I. elderly more likely to fall. Both fall

I. Introduction
The reason why I’m choosing this article that related to balance performance in older adults is because the number of elderly deaths associated with falls has been gradually increasing each year and the risk of falls increasing proportionally with age. One out of five falls among older adults causes a serious injury such as bone fracture or head injury and imbalance is one of the most common conditions that make elderly more likely to fall. Both fall with or without injury are carrying a heavy quality life impact. Therefore, there is a significant growing number of elderly who are fear from falling down limit their daily activities and social engagements. This can be result in decline of their physical health, easy to get depression and social isolation. This article is important to physiotherapy practice is because it include comparison of both the effects of single task and dual task training on balance performance in older adults with balance impairment and the interventions given are also included in physiotherapy area of practice.

II. Critical Appraisal of the Selected Literature

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A. Eligibility criteria were specified
YES

• This clearly defines which subjects included in the studied
• This research consist inclusion criteria which is,
(1) 65 years old or older
(2) Ability to walk 10 m without the assistance of another person
(3) no neurologic or musculoskeletal diagnosis such as cerebral vascular accident, significant orthopaedic involvement or significant visual and auditory impairments (4)Approval of their primary care physician to participate
(5) BBS scored less than 52 out of 56 points
(6) Completed 10 m walk with self-selected gait speed of 1.1m/s or less

Exclusion criteria included,
(1) MMSE scored less than 24
• These inclusion and exclusion criteria defined the study population to which results of this clinical trial can reasonably be generalized
• These can enhance the quality of subject selection, simplify and speed up the enrolment process and minimize violations of protocol and amendments to the protocols
• Deviation eligibility criteria is potentially detrimental to patient safety and impacts on data integrity
B. Subjects were randomly allocated to groups( in a crossover study, subjects were randomly allocated an order in which treatments were received)
YES

• Randomization means that every participant or subject has an equal chance of being assigned to study or control group on a random basis
• Randomization can minimize the threat of internal validity of the study and eliminate the effect of extraneous variables on dependent variables
• Randomization eliminates selection bias which ensures that investigator has no control over allocation of participants or subjects to the 3 different types of training groups and allows comparability of groups

C. Allocation was concealed
NO
• This study did not mention about the allocation was concealed
• Concealed allocation means that the person who generates the random assignment in research remains blind to what condition the subjects will enter
• Concealed allocation in research prevents the foreknowledge of investigator regarding the assignment of the participants or subjects to either of which training group or in intervention or control group.
• Allocation concealment can prevent selection bias or allocation bias
• Research staff is prone to assign “better ” subjects to intervention rather than control which can bias the treatment effect if allocation is no concealed
• Preferably, it should be completed by someone who has no other responsibilities in the study

D. The groups were similar at baseline regarding the most important prognostic indicators
YES

• There is no statistical significant of groups at baseline regarding the most important prognostic indicators in this research means that the groups were homogenous and comparable at the baseline
• Selection bias will lead to non-comparable groups or statistical significant groups at the baseline and will affect the result of study

E. There was blinding of all subjects
YES

• The study was double blind which subjects are unaware which treatment they are taking and investigator unaware about group assignment
• Blinding of subject can help to reduce the psychological effect of patient over the effect of intervention.
• For example, a subject who knows that he or she is receiving a new treatment for his/her problem which he/she expects to be beneficial may perceive or actually feel better than he would do if he/she thought he/she was receiving the old treatment
• Ascertainment bias can be reduce when blinding all concerned to the intervention group
• Knowledge of which intervention or treatment each participant is receiving will systematically distorted the results of the study or trial and lead to ascertainment bias occurs.

F. There was blinding of all therapists who administered the therapy
YES

• Double blind means where both participant and investigator unaware about of the group assignment and this eliminate observer bias to a large extent
• Blinding can improve the research validity and main goal of blinding is to avoid potential bias caused by conscious o subconscious factor
• Both participant’s and therapist’s expectations can influence the result if they know the group assignment. Thus, double blind can reduce the expectation bias
• Double blinding is done to eliminate investigator bias and Hawthorne effect

G. There was blinding of all assessors who measured at least one key outcome
NO

• The research is a double blind study which neither tester nor the participants were aware of group identity
• Triple blinding means where even the evaluator is also unaware of the process and may eliminate evaluator bias
• Triple blind use to maintain a blind data analysis of study
• Allows the evaluation of true effect of experimental intervention in subjects

H. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated groups
YES

• For single-task balancing training group, 87.5% of the subject was followed up
• For dual-task balancing training with fixed priority instructions group, 100% of subject was followed up
• For dual task balancing training with variable priority instructions group, 85.7% of subject was followed up
• More than 20% of subjects drop up will lead to the results of the research unable to be generalized to the population
• This is because lesser amount of participant in the research is unable to represent the population

I. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by “intention to treat”
YES

• Intention to treat analysis means all subjects allocated to each type of treatment regimen are analysed together as intended upon randomization, whether or not they actually received or completed the prescribed regimen
• Advantages of ITT including randomization is maintained, treatment assignment is based on chance alone and randomization provides theoretical foundation for statistical test of significance.
• Disadvantages of ITT including protocol violation, groups do not remain comparable at the end and analysis may underestimate the adverse effect.

J. The results of between group statistical comparisons are reported for at least one key outcome
YES

• ANOVA is an analysis of the variation present in the experiment or studies which is used for examining the differences in the mean values of the dependent variable associated with the effect of independent variables. It is used as a test of means for two or more population
• One way ANOVA is analyse for the single hypothesis from the obtained data
• Two way ANOVA is two main effects of two factors and one two way interaction effect between two
• Three way ANOVA is 3 main effects of 3 factors, 3 two way interaction and 1 three way interaction
• Advantages of ANOVA are ,It is the simple model which allow us to statistically assess differences across a grouping variable and commonly used and understood
• Repeated measure ANOVA advantages are individual differences among participants do not influence outcome and smaller number of participants needed to test all the treatments
• Disadvantages of repeated measure design including some unknown factor other than treatment may cause participant’s score or result to change and experience may affect the result independently of the actual treatment effect

K. The study provides both point measures and measures of variability for at least one key outcome
YES

• Point measures express in P value and confidence interval in this research
• Variability express in standard deviation in this research

x

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