RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / PUJASHREE PANDA
C/O.P.C.PRADHAN, KAMAL NIWAS (Dr. ISHAN NAIK GALI), A. N. GUHA LANE, SAMBALPUR, ORISSA.
2 / NAME OF THE
INSTITUTION / KRUPANIDHI COLLEGE OF PHYSIOTHERAPY, BANGALORE.
3 / COURSE OF THE STUDY AND SUBJECT / MASTERS OF PHYSIOTHERAPY IN MUSCULOSKELETAL DISORDER AND SPORTS PHYSIOTHERAPY
4 / DATE OF ADMISSION TO THE COURSE / JUNE 2008
5 / TITLE OF THE TOPIC:
EFFECT OF FLOOR LEVEL CORE STABILITY EXERCISES IN IMPROVING BALANCE IN GERIATRIC POPULATION- A QUASI EXPERIMENTAL STUDY
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8 / BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Geriatrics is the branch of medicine concerned with the diagnosis, treatment and prevention of disease in the older people and the problems specific to aging01.
The geriatric population is defined as population aged 60 years and above.
According to a community-based study conducted in an urban slum area in India, which has depicted the socio-demographic and health profile of the aged population, the geriatric population comprised 6.4% out of the total population comprising 3,157 individuals. Out of 202 participants in the study, 17.33% were economically active. 32.18% suffered from cataract, 16.34% from hypertension and 9.41% from diabetes. There is an urgent need for interventions in order to cope with the consequences of increasing longevity in the Indian population. As a proportion of the total population, the geriatric population has been steadily increasing over the decades. The elderly people suffer from a variety of problems which are increasingly drawing the attention of the Government and the public02
Aging brings about many changes in the body such as reduction in muscle capacity leading to reduction in functional activities and activities of daily living (ADL), loss of peripheral motor and sensory nerves, loss of both vision and control of eye through the vestibular and visual cortex, increased blood pressure during exercises and an increase in isometric endurance03, 04, 05, 06, 07..
ADL are frequently impaired due to weakness in core muscles such as rectus abdominis, transverse abdominis, internal and external oblique muscles08.This results in an inability to reach objects away from the body.
Many programs have been developed to increase muscle strength and balance09, 10. Exercise programs designed for fall prevention in older people should address three major areas-strength, balance and endurance11.
Studies show that strengthening core muscles does aid in functional abilities12,13. According to Clark (2002), core is where human body’s center of gravity is located and is where all movements begin, it is important that we get the training of core correct resulting in more efficient movement patterns and optimal performance.
Core stability includes concepts of core strengthening, muscular fusion lumbo-pelvic stabilization and dynamic stabilization. Core strength refers to muscle strength and endurance. Dynamic activities are those that cause perturbations in center of gravity in response to muscle activity. Dynamic stabilization refers to the ability to utilize strength and endurance in a functional manner through all planes of motion and action despite changes in center of gravity. Lumbo-pelvic control, and therefore, strength is thought to be inefficient without proper dynamic stabilization of the lumbo-pelvic region during daily activities14.
Balance is a state of bodily equilibrium or ability to maintain the center of body mass over base of support whereas neuromuscular control is the motor response to sensory input of muscles .A combined core stabilization/balance training-program could be used to improve semi dynamic balance, whereas a core stabilization-training program or balance-training program could be used to improve dynamic balance. This should lead to a strong, stable core that will maintain normal length-tension relationship of functional agonists and antagonists. This will allow normal force-couple relationships to be maintained in lumbo-pelvic-hip complex15.
Hence, in this study the researcher aims to find out the effectiveness of core strengthening in increasing balance in elderly subjects.
6.1 NEED FOR THE STUDY:-
Studies have shown that 65% of individuals older than 60 years of age experience dizziness or loss of balance, often on a daily basis. Some degree of imbalance is present in all individuals older than 6016.
There has been a limited physiotherapy intervention in the field of balance retraining in geriatric population using the core concept. Hence, we aim to establish an evidence-based therapy in treating balance by doing this research study.
6.2 OBJECTIVES OF THE STUDY:-
A) OBJECTIVES
To analyze and interpret the effect of core stability exercises in improving balance in geriatric population.
B) HYPOTHESIS
·  NULL HYPOTHESIS: There is no significant improvement in balance of geriatric population with floor level core stability exercises.
·  EXPERIMENTAL HYPOTHESIS: There is significant improvement in balance of geriatric population with floor level core stability exercises.
6.3 REVIEW OF LITERATURE:-
1. Relationship between age and measures of balance, strength and gait: linear and non-linear analyses17
Natalie EL HABER, Bircan ERBAS, Keith D. HILL and John D. WARK ; Clinical Science (2008) 114, 719–727
An age-related decline in balance, gait and lower-extremity muscle strength measures may lead to increased risk of falls and fractures. Previous studies have reported a possible non-linear age-related decline in these measures, but the choice of methodological approach has limited its interpretation. Healthy community-dwelling women (n=212) 21–82 years of age were evaluated for strength [Nicholas MMT (manual muscle tester)], gait [CSA (clinical stride analyzer)], activity [HAP (human activity profile)] and static and dynamic balance [CBS (Chattecx balance system), LBT (Lord’s balance test) and the ST (step test)].
A GAM (generalized additive model) was developed for each outcome variable to
estimate the functional relationship, with age as a continuous variable. Performance was maintained until 45–55 years of age, depending on the outcome measure. Thereafter a decline in performance was evident with increasing age in all measures. Overall, a significant nonlinear relationship with age was demonstrated for lower-extremity strength measures (MMT), velocity and double support duration of gait (CSA) and some clinical and laboratory balance tests [ST, LBT (eyes open) and the CBS]. Linear relationships were demonstrated by the LBT with eyes closed and activity measures. Balance, lower-extremity muscle strength and gait may decline non-linearly with age. Our study suggests possible threshold effects between age and balance, muscle strength and gait measures in women. Further research into these threshold effects may have implications for the optimal timing of exercise and other interventions to reduce the risk of falls and fractures.

2. Choice Stepping Response and Transfer Times: Effects of Age, Fall Risk, and Secondary Tasks 18

Rebecca J. St George, Richard C. Fitzpatrick, Mark W. Rogers and Stephen R. Lord ; The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62:537-542(2007)
Background:Deterioration with age of physiological components of balance control increases fall risk. Avoiding a fall can also require higher level cognitive processing to select correct motor and stepping responses. Here we investigate how a competing cognitive task and an obstacle to stepping affect the initiation and execution phases of choice stepping reaction times in young and older people. Methods:Three groups were studied: young persons (YOUNG: 23–40 years, n = 20), older persons with a low risk of falls (OLR: 75–86 years, n = 18), and older persons with a high risk of falls (OHR: 78–88 years, n = 22). Four conditions were examined: choice stepping, choice stepping + obstacle, choice stepping + working
memory task, and choice stepping + working memory task + obstacle. Step
response and transfer times were measured for each condition, in addition to hesitant stepping, contacts with the obstacle and errors made in the memory tests. Results: Older participant groups had significantly longer response and transfer times than the young group had, and the OHR group had significantly longer response and transfer times than the OLR group had. There was a significant Group x Secondary task interaction for response time (F2, 215 = 12.6, p <.001). With the memory task, response time was minimally affected in the YOUNG (7% increase, p =.11) but was slowed significantly in the OLR fallers (42% increase, p <.001) and more so in the OHR fallers (48% increase, p <.001). The obstacle had a small but significant effect on response time (9.4%) and a larger effect on transfer time (43.3%), with no differences among the groups. Errors in stepping, performing the secondary task and contacting the obstacle increased with age and fall risk. Conclusions:Compared with young people, older people, and more so those at risk of falling, have an impaired ability to initiate and execute quick, accurate voluntary steps, particularly in situations where attention is divided.
3. Berg Balance Scale: Intrarater Test-Retest Reliability Among Older People Dependent in Activities of Daily Living and Living in Residential Care Facilities19
Mia Conradsson, Lillemor Lundin-Olsson, Nina Lindelo¨f, Håkan Littbrand, Lisa Malmqvist, Yngve Gustafson, Erik Rosen Dahl ; September 2007 Volume 87 Number 9 Physical Therapy
Background and Purpose: The Berg Balance Scale (BBS) is frequently used to assess balance in older people, but knowledge is lacking about the absolute reliability of BBS scores. The aim of this study was to investigate the absolute and relative intrarater test-retest reliability of data obtained with the BBS when it is used among older people who are dependent in activities of daily living and living in residential care facilities. Subjects: The participants were 45 older people (36
women and 9 men) who were living in 3residential care facilities. Their mean age was 82.3 years (SD_6.6, range_68–96),and their mean score on the Mini Mental State Examination was 17.5 (SD_6.3,range_4–30).Methods: The BBS was assessed twice by the same assessor. The intrarater test-retest reliability assessments were made at approximately the same time of day and with 1 to 3 days in between assessments. Absolute reliability was calculated using an analysis of variance with a 95% confidence level, as suggested by Bland and Altman. Relative reliability was calculated using the intraclass correlation coefficient (ICC).Results: The mean score was 30.1 points (SD_15.9, range_3–53) for the first BBS test and 30.6 points (SD_15.6, range_4–54) for the retest. The mean absolute difference between the 2 tests was 2.8 points (SD_2.7, range_0–11). The absolute reliability was calculated as being 7.7 points, and the ICC was calculated to .97.Discussion and Conclusion: Despite a high ICC value, the absolute reliability showed that a change of 8 BBS points is required to reveal a genuine change in function among older people who are dependent in activities of daily living and living in residential care facilities. This knowledge is important in the clinical setting when evaluating an individual’s change in balance function over time in this group of older people.
4. Timed “Up & Go” Test: Reliability in Older People Dependent in Activities of Daily Living—Focus on Cognitive State 20
Ellinor Nordin, Erik Rosendahl, Lillemor Lundin-Olsson; Physical Therapy. Volume 86. Number 5. May 2006
Background and Purpose: It is unknown how cognitive impairment affects the reliability of Timed “Up & Go” Test (TUG) scores. The aim of the present study was to investigate the expected variability of TUG scores in older subjects dependent in activities of daily living (ADL) and with different levels of cognitive state. The hypothesis was that cognitive impairment would increase the variability of TUG scores. Subjects: Seventy-eight subjects with multiple impairments,
dependent in ADL, and living in residential care facilities were included in this study. The subjects were 84.8_5.7 (mean_SD) years of age, and their Mini-Mental State Examination score was 18.7_5.6. Methods: The TUG assessments were performed on 3 different days. Intrarater and interrater analyses were carried out. Results: Cognitive impairment was not related to the size of the variability of TUG scores. There was a significant relationship between the variability and the time taken to perform the TUG. The intraclass correlations were greater than .90 and were similar within and between raters. In repeated measurements at the individual level, an observed value of 10 seconds was expected to vary from 7 to 15 seconds and an observed value of 40 seconds was expected to vary from 26 to 61 seconds for 95% of the observations. Discussion and Conclusion: The measurement error of a TUG assessment is substantial for a frail older person dependent in ADL, regardless of the level of cognitive function, when verbal cuing is permitted during testing. The variability increases with the time to perform the TUG. Despite high intraclass correlation coefficients, the ranges of expected variability can be wide and are similar within and between raters. Physical therapists should be aware of this variability before they interpret the TUG score for a particular individual.[Nordin E, Rosendahl E, Lundin-Olsson L. Timed “Up & Go” Test :reliability in older people dependent in activities of daily living—focus on cognitive state.
5. Control of rapid limb movements for balance recovery: age related changes and implications for fall prevention 21
Brian E.Maki, William E. Mcilroy; Age and Ageing 2006; 35-S2: ii12–ii18
Background: balancing reactions that involve rapid stepping or reaching movements are critical for preventing falls. These compensatory reactions are much more rapid than volitional limb movements and can be very effective in decelerating the centre-of-mass motion induced by sudden unpredictable balance perturbation; however, age-related deterioration in the neural,
sensory and/or musculoskeletal systems may impede the ability to execute these reactions effectively. Objective: this paper summarizes recent research regarding age-related changes in compensatory stepping and reaching reactions and the practical implications of these findings for fall prevention programmes. Results: even healthy older adults experience pronounced difficulties. For stepping reactions, the main problems pertain to control of lateral stability—arresting the lateral body motion that occurs during forward and backward steps, and controlling lateral foot movement so as to avoid collision with the stance limb during lateral steps. Older adults appear to be more reliant on arm reactions than young adults but are less able to execute reach-to-grasp reactions rapidly. Conclusions: it is important for clinicians to assess compensatory stepping and reaching, in order to identify individuals who are at risk of falling and to pinpoint specific control problems to target for balance or strength training or other intervention. More effective use of stepping and reaching reactions can be promoted through improved design and appropriate use of sensory aids, mobility aids, footwear, handrails and grab-bars. It is particularly important to address the problems associated with the control of lateral stability because it is the lateral falls that are most likely to result in hip fracture.