RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

FOR

DISSERTATION

1. / NAME OF THE CANDIDATE / MS.RINCY ROBERT
2. / NAME OF THE INSTITUTION AND ADDRESS / AECS MAARUTI COLLEGE OF NURSING, NO.99, NEAR AECS MAARUTI DENTAL COLLEGE, OFF BANNERGHATTA ROAD, KAMMANAHALLI, BANGALORE-560076
3. / COURSE OF THE STUDY AND SUBJECT / 1ST YEAR M.SC, (NURSING), MEDICAL AND SURGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / 24TH SEP 2010
5. / TITLE OF THE TOPIC / EFFECTIVENESS OF VESTIBULAR REHABILITATION THERAPY IN IMPROVING BODY BALANCE AMONG SENIOR CITIZENS RESIDING IN SELECTED OLD AGE HOMES AT BANGALORE.

INTRODUCTION

“The size of candles may differ but they yield the same brightness. It’s not the matter of your position, but your ability that shines”.

Long life is a sign of divine blessing. Aging is inevitable and irreversible, yet we can live happy, healthy, and productive lives and the period of ill- health and dependence can be squeezed into shortest possible time before we leave the world. Elderly people are like the setting sun that retreats into the night after giving light during day. 1

A study by WHO showed that there are 580 million aged people in the world by 2010, approximately 70 percent of the elderly population will be living in developing countries. Elderly population in India has risen from 5.7 percent in 1961 to 6.7percent in 1991 and will increase to 8.3 percent by 2016. India and Indonesia will have the largest elderly population with increase in life expectancy. 2

The common problems due to aging includes pulmonary, renal, endocrinal, skin, cardiac and balance disorders. Aged individuals are more prone to lose their body balance due to various balance disorders. Bones are already weak, even a minor fall leads to bone fracture, hospitalization, reduced independence and thus initiate a negative feedback loop that can ultimately lead to death.3

Weakness in the core stabilizing muscles, altered muscle activation patterns, loss of proprioception, and an inability to control normal postural sway can all result in decreased balance in the elderly. A decrease in physiological reserves as we age, limits the ability to react quickly to perturbations. If the brain cannot rely on the information it receives from the vestibular system, a person's ability to maintain posture and co-ordinate balance can become overly dependent on vision or on the information received from the muscles and joints. 4

There is not a single solution for balance problems. Evidence shows that the most effective treatment strategies for balance disorders consists of a multimodal approach including a re-evaluation of medications, manual therapy, exercises, and behavioral modification programs.3

Exercise is essential for aged people. As one ages, blood circulation gradually tends to decline, which affects the proper functioning of all organs. Regular exercise improves blood circulation to almost all organs and helps maintain normal functioning. Balance exercises, enhance the body’s flexibility, maintain the balance of the body during routine activities, and help to reduce the risk of fall in elderly.1

Vestibular rehabilitation exercises are effective in improving body balance and postural control in clients with dizziness and vertigo. The goal of the therapy is to retrain the brain to recognize and process signals from the vestibular system in coordination with vision and proprioception. This often involves desensitizing the balance system to movements that provoke symptoms. Head and total body exercises are performed by the client to hasten compensation. 1

Nurses can play a great role in vestibular rehabilitation therapy. Taking specific protective measures to reduce the risk of fall and injury by training them in various exercises, maintaining a positive and ongoing support to the client throughout the rehabilitation period, can increase adherence and improve treatment outcomes in managing the balance disorders in elderly patients.5

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY

The elderly are prized resources. We need to create a greater awareness to safeguard the health and dignity of this vulnerable section of society and help them live the rest of their lives with dignity. Imbalance is an extremely common problem in the older population. Worldwide overall prevalence of balance problems at age 70 is 36 percent in women and 29 percent in men. Balance symptoms are more common among women than men, and increase as age increases. 6

The population of older adults is increasing worldwide and is expected to be 1.4 billion by 2050. One out of 10 people worldwide will be 65 years of age or more by 2050. The elderly are the fastest growing population. In India, the population of aged 65 years and older is either, facing or is prone to face the far-reaching impact of poor balance remains unmeasured.5

Studies show that 8 million older American adults reported having problems with balance, in that 39 percent of older adults were 65 year and older. 2.4 million Adults report having a chronic problem with dizziness alone. In India 30 – 50 percent of older individuals are accounted for and are at a major threat to their health and independence. 7

Balance disorders can have a serious impact on an older person's life. According to Asian studies, annual fall of incidence due to balance problem is about 300 per 1000 in elderly. And among older adults, the consequences of falling include fear of falling in 31-48 percent, Reduced activity levels in 19-26 percent and fall injuries occurring in 46- 60 percent of all falls. Serious injuries have been found to occur in 6 -14percent of falls. Deaths from falls also occur for people over the age of 65 years, with one study finding 2.2 deaths occurring for every fall injury event admitted to acute medical facilities Falls can have physical, psychological and functional changes in older adults including restriction of activity, loss of autonomy, reduced self confidence, depression and anxiety. A study conducted in US reports that approximately 30 percentage of people over 65 years and 40 percent over 80 years suffer the consequences of fall and related complication annually.8, 9

When the vestibular organs are damaged with disease or injury, the brain can no longer rely on them for accurate information about equilibrium and motion, often resulting in dizziness, vertigo, balance problems, and other symptoms. Many people are able to recover from these symptoms on their own after a few weeks of normal activity because the brain has adapted with a process called vestibular compensation.4

Vestibular rehabilitation therapy has been demonstrated to be a highly effective treatment for most individuals with vestibular or central balance system disorders. In a number of studies, customized vestibular rehabilitation programs have been reported to be significantly more effective in resolving symptoms than generic exercises, and especially medications.8

Having good balance means able to control and maintain body’s position, either moving or still. An intact sense of balance helps to walk without staggering, get up from a chair without falling, and climb stairs without tripping. Balance is important to get around, stay independent, and carry out daily activities. In Karnataka, balance problems remain unmeasured. Hence the researcher felt that it is important to study in depth about the problems of imbalance, and plan effective supportive strategies for geriatric men and women which will be beneficial in reducing the ill effects of imbalance.9

6.2 REVIEW OF THE LITERATURE:

An epidemiological study was conducted in elderly people to find out the prevalence of balance symptoms i.e. Vertigo, dizziness, and disequilibrium. 3 different age cohorts were studied, one at age 70, one at age 75 and one at ages 79, 82, 85, 88 and 90 years. 2011 participants answered the questionnaire and the overall prevalence of balance problems at age 70 was 36 percent in women and 29 percent in men. Balance symptoms were more common among women than men, and increased with increasing age. At ages 88-90 years the corresponding values were 51-45 percent. The most common symptom was poor balance/general unsteadiness in 11-41percent subjects and rotatory symptoms occurred in 2-17 percent. Other types of symptoms were less common. Precipitating factors were rising from supine to sitting position in 17-40 percent.6

A Single-blind randomized, controlled trial was conducted to evaluate the effectiveness of nurse-delivered vestibular rehabilitation.170 adult patients with chronic dizziness were randomly assigned to vestibular rehabilitation ( n=83) and usual medical care (n= 87). Each patient received 30 - 40minute training regarding vestibular rehabilitation exercise from the nurse. Assessment was done of self-reported spontaneous and provoked symptoms of dizziness, dizziness-related quality of life, and objective measurement of postural stability with eyes open and eyes closed. After 1 month, improvement was seen in the vestibular rehabilitation group where the result was significantly greater than in the usual medical care group; of 83 treated patients, 56 i.e. 67 percent reported clinically significant improvement compared with 33 of 87 i.e. 38percent of usual care patients, which shows vestibular rehabilitation delivered by nurses improves balance, postural stability, and dizziness-related handicap in patients with chronic dizziness.10

In a study to evaluate the effectiveness of vestibular rehabilitation exercise between supervised and home-based programs in senior age groups of patients with chronic dizziness, Dizziness Handicap Inventory, Tinetti fall risk performance scales and Timed "Up and Go" test were administered to 41 patients. 28 patients received three 30-min vestibular training exercise sessions per week. 13 patients who could not visit the clinic on regular basis were instructed to do the same set of exercises at home, with the same duration and frequency. The patients were evaluated again on their follow-up visits 1month later, and both groups showed statistically significant improvement in dizziness Handicap inventory and Tinetti scales. A higher percentage of patients in the supervised-exercise-program group showed clinically significant outcome improvements, and it was concluded that for all ages of chronically dizzy patients, 1 month of vestibular rehabilitation can, improve balance function and a consequent improvement of life quality. 11

A clinical-prospective, longitudinal, and observational study was conducted, with 40 elder citizens of both genders, divided in 2 groups with dizziness of vascular and metabolic origin. The patients were evaluated and underwent vestibular rehabilitation based on Cawthorne and Cooksey's protocol. The statistical analysis from the data was done through the Student T test, and concluded that vestibular rehabilitation, based on the protocols of Cawthorne and Cooksey, is beneficial to this population.12

A prospective, randomized, single-blind clinical pilot study was conducted to determine whether the addition of gaze stability exercises to balance rehabilitation would lead to greater improvements of symptoms and postural stability in older adults with normal vestibular function who reported dizziness. Participants who were referred from outpatient physical therapy for dizziness were randomly assigned to the gaze stabilization group (n= 20) or control group (n = 19). Both groups improved significantly in all outcome measures with the exception of perceived disequilibrium. 90percent of the gaze stabilization group demonstrated a clinically significant improvement in fall risk versus 50percent of the control group. This study provides evidence that in older adults with symptoms of dizziness and no documented vestibular deficits, the addition of vestibular-specific gaze stability exercises results in greater reduction in fall risk.13

A prospective observational study was conducted in performance of patients enrolled in an individually customized program of habituation and balance rehabilitation physical therapy. Patients were ranged in age from 20 to 89 years, with a wide variety of diagnoses. Two global outcome measures post therapy symptom response score and pre therapy and post therapy disability score were developed and used to judge overall patient performance, and two specific indicators 1) dynamic posturography for balance performance 2) motion sensitivity quotient for sensitivity to rapid head movements. Results indicate statistically significant changes before versus after therapy for both specific measures, and 80 – 85 percent of the patients showed a reduction in symptoms and disability score following therapy.14

PROBLEM STATEMENT:

“Effectiveness of vestibular rehabilitation therapy in improving body balance among senior citizens residing in selected old age homes at Bangalore.”

6.3 OBJECTIVES:

1.  Assess the body balance status among senior citizens.

2.  Assess the effectiveness of vestibular rehabilitation therapy in improving the body balance among senior citizens.

3.  Find out the association between pre interventional body balance status and selected demographic variables.

OPERATIONAL DEFINITION:

EFFECTIVENESS: In this study it refers to the extent of the improvement in the body balance status after vestibular rehabilitation therapy among senior citizens by using Modified Berg balance scale.

VESTIBULAR REHABILITATION THERAPY: In this study it refers to Cawthorne Cooksey protocol which includes; Exercises in bed including eye and head movements, Exercises in sitting position including eye movement, head movement, shoulder shrugging and shoulder circling, Exercises in standing position including changing the posture, passing objects with eyes closed and opened, walking exercises which includes walking around, walking across, walking up and down with eyes closed and opened and this is done 3 times a day for 20 minutes continued for 3 weeks.

BODY BALANCE: Body balance is the coordinated execution of body movement like stable walk, fall free bending, ability to stand without swaying and carrying out the daily activities.

SENIOR CITIZENS: In this study it refers to the elderly individuals between the age group of 60-85 years, who are having balance disorders, residing in old age homes.

HYPOTHESIS:-

H1: There is a significant improvement in body balance status after the vestibular rehabilitation therapy.

H2: There is a significant association between the body balance status and selected demographic variables among senior citizens.

VARIABLES:

Independent variables: vestibular rehabilitation therapy.

Dependent variables: body balance status among senior citizens.

Demographic variables: Age, gender, religion, education, occupation, source of income, therapeutic diet, body weight, source of information about balance improvement and presence of other physical illnesses.

DELIMITATION:

The study is delimited to selected senior citizens between the age group of 60-85years, who are having any of the balance disorder.

7. MATERIAL AND METHODS:

7.1 Sources of data: