Journal of health research in community

Introduction
With increasing life expectancy and the aging of the population in the world, including Iran, it is expected that by 2050, older people (aged 65 and older) will make up approximately 16% of the world’s population and 25% of Iran’s population. Age-related decline in sensorimotor function significantly increases the fall risk, compromising independence and quality of life in older adults. Physiological changes, including reduced muscle volume, strength, flexibility, agility, speed, and musculoskeletal capabilities, impaired balance and gait patterns, can lead to postural instability, falls, bone fractures, chronic pain, reduced mobility, and diminished movement independence.
Frankel’s exercises, which are based on proprioceptive neuromuscular facilitation (PNF), emphasize repetitive, slow, controlled movements in supine, sitting, and standing positions to enhance proprioception, coordination, and balance. Despite their potential for improving motor control, the simultaneous effects on static and dynamic balance, choice reaction time, gait speed, step length, and quality of life in older men over 75 years of age remain unclear. This group, due to mobility and environmental constraints, requires simple, low-cost interventions that do not require specialized equipment. Therefore, this study aimed to evaluate the impact of an eight-week Frankel exercise program on these variables in older men attending elderly day care centers in Sabzevar, Iran, providing evidence for its integration into fall prevention and rehabilitation programs for older adults. 

Methods 
This randomized controlled clinical trial was conducted on 40 inactive older men (<150 minutes of moderate-intensity activity per week) aged 75–85 years (mean age: 78.52±2.52 years) attending elderly day care centers in Sabzevar. From five centers, three were randomly selected, and participants were chosen proportionally based on the population of the centers and inclusion criteria: Ability to stand/walk 10 meters independently or with a cane, an MMSE score˃23 indicating no cognitive impairment, no use of medications affecting balance/central nervous system in the past four weeks, no uncontrolled diseases or severe musculoskeletal disorders. Exclusion criteria were: absence from ≥2 consecutive sessions or three sessions, injury, or unwillingness to continue participation. Sample size was calculated at 16 per group using G*Power (80% test power, α=0.05, effect size= 0.5), increased to 20, considering a 20% sample dropout. The block randomization method (block size of 4) was used to allocate groups. Participants and therapists were aware of allocation, but assessors and statisticians were blinded.
The intervention group (n=20) received 24 supervised sessions (3 sessions/week, 45–60 minutes): 10-minute warm-up, main protocol (supine/side-lying exercises such as knee/hip flexion, abduction/adduction, heel slides, bicycling, leg pressure; sitting exercises such as thigh lifts, sit-to-stand; standing exercises such as side/back/zigzag walking on heels/toes, 90-degree turns; 2 sets, 6–10 repetitions/5–10 seconds, progressive overload: +2 repetitions after 2 weeks, +1 set after 4 weeks), and 10-minute cool-down. The control group received usual care (with access to the post-study program). Pre-intervention and post-intervention (48 hours after the final session) assessments included static balance tests (Sharpened Romberg test with eyes-open/closed), dynamic balance (Timed up & go test), choice reaction time (Nelson’s modified test: 12.6 meters, 10 random right/left trials), gait speed/step length (8-meter walk, 3 trials), and quality of life (36- short form survey). Normality was confirmed by the Shapiro-Wilk test (P>0.05). The data were analyzed using a mixed ANOVA in SPSS software, version 27, with a significance level set at 0.05. 

 Results
Descriptive analysis confirmed group homogeneity in terms of age (control: 78.45±2.7 vs. intervention: 78.6 ±2.39 years, P=0.854), weight (68.6±5.74 vs. 66.25±6.43 kg, P=0.777), height (1.66±0.64 vs. 1.68±0.05 m, P=0.509), and BMI (24.02±2.18 vs. 23.41±1.96, P=0.356). 
Mixed ANOVA results revealed significant time×group interaction effect (P<0.001) and main effects of time and group for all study outcomes. The intervention group demonstrated superior improvements (Table 1).


No adverse events were reported. Large effect sizes (η²>0.64) indicated strong clinical impact of the intervention. 

Conclusion
An 8-week Frankel exercise program can significantly improve balance, reaction time, gait, and quality of life in older men aged >75. These findings support the integration of Frankel exercises into fall prevention and rehabilitation programs for older adults, particularly in institutional settings. Given their low cost, minimal equipment requirements, and absence of adverse effects, Frankel exercises offer a practical and promising strategy for enhancing functional independence in older men.

Ethical Considerations
Compliance with ethical guidelines
This study received ethical approval from the Ethics Committee of Hakim Sabzevari University (Code: IR.HSU.REC.1404.010). All participants provided written informed consent; they were informed of their rights, including the right to leave the study. No identifying information was used. The trial was registered by the Iranian Registry of Clinical Trials (ID: IRCT20220919055988N2).

Funding
This article was extracted from a research project at Hakim Sabzevari University. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contributions
Study design, supervision, editing & review: Hossein Shahrokhi; Exercise program implementation, initial draft preparation, statistical analysis, review: Ebrahim Ebrahimi; exercise program implementation, writing, data analysis: Abolfazl Tarkhasi; All authors read and approved the final version of the manuscript.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank all seniors, nurses, and managers of elderly day care centers in Sabzevar. 

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