Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the Candidate& Address / RATIKA KHOSHU
C/o Mr. Ravi Kumar Khoshu
T-120, Government Quarters
Poonch House, Talab Tillo,
JAMMU (TAWI)
JAMMU & KASHMIR
2 /
Name of the Institution
/ PADMASHREE INSTITUTE OF PHYSIOTHERAPY3 /
Course of study and subject
/ MASTERS IN PHYSIOTHERAPY(Physiotherapy in Neurological and Psychosomatic Disorders)
4 /
Date of admission to course
/ 12th May 20065 /
TITLE OF THE TOPIC
“COMPARISON OF SINGLE AND DUAL-TASK BALANCE TRAINING IN OLDER ADULTS WITH BALANCE –IMPAIRMENT. ”6 / Brief resume of the intended work:
6.1 Need for the study
Balance is defined as the ability to maintain the body’s center of mass over its base of support. 1 Falls are one of the leading causes of death among adults over 65 years of age. 2-5 Nonfatal falls often lead to physical injury, most commonly fracture neck of femur, reduced levels of activity, loss of confidence and altered lifestyle in elderly people (Campbell AJ et al).4, 6,7
Research shows that balance impairment is the major contributing factor for falls in elderly people. 2,7 (Tang PF et al ) 8, (Wollacott MH et al )9, (Brown LA et al ).10 The elderly exhibited longer onset latencies to distal muscle responses, longer
agonist/antagonist co- activation9 and reaction time delayed with aging and slowed more remarkably as the complexity of the situation increased8,9. This shows that balance depends on both motor and sensory system functions. Balance is most often trained under single- task conditions that include practicing functional tasks requiring balance in isolation. Research shows that such training improves balance (Toulotte C et al). 11,12
Daily activities mainly consists of performing two tasks simultaneously .It has been shown that the ability to maintain postural stability is reduced when performing two or more tasks concurrently in elderly with balance impairment (Brauer SG et al ). 13 Studies show that dual task training in which both tasks are motor in nature lead to improvement in balance in elderly. 11,12 Cognitive plasticity plays a role in dual task training that leads to improved dual task processing skill in older adults (Bherer L et al). 14,15
However in recent years the contribution of other neural systems, including cognitive resources on balance has become increasingly apparent10,13 (Rankin JH et al ).16’ 17 But evidence of benefits of dual task training in which one component is motor and other is cognitive on balance is limited. (Pellecchia GL),18 (Shumway –Cook A et al ). 19 Despite the importance of dual task training there is limited evidence about the comparison of single and dual task activity training on balance in older adults with balance impairment.
So this study intends to compare the single –task and dual-task activity training on balance in older adults with balance impairments.
HYPOTHESIS:
NULL HYPOTHESIS:
There will be no significant difference between dual task training and single task training on balance in older adults with balance impairment
EXPERIMENTAL HYPOTHESIS:
There will be significant difference between dual task training and single task training on balance in older adults with balance impairment.
6.2 Review of Literature
Campbell AJ, Borrie MJ, Spears GF et al (6) 1990, have studied the incidence and factors related to falls on 761 subjects of 70 years and over. They found an increased fall rate for those aged 70 to 80 years and over. There was no sex difference in fall rate and men were more likely to fall outside and at greater activity levels. Also ten percent of falls resulting in significant injury and subsequent risk of death.
Tang PF, Wollacott MH, (8) 1998, studied the hypothesis that active and healthy and older adults use a less effective a reactive balance strategy than young adults when experiencing an unexpected forward slip occurring at heel strike during walking. They did this study on 33 young adults, 32 older adults and concluded that the combination of slower onset and smaller magnitude of postural responses to slips in older adults resulted in and inefficient balance strategy, older adults showed lengthened response duration and the use of the arms to regain balance and prevent fall. They also showed shorter stride length and earlier contralateral foot strike following the slip.
Woollacott MH, Shumway-Cook A, (9) 1990, studied a system approach to the development of posture control across the life span and its integration with voluntary tasks such as walking. They found that older adults have increased onset latencies, disruptions in the temporal organisation of postural muscle responses when given external threats to balance, increased use of antagonist muscles in coactivation with agonist muscle and increased difficulty in balancing when sensory inputs are reduced experimentally or pathologically.
Brown LA, Shumway-Cook A, Wollacott MH, (10) 1999, have investigated whether performing secondary cognitive task affects postural recovery in 15 young and 10 healthy older adults and concluded that the ability to recover a stable posture following an external pertubation is more attentionally demanding for older adults if sufficient attentional resources are not allocated to the task of postural recovery.
Toulette C, Thevonon A, Fabre C, (11) 2006, have evaluated the effects of training based on static and dynamic balance in single and dual task conditions in 8 healthy fallers and 8 non-fallers and concluded that training permits an improvement in static balance and the pattern of walking under single and dual task conditions.
Toulotte C, Thevenon A, Fabre C, (12) 2004, have evaluated the effects of a physical training program on static and dynamic balance during single and dual task conditions in two groups of elderly subjects consisting 16 fallers and 17 non fallers and concluded that physical training program improved static balance and quality of gait in elderly subjects who had a fall or not.
Brauer SG, Woollacott M, Shumway – Cook A, (13) 2001, have examined balance recovery from postural disturbance in balance impaired 15 healthy and 13 older adults by using a dual task paradigm and concluded that recovery of balance less efficient in balance impaired older adults when simultaneously performing a cognitive task.
Bherer L, Kramer AF, Peterson MS, Colcombe S, Erickson K, Becic E, (14) 2006, have suggested that older adults can benefit from training in tasks that tap control aspect of attention. It was seen using on adaptive and individualized dual task training program. Its results showed improve overlapping task performance in both younger and older age groups suggesting the availability of cognitive plasticity in both age groups.
Bherer L, Kramer AF, Peterson MS, Coleombe S, Brickson K, Becic E, (15) 2005, have examined the extent to which age related deficits in dual-task performance with similar motor requirements could be moderated by training. The results showed that training could substantially improve dual task processing skills in older adults.
Rankin JK, Woollacott MH, Shumway-Cook A, Brown LA, (16) 2000, have described the effect of a cognitive task on a neuromuscular response in young versus older adults and concluded that the dual task activity has a greater impact on balance control in the older adults than in the young adults.
Pellecchia GL, (18) 2005, examined the effect of concurrent cognitive task on postural sway on no-training, single-task training or dual-task training groups of 18 subjects each. After training, performance of a concurrent cognitive task increased postural sway in no training and single-task training groups but not in the dual-task training group. Hence found out that dual-task practice improves dual-task performance.
Shumway –Cook A, Woollacott M, Kerns KA, Baldwin M, (19) 1997, examined the effect of a physical activity program on postural sway and attentional control of postural abilities in 12 elderly frail adults by giving posture- balance- mobility (PBM) twice a week for 12 weeks under single- task and dual-
task condition. They concluded that the training program allowed elderly subject to improve their ability to perform an attention- demanding cognitive task by standing still, in particular with their eyes closed. Balance seemed to be less stable under dual-task condition but these results could be interpreted as an improvement of the attentional control of postural stability.
6.3 Objectives of the study:
· To study the effects of single task training on older adults with balance impairments.
· To study the effects of dual task training on older adults with balance impairments.
· To compare dual-task training and single task activity training in older adults with balance impairment.
7 / Materials and Methods:
7.1 Source of Data
· Nightingale Elders Day Care Center, Malleshwaram, Bangalore.
· Padmashree Clinic, Nagarbhavi, Bangalore.
7.2 Method of collection of data:
· Population : Elderly subjects with balance impairment.
· Sample design for study : Simple random sampling.
· Sample size : 30 subjects.
· Study design : Comparative study with pre test and post
test design.
INCLUSION CRITERIA:
· Subjects of or above 65 years including both males and females
· Subjects having self reported history of at least 2 falls in previous one year.
· Subjects should have Mini-Mental State Examination (MMSE) scores greater than 24 to rule out any cognitive impairment. 20
EXCLUSION CRITERIA:
· Subjects with history of neurological diseases .
· Subjects with symptoms of giddiness while getting up from lying.
· Subjects with lower extremity joint replacements.
· Subjects with any medication use which alters alertness .
· Subjects unable to stand unassisted for a minimum of 1 minute.
· Subjects with vertigo.
Materials Required:
· Chair
· Examination table.
· Foot stool
· Stop watch
· Measurement tape, Ruler
· Berg Balance Scale Sheets
· Activities-specific Balance Scale Sheets
· Pencil
Methodology
Older adults with balance impairment will be taken for the study. They will be assessed using the Berg Balance scale, Timed “ Up and Go” Test and Activities-specific Balance Confidence scale.
Measuring Tools:
· Berg Balance scale. 21,22
· Timed “Up and Go’ Test 23
· Activities – specific Balance Confidence scale24,25
7.3 Intervention to be conducted on the participants:
After taking informed consent, subjects who will meet the inclusion criteria will be randomly assigned and equally distributed into two groups, Group-I (N=15) and Group-II (N=15).
Demographic data will be collected. The subjects would be evaluated for Berg Balance scale, Timed “Up and Go’ Test and their scores will be recorded by the therapist. The subjects themselves will fill the Activities-specific Balance Confidence Scale.
The older adults would be then given balance training under two different programs.
Group-I will receive balance training under single-task activities such as:
Tandem standing – eyes open, Tandem standing – eyes closed, Standing – Draw letter with right foot, Standing – draw letter with left foot, Perturbed standing, Walk with narrow base of support, Walk by stepping sideways with a narrow BOS.
Group-II will receive balance training dual-task activities such as:
Pry. Task/Balance Activities Sec. Task
Tandem standing – eyes open - Spell a word
Tandem standing – eyes closed - Spell a word
Normal
Standing – Draw letter with right foot - Name any word starting
with a part. letter eg. A-K
Normal
Standing – Draw letter with left foot - Name any word starting
with a part. letter eg. A-X
Perturbed Standing - Remember prices of grocery.
Walk with narrow BOS - Count backwards by 2/3
Walk by stepping sideways with a - Count backwards by 2/3
narrow BOS
The treatment session will be given for a total duration of 45 minutes per session, 3 times per week for 4 weeks.
At the end of the 4th week the patients will be reassessed using Berg Balance Scale, Timed Up and Go and Activities – specific Balance Confidence scale and the comparison will be done.
Statistics:
Statistical analysis will be performed by using SPSS software for Window (Version 14) with p value set as 0 .05.
1. Paired t-test will be used to compare measures in ratio scale within the groups.
2. Wilcoxon signed rank test will be used to compare measures in ordinal scales within the groups.
3. Unpaired t-test will be used to compare measures in ratio scale between groups.
4. Mann-Whitney U test will be used to compare measure in ordinal scales between groups.
7.4 Ethical Clearance
As my study includes human subjects, ethical clearance for the study has been obtained from the Institutional Ethical Committee, Padmashree Institute of Physiotherapy, Bangalore, as per the Ethical Guidelines for Biomedical Research On Human Subjects, 2000, ICMR, New Delhi.
8 /
List of References:
1. Nashner L: Evaluation of postural stability,movement and control. In Hassoon S, editor: Clinical exercise physiology, Philadelphia, Mosby,1994,2. Hornbrook MC, Stevens VJ, Wingfield DJ, et al. Preventing falls among community-dwelling older persons : results from a randomized trial. Gerontologist 1994; 34:16-23.
3. Nelson RC, Amin MA. Falls in the elderly. Emerg Med Clin North Am 1990; 8:309-324.
4. Sattin RW. Falls among older persons: a public health perspective. Annu Rev Public Health 1992 ;13 :489-508.
5. Tinetti ME, Speechley M, Ginter SF. Risk factor for falls among elderly persons living in the community. N Engl J Med 1988; 319 : 1701-1707.
6. Campbell AJ, Borrie MJ, Spears GF, et al. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19:136-141.
7. Tinetti ME, Baker DI, Mc Avay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331: 821-827.
8. Tang PF, Wollacott MH. In efficient postural responses to unexpected slips during walling in older adults. J Gerontol A Biol Sci Med Sci 1998; 53:M471-M480.
9. Woollacott MH, Shumway-Cook A. Changes in posture control across the life span a systems approach. Phys Ther 1990; 70:799-807.
10. Brown LA, Shumway-Cook A, Wollacott MH. Attentional demands and postural recovery: the effects of aging. J. Gerontol A Biol Sci Med Sci 1999; 54:M165-M171.
11. Toulette C, Thevonon A, Fabre C. Effects of training and detraining on the static and dynamic balance in elderly fallers and non fallers: a pilot study. Disabil Rehabil. 2006 30; 28(2): 125-33.