Movement repetitions in physical and occupational therapy during spinal cord injury rehabilitation.

STUDY DESIGN: Longitudinal observational study. OBJECTIVE: To quantify the amount of upper- and lower-extremity movement repetitions (that is, voluntary movements as part of a functional task or specific motion) occurring during inpatient spinal cord injury (SCI), physical (PT) and occupational therapy (OT), and examine changes over the inpatient rehabilitation stay. SETTING: Two stand-alone inpatient SCI rehabilitation centers. METHODS: Participants: A total of 103 patients were recruited through consecutive admissions to SCI rehabilitation. INTERVENTIONS: Trained assistants observed therapy sessions and obtained clinical outcome measures in the second week following admission and in the second to last week before discharge. MAIN OUTCOME MEASURES: PT and OT time, upper- and lower-extremity repetitions and changes in these outcomes over the course of rehabilitation stay. RESULTS: We observed 561 PT and 347 OT sessions. Therapeutic time comprised two-thirds of total therapy time. Summed over PT and OT, the median upper-extremity repetitions in patients with paraplegia were 7 repetitions and in patients with tetraplegia, 42 repetitions. Lower-extremity repetitions and steps primarily occurred in ambulatory patients and amounted to 218 and 115, respectively (summed over PT and OT sessions at discharge). Wilcoxon-signed rank tests revealed that most repetition variables did not change significantly over the inpatient rehabilitation stay. In contrast, clinical outcomes for the arm and leg improved over this time period. CONCLUSIONS: Repetitions of upper- and lower-extremity movements are markedly low during PT and OT sessions. Despite improvements in clinical outcomes, there was no significant increase in movement repetitions over the course of inpatient rehabilitation stay.

Knowledge translation and implementation in spinal cord injury: a systematic review.

OBJECTIVE: To conduct a systematic review examining the effectiveness of knowledge translation (KT) interventions in changing clinical practice and patient outcomes. METHODS: MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO were searched for studies published from January 1980 to July 2012 that reported and evaluated an implemented KT intervention in spinal cord injury (SCI) care. We reviewed and summarized results from studies that documented the implemented KT intervention, its impact on changing clinician behavior and patient outcomes as well as the facilitators and barriers encountered during the implementation. RESULTS: A total of 13 articles featuring 10 studies were selected and abstracted from 4650 identified articles. KT interventions included developing and implementing patient care protocols, providing clinician education and incorporating outcome measures into clinical practice. The methods (or drivers) to facilitate the implementation included organizing training sessions for clinical staff, introducing computerized reminders and involving organizational leaders. The methodological quality of studies was mostly poor. Only 3 out of 10 studies evaluated the success of the implementation using statistical analyses, and all 3 reported significant behavior change. Out of the 10 studies, 6 evaluated the effect of the implementation on patient outcomes using statistical analyses, with 4 reporting significant improvements. The commonly cited facilitators and barriers were communication and resources, respectively. CONCLUSION: The field of KT in SCI is in its infancy with only a few relevant publications. However, there is some evidence that KT interventions may change clinician behavior and improve patient outcomes. Future studies should ensure rigorous study methods are used to evaluate KT interventions.

An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life.

STUDY DESIGN: Systematic review. OBJECTIVES: To identify changes in subjective quality of life (QoL) as one ages with a spinal cord injury (SCI). SETTING: Vancouver, Canada. METHODS: Electronic databases were searched for studies reporting on age-related QoL changes over time. Data from relevant studies were transcribed into data extraction forms and analyzed by years post injury (YPI) and chronologic age. Each study was assigned a level of evidence based on a modified Sackett scale. RESULTS: In all, 21 studies, each with a low level of evidence, were included for review. The results indicated that regardless of chronologic age, individuals with relatively new SCI have the potential to improve their QoL. Among individuals with advanced YPI, overall QoL is consistently reported as good or excellent over time, however, with variations in different QoL domains. CONCLUSION: The QoL of individuals aging with a SCI has the potential to improve, and remain high and stable over time. As the identified studies provide low levels of evidence, more longitudinal research with greater methodological and measurement rigor is needed to corroborate the findings and conclusions of this review.

Participation and Well-Being Among Older Adults Living with Chronic Conditions.

This study explored the unique contribution of participation (daily activities and social roles) in explaining well-being of older adults living with chronic conditions and examined which aspect of participation (accomplishment of participation or satisfaction with participation) was more important in describing their well-being. Two hundred older adults with chronic conditions completed the following assessments: Satisfaction with Life Scale to measure well-being; Assessment of Life Habits to evaluate two aspects of participation: (a) accomplishment of daily activities and social roles and (b) level of satisfaction with participation; Interpersonal Support Evaluation List to assess level of social support and Affect Balance scale to measure level of balance confidence. In addition, participants' level of mobility was assessed using the Timed Up and Go test. Regression analysis was performed. Results indicated that number of chronic conditions, social support and satisfaction with participation had a significant contribution to well-being and altogether explained 31% of its variance whereas accomplishment of participation did not play as significant role in the model. In conclusion, participation has a unique contribution to older adults' well-being where satisfaction with participation rather than the accomplishment of activities is of importance. Additional aspects of participation and level of disability are key factors identified for further inquiry.

Postural Control Is Impaired in People with COPD: An Observational Study.

PURPOSE: We investigated deficits in postural control and fall risk in people with chronic obstructive pulmonary disease (COPD). METHOD: Twenty people with moderate to severe COPD (mean age 72.3 years, standard deviation [SD] 6.7 years) with a mean forced expiratory volume in 1 second (FEV(1)) of 46.7% (SD 13%) and 20 people (mean age 68.2 years, SD 8.1) who served as a comparison group were tested for postural control using the Sensory Organization Test (SOT). A score of zero in any trial of the SOT was registered as a fall. On the basis of the SOT results, participants were categorized as frequent fallers (two or more falls) or as fallers (one fall). To explore the potential influence of muscle weakness on postural control, knee extensors concentric muscle torque was assessed with an isokinetic dynamometer. Physical activity level was assessed with the Physical Activity Scale for the Elderly. RESULTS: People with COPD showed a 10.8% lower score on the SOT (p=0.016) and experienced more falls (40) than the comparison group (12). The proportion of frequent fallers and fallers during the SOT was greater (p=0.021) in the COPD group (four of 10) than in the comparison group (two of seven). People with COPD showed deficits in knee extensors muscle strength (p=0.01) and a modest trend toward reduced physical activity level. However, neither of these factors explained the deficits in postural control observed in the COPD group. CONCLUSIONS: People with COPD show deficits in postural control and increased risk of falls as measured by the SOT. The deficits in postural control appear to be independent of muscle weakness and level of physical activity. Postural control interventions and fall risk strategies in the pulmonary rehabilitation of COPD are recommended.

An evidence-based review of aging of the body systems following spinal cord injury.

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically review evidence on aging of the body systems after spinal cord injury (SCI). SETTING: Toronto, Ontario and Vancouver, British Columbia, Canada. METHODS: Electronic databases (MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO), were searched for studies published between 1980 and 2009. The search was augmented by reviewing the reference lists of relevant papers. Non-intervention studies that were longitudinal or cross-sectional with able-bodied controls that were at minimum matched on chronological age were included for review. Levels of evidence were assigned to the study design using a modified Sackett scale. RESULTS: Of the 74 studies selected for inclusion, 16 were longitudinal in design. The hypothesis that SCI represents a model for premature aging is supported by a large proportion of level 5 evidence for the cardiovascular and endocrine systems, level 2, 4 and 5 evidence for the musculoskeletal system, and limited level 5 evidence for the immune system. Only a few level 4 and 5 studies for the respiratory system were found. The evidence on the genitourinary system, gastrointestinal system, and for skin and subcutaneous tissues provide level 4 and 5 evidence that premature aging may not be occurring. The evidence on the nervous system does not provide evidence of premature aging as a result of SCI. CONCLUSIONS: Premature aging appears to occur in some systems after SCI. Additional longitudinal studies are required to confirm these findings.

Falls in people with chronic obstructive pulmonary disease: an observational cohort study.

STUDY OBJECTIVE: To investigate incidence, risk factors and impact of falls on health related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Observational cohort study. METHODS: Patients completed these questionnaires at baseline and at 6-months: Medical Outcomes Study Short Form 36 (SF-36), Chronic Respiratory Questionnaire (CRQ), Activities Balance Confidence (ABC) Scale and a form to record demographic data, medications, co-morbidities, oxygen use, acute exacerbations, fall history and assistive device use. Physical activity was measured with the Physical Activity Scale for the Elderly (PASE) only at baseline. Fall incidence was monitored through monthly fall diaries. Patients were categorized as non-fallers (0 falls) or fallers (≥ 1 falls). RESULTS: Data from 101 patients with a forced expiratory volume in 1 s of 46.4 ± 21.6% predicted were analyzed. Thirty-two patients (31.7%) reported at least one fall during the 6-months. Fall incidence rate was 0.1 (95% CI: 0.06-0.14) falls per person-month. Fallers tended to be older (p = 0.04), female (p = 0.04) and oxygen dependent (p = 0.02), have a history of previous falls (p < 0.001), more co-morbidities (p = 0.007) and take more medications (p = 0.001). Previous falls (OR = 7.36; 95% CI: 2.39-22.69) and diagnosis of coronary heart disease (OR = 7.07; 95% CI: 2.14-23.36) were the most important predictors of falls. The Dyspnea Domain of the CRQ declined significantly more (p = 0.02) in the fallers group at 6-months. CONCLUSIONS: Patients with COPD have a high susceptibility to falls, which is associated with a worsening of dyspnea perception as related to HRQoL. Fall prevention programs in COPD are recommended.

Neurogenic bowel management after spinal cord injury: a systematic review of the evidence.

STUDY DESIGN: Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included. OBJECTIVE: To systematically review the evidence for the management of neurogenic bowel in individuals with SCI. SETTING: Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature. METHODS: Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned. RESULTS: A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications. CONCLUSIONS: Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

Compromised bone strength index in the hemiparetic distal tibia epiphysis among chronic stroke patients: the association with cardiovascular function, muscle atrophy, mobility, and spasticity.

SUMMARY: The purpose of this study was to identify the determinants of the bone strength index of the distal tibia epiphysis in chronic stroke patients. The results showed that lower cardiovascular fitness, more muscle atrophy, poorer mobility, and more severe spasticity were independently associated with lower tibial bone strength index. INTRODUCTION: To identify the determinants of the bone strength index (BSI) at the distal tibia in chronic stroke patients METHODS: Sixty-three chronic stroke survivors underwent scanning of the distal tibia at the 4% site on both sides using peripheral quantitative computed tomography. The primary outcomes were trabecular bone mineral density (BMD; milligram per cubic centimeter), total BMD (milligram per cubic centimeter), total bone area (square millimeter), and BSI (square gram per centimeter to the power of four). Cardiovascular fitness, leg lean mass, gait velocity, and spasticity were also measured. RESULTS: Scans from 45 subjects were deemed to have acceptable quality and were included for subsequent analysis. The paretic side had significantly lower trabecular BMD, total BMD, and BSI than the nonparetic side (p < 0.05). However, the total bone area demonstrated no significant side-to-side difference (p > 0.05). After adjusting for relevant biological factors, peak oxygen consumption, leg muscle mass, and gait velocity remained positively associated with tibial BSI on both sides (R (2) change = 6.9-14.2%), whereas spasticity of the paretic leg was negatively associated with tibial BSI on the same side (R (2) change = 4.8%). CONCLUSIONS: Cardiovascular function, muscle atrophy, mobility, and spasticity are independently associated with BSI of the distal tibia epiphysis among chronic stroke patients.

Physiatrists' opinions and practice patterns for bone health after SCI.

STUDY DESIGN: Self-report survey. OBJECTIVE: To ascertain physiatrists' opinions and current practice patterns for bone health management after spinal cord injury (SCI). PARTICIPANTS: Physiatrists who work in teaching rehabilitation centers in Canada. METHODS: A 4-page 17-question survey (available in French and English) was sent to working physiatrists in all major Canadian SCI rehabilitation centers. RESULTS: We had an 85% response rate (22 responses). Physiatrists reported that they should be managing bone health issues after SCI in conjunction with family physicians, and most respondents assess and treat for bone health after SCI. However, just over one-third of the physiatrists reported that the current treatment options are not effective for low bone mass; there was more support for pharmacological treatments than there was for rehabilitation modalities. CONCLUSION: Bone health after SCI is an important health concern that is being managed by physiatrists; however, more discussion and research is needed to ascertain the effectiveness of assessment and treatment options for low bone mass.

Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study.

STUDY DESIGN: This was a prospective cross-sectional study for people with chronic spinal cord injury (SCI). OBJECTIVES: To (1) evaluate the intensity level and nature of physical activity in community-dwelling individuals living with SCI, and (2) explore the relation between descriptive individual variables (for example, lesion level), secondary complications and participation in physical activity. SETTING: Urban community setting. METHODS: A total of 49 subjects with SCI who used a manual wheelchair for primary mode of mobility (mean years since injury, 11.8; mean age, 43.7 years; 67% paraplegia) completed the physical activity recall assessment for people with SCI (PARA-SCI). RESULTS: Approximately 50% of reported physical activity among individuals with SCI is due to activities of daily living. The amount of physical activity was not related to lesion level, age, body mass index or waistline size. Greater heavy-intensity activity was related to lower levels of pain and fatigue and higher levels of self-efficacy, whereas higher amounts of mild-intensity activity and total activity were related to less depressive symptoms. CONCLUSIONS: Activities of daily living are a large component for physical activity among individuals with SCI. It appears that greater physical activity is associated with less secondary complications (pain, fatigue and depression) in individuals with SCI.

The effects of functional electrical stimulation leg cycle ergometry training on arterial compliance in individuals with spinal cord injury.

STUDY DESIGN: A prospective intervention of functional electrical stimulation leg cycle ergometry (FES-LCE) of four women with spinal cord injury (SCI). OBJECTIVE: To evaluate the effect of FES-LCE training on arterial compliance in individuals with chronic SCI of traumatic origin. SETTING: Tertiary rehabilitation center in Canada. METHODS: Large and small artery compliance were measured at the radial artery before and after a 3-month training program using FES-LCE. RESULTS: There was no significant change in large artery compliance after FES-LCE (16.0+/-4.2 to 16.8+/-6.1 ml mm Hg(-1) x 10, P=NS). There was a marked (63%) increase in small artery compliance after the FES training program (4.2+/-1.8 to 6.9+/-3.2 ml mm Hg(-1) x 100, P<0.05). CONCLUSION: It appears that FES-LCE is effective in improving small artery compliance in females with SCI.

A systematic review of functional ambulation outcome measures in spinal cord injury.

STUDY DESIGN: Systematic review. OBJECTIVES: To systematically review the psychometric properties of outcome measures used to assess ambulation in people with spinal cord injury (SCI). SETTING: Vancouver, BC, Canada. METHODS: A keyword literature search of original articles that evaluated the psychometric properties of ambulation outcome measures in the SCI population was conducted using multiple databases. Multidimensional scales of function were included if specific data were available on ambulation-related subscales. Reliability, validity and responsiveness values were extracted and conclusions drawn about the psychometric quality of each measure. RESULTS: Seven outcome measures were identified and were broadly categorized into timed and categorical measures of ambulation. Timed measures included timed walking tests that showed excellent reliability, construct validity and responsiveness to change. The psychometric properties of the categorical scales were more variable, but those that were developed specifically for the SCI population had excellent reliability and validity. Categorical scales also exhibited some floor or ceiling effects. CONCLUSION: Excellent tools are available for measuring functional ambulation capacity. Further work is required to develop and evaluate outcome measures to include environmental factors that contribute to the ability to achieve safe, functional ambulation in everyday settings.

Fall-related self-efficacy, not balance and mobility performance, is related to accidental falls in chronic stroke survivors with low bone mineral density.

UNLABELLED: Chronic stroke survivors with low hip bone density are particularly prone to fractures. This study shows that fear of falling is independently associated with falls in this population. Thus, fear of falling should not be overlooked in the prevention of fragility fractures in these patients. INTRODUCTION: Chronic stroke survivors with low bone mineral density (BMD) are particularly prone to fragility fractures. The purpose of this study was to identify the determinants of balance, mobility and falls in this sub-group of stroke patients. METHODS: Thirty-nine chronic stroke survivors with low hip BMD (T-score <-1.0) were studied. Each subject was evaluated for the following: balance, mobility, leg muscle strength, spasticity, and fall-related self-efficacy. Any falls in the past 12 months were also recorded. Multiple regression analysis was used to identify the determinants of balance and mobility performance, whereas logistic regression was used to identify the determinants of falls. RESULTS: Multiple regression analysis revealed that after adjusting for basic demographics, fall-related self-efficacy remained independently associated with balance/mobility performance (R2 = 0.494, P < 0.001). Logistic regression showed that fall-related self-efficacy, but not balance and mobility performance, was a significant determinant of falls (odds ratio: 0.18, P = 0.04). CONCLUSIONS: Fall-related self-efficacy, but not mobility and balance performance, was the most important determinant of accidental falls. This psychological factor should not be overlooked in the prevention of fragility fractures among chronic stroke survivors with low hip BMD.

Muscle weakness, spasticity and disuse contribute to demineralization and geometric changes in the radius following chronic stroke.

UNLABELLED: Bone health status of the radius in individuals with chronic stroke was evaluated using peripheral quantitative computed tomography. Bone mineral density and cortical thickness on the affected side were compromised when compared with the unaffected side. Muscle weakness, spasticity, and disuse were identified as contributing factors to such changes. INTRODUCTION: Following a stroke, demineralization and geometric changes occur in bone as a result of disuse and residual impairments, and these can contribute to an increased risk of fragility fractures. METHODS: This study used peripheral quantitative computed tomography (pQCT) to evaluate volumetric bone mineral density and geometry at the midshaft radius in people living with chronic stroke. Older individuals with chronic stroke were recruited. Each subject underwent a pQCT scan of the midshaft radius at the 30% site on both upper limbs. Muscle strength, motor function, spasticity, and chronic disuse were also evaluated. Data from 47 subjects (19 women) were assessed. RESULTS: A significant difference was found between the two limbs for cortical bone mineral content, cortical bone mineral density, cortical thickness, and polar stress-strain index. There was no significant side-to-side difference in total bone area. Percent side-to-side difference in muscle strength, spasticity, and chronic disuse were significant determinants of percent side-to-side difference in cortical bone mineral content and cortical thickness. CONCLUSIONS: The findings suggest that following chronic stroke, endosteal resorption of the midshaft radius occurred with a preservation of total bone area. Muscle weakness, spasticity, chronic disuse significantly contributed to demineralization and geometric changes in the radius following chronic stroke.

Bone geometric response to chronic disuse following stroke: a pQCT study.

OBJECTIVES: The objectives of this study were to 1) assess volumetric bone geometry and density at the distal radius of individuals with chronic stroke and 2) assess whether bone strength is associated with measures of muscle strength and impairment. MATERIAL AND METHODS: Cross-sectional study of bone and muscle parameters in 15 community-dwelling people living with the residual effects of a stroke (between 1 and 9 years post-incident stroke). RESULTS: The 4% site of the distal radius had significantly lower bone mineral content and density on the paretic side (p<0.006). There was a significant difference in pQCT measures of bone cortical density (p<0.03), area (p<0.05) and bone strength [Stress-Strain Index; SSI] (p<0.01) (lower on the paretic side) at the 30%. We found significant correlations between composite muscle strength score of the upper extremities and pQCT-generated bone strength. CONCLUSIONS: This cross-sectional study highlights lower bone strength on the paretic limb and an adaptive response to disuse.

A 19-week exercise program for people with chronic stroke enhances bone geometry at the tibia: a peripheral quantitative computed tomography study.

BACKGROUND: We assessed the impact of a 19-week exercise program on bone health in chronic stroke. RESULTS: Those who underwent the program reported significantly more gain in tibial trabecular bone content and cortical bone thickness on the affected side. CONCLUSION: Regular exercise is thus beneficial for enhancing bone health in this population.

Reliability of surface EMG during sustained contractions of the quadriceps.

The purpose of this study was to determine test-retest reliability for median frequency (MDF) and amplitude of surface EMG during sustained fatiguing contractions of the quadriceps. Twenty-two healthy subjects (11 males and 11 females) were tested on two days held one week apart. Surface EMG was recorded from rectus femoris (RF), vastus lateralis (VL) and vastus medialis (VM) during sustained isometric contractions at 80% and 20% of maximal voluntary contraction (MVC) held to exhaustion. Quadriceps fatigue was described using four measures for both MDF and amplitude of EMG: initial, final, normalized final and slope. For both MDF and amplitude, the initial, final and normalized EMG showed moderate to high reliability for all three muscle groups at both contraction levels (ICC=0.59-0.88 for MDF; ICC=0.58-0.99 for amplitude). Slope of MDF and amplitude was associated with a large degree of variability and low ICCs for the 80% but not the 20% MVC. MDF and amplitude of EMG during sustained contractions of the quadriceps are reproducible; normalized final values of MDF and amplitude show better reliability than slope.

Pain following spinal cord injury: the impact on community reintegration.

STUDY DESIGN: Prospective, correlational. OBJECTIVES: (1) Describe how pain changes over recovery from admission to spinal cord injury (SCI) rehabilitation, discharge and after 6 months of community living and (2) examine the relationship between pain and community integration at 6 months of community living. SETTING: Tertiary rehabilitation centre, SCI unit, Vancouver, Canada. METHODS: Subjects from 66 consecutive admissions to the SCI Program of a tertiary rehabilitation centre for the treatment of a traumatic SCI during the years 2000-2002 were followed using data from the National Rehabilitation Reporting System (NRS). Information was obtained from NRRS standardized assessments performed on admission, discharge and 6 months of community living. Early community living was defined as 6 months postdischarge. Community reintegration was assessed by the Reintegration to Normal Living Index (RNL). Pain presence, pain impact and pain intensity were assessed using single item Likhert-type scales. RESULTS: In all, 86% of individuals with a SCI reported pain at 6 months postdischarge, with 27% of these individuals reporting pain that impacted on many or most activities. Pain impact and pain intensity were related to the community reintegration (r = -0.39 and -0.55, P < 0.001), with pain intensity accounting for 25% of the variance in RNL scores. CONCLUSIONS: Pain is a major consequence of a SCI, impacting on an individual's activities and perception of how well they are integrated into the community. The results of this study highlight the need to address pain during both the rehabilitation phase of treatment and the early transition into the community.

Balance confidence improves with resistance or agility training. Increase is not correlated with objective changes in fall risk and physical abilities.

BACKGROUND: While the fear of falling is a common psychological consequence of falling, older adults who have not fallen also frequently report this fear. Fear of falling can lead to activity restriction that is self-imposed rather than due to actual physical impairments. Evidence suggests that exercise can significantly improve balance confidence, as measured by falls-related self-efficacy scales. However, there are no prospective reports that correlate change in balance confidence with changes in fall risk and physical abilities as induced by participating in a group-based exercise program. OBJECTIVE: The primary purpose of this prospective study was to examine the relationship between the change in balance confidence and the changes in fall risk and physical abilities in older women with confirmed low bone mass after 13 weeks of exercise participation. The secondary purpose of this study was to examine the relationship between the change in balance confidence and the change in physical activity level. METHODS: The sample comprised 98 women aged 75-85 years with low bone mass. Participants were randomly assigned to one of three groups: resistance training (n = 32), agility training (n = 34), and stretching (sham) exercises (n = 32). The 50-min exercise classes for each study arm were held twice weekly at a local YMCA community centre. RESULTS: Both resistance training and agility training significantly improved balance confidence by 6% from baseline after 13 weeks. However, the change in balance confidence was only weakly correlated with improved general physical function and not significantly correlated with the changes in fall risk score, postural stability, gait speed, or physical activity level. As well, we observed balance confidence enhancement in the presence of increased fall risk or deterioration in physical abilities. CONCLUSIONS: Two different types of exercise training improved balance confidence in older women with low bone mass. This change in balance confidence was significantly correlated with change in general physical function. Because of the observation of discordance between balance confidence change and changes in fall risk and physical abilities, those who design group-based exercise programs for community-dwelling older adults may wish to consider including an education component on factors that influence fear of falling. Objective changes in fall risk factors cannot be assumed to mirror change in fear of falling and physical abilities in older adults in the short-term.