Simplified Pilates Training in Older Adults in Hong Kong

This study will be a randomised controlled trial to investigate the efficacy of the simplified Pilates exercise programme (developed by a group of Pilates and rehabilitation experts in Hong Kong in our completed pilot study) by comparing it with the wait-list control.

A total of 60 older adults will be recruited from different collaborating community elderly and rehabilitation centres in Hong Kong using convenience sampling. The inclusion criteria will be the following: (1) age 65 or above and (2) score of less than 24/28 in the Tinetti Performance Oriented Mobility Assessment (POMA). The exclusion criteria will be the following: (1) total score of less than 24 in the Chinese version of the Mini-Mental State Examination (MMSE-C), (2) presence of any untreated cerebral vascular disease, Parkinson's disease, or any other major neurological deficit, (3) presence of any unstable medical condition that can affect safety during the exercise training, and (4) inability to sit and lie down on a Pilates exercise mat on the floor even with assistance.

The participants (N = 60) will be randomly assigned using concealed block randomisation by an independent person through a sealed and opaque envelope system to either the simplified Pilates exercise group (SPEG; n = 30) or the wait-list control group (WLCG; n = 30). A computerised random-number generator will be utilised to prepare an allocation schedule. The participants in the SPEG will partake in exercise sessions (about 60 minutes each) in a group (about 10 participants in each group) twice a week for 12 weeks. Each participant will undertake a total of 24 exercise sessions. All the training sessions will be conducted in Hong Kong by two experienced and certified Pilates trainers under the supervision of a registered physiotherapist. The participants in the SPEG will practise the 16-style simplified Pilates exercise programme. The WLCG will participate in the 16-style simplified Pilates exercise programme after two scheduled assessment sessions and a waiting period of 12 weeks in between.

To examine the efficacy of the exercise programme, the participants of both the SPEG and WLCG will undergo two assessment sessions before training at baseline (T0) and just after the completion of all the exercise sessions (T1). In the baseline assessment (T0), a structural questionnaire will be used to ask the participants for their demographic information, detailed information regarding any previous falls, detailed medical history, use of prescribed drugs, social history, and socio-economic status. Following this, a series of assessments will be conducted to examine their balance ability, which will be measured by the Berg Balance Scale (BBS; primary outcome measure), and other physical and psychological fall risk factors (secondary outcome measures) in the two assessment sessions (T0 \& T1). Any adverse events will be reported and tracked. Participants will also be asked to prospectively record the number of falls they have experienced during the time between T0 and T1 using a structural calendar. The frequency of falls (secondary outcome measure) will then be collected at T1.

Balance ability (primary outcome measure) will be assessed using the BBS. Regarding the other physical fall risk factors (secondary outcome measure), flexibility will be measured using the 'sit-and-reach' (S\&R) test. A functional gait and balance assessment will be conducted using the POMA and Timed Up and Go (TUG) tests.

On the other hand, for the assessment of the psychological fall risk factors (secondary outcome measure), the MMSE-C will be used as a screening tool to examine the preliminary cognitive function at the beginning of training. Depression levels will be assessed using the Chinese version of the 4-item Geriatric Depression Scale (GDS-4C). Anxiety levels will be measured using the valid and reliable Chinese version of the State-Trait Anxiety Inventory (STAT-SC \& STAI-TC). The valid and reliable Chinese version of the Falls Efficacy Scale International [FES-I (Ch)] will be utilised to assess the fear of falling. The valid and reliable Chinese version of the Activities-Specific Balance Confidence Scale [ABC (Ch)] will be used to evaluate balance confidence.