \text{s}\text{c}\text{o}\text{r}\text{e}}{\text{p}\text{r}\text{e}\text{t}\text{e}\text{s}\text{t}\ \text{s}\text{c}\text{o}\text{r}\text{e}}\times 100\)

The Chi-square or Fisher’s exact test was used to evaluate the homogeneity of background (demographic) variables in the two intervention and control groups. All calculations were performed at a significant level of P < .05.

Ethical consideration

This study was performed under the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. For illiterate participants, informed consent was obtained from their literate legally authorized representatives/guardians.

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