Rajiv Gandhi University of Health Sciences, KarnatakaBangalore.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 Name of the Candidate

& AddressVEENA MOHAN NAIRA401, Parijat Bldg , Poonam complex,Kandivili-(E) , Mumbai -400101Maharashtra.

2 Name of the Institution Padmashree Institute of Physiotherapy

3 Course of study and subject Master of Physiotherapy(Physiotherapy in Musculoskeletal Disorders and Sports)

4 Date of admission to course 8th July 2013

5 Title of the topic:

“EFFECT OF HIP STRENGTHENING VERSUS ANKLE PROPRIOCEPTION IN FRONTAL PLANE TO IMPROVE STATIC BALANCE AMONG

GERIATRIC POPULATION”

6 Brief resume of the intended work

6.1 Need for the study

India’s older population will increase dramatically over the next four decades. The share of India’s

population ages 60 and older is projected to climb from 8 percent in 2010 to 19 percent in 20501.

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Geriatrics is defined as a "subspecialty of medicine concerned with the physiological and pathological

aspects of the aged, including, but not limited to, the clinical problems of senescence and senility. The

practice of geriatrics evolves from internal medicine and provides focus for the issues of the elderly2.

The geriatric population is defined as population of age 60 years and above3.People aged over 60 years

is expected to constitute10.2% of the total population by 20254.

Quantitative and qualitative changes occur in muscles and nerves with aging5. These include a

decrease in the number of alpha motoneurons, reduced motoneuron excitability, and loss of type II

muscle fibers leading to decreased muscle mass and slower muscle response latencies6. In the elderly,

impaired motor performance is often associated with motor retardation, decreased muscle force and

decreased balance function7. Such changes adversely affect motor control and balance in older persons

leading to falls.

Balance is the ability to maintain the body’s centre of mass within the limits of its base of support

when standing and sitting, or while moving to a new base when walking8 .Safe mobility is primarily

based on the integration of the proprioceptive, visual, and vestibular inputs9-13. With age, these abilities

decline and become harder to control, which results in an increased risk of falling, even in the absence

of specific neurological or musculoskeletal problems.

Poor balance has been recognized as one of many precursors of falls14, 15. The safety of walking and

balance are indispensable requirements to prevent falls and loss of independence16-19. Multiple factors

play a role in falls and related injuries, although balance disorder is the cause of the majority of falls in

older, compared with younger, adults20.

Falls and their consequences are a major health problem in elderly population21. The population of

elderly people is probably among the most sensitive groups of people regarding the decline of postural

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stability and general mobility. An impaired ability to control postural balance stability in the lateral

plane of motion appears to be particularly relevant to the problem of falling among older

people .Aging effects on balance are accentuated in the mediolateral (M-L) direction, and measures of

M-L sway are well associated with future risk of falls and past falls22. COP-based findings show that

older people with increased ML sway in narrow stance were three times more prone to falling than

those who had a lower ML sway23.

Control of frontal plane stability is particularly important given that lateral falls are associated with

hip fractures in older adult 24. A study of slips noted that older persons used frontal plane mechanisms

for recovery24, 25.

Unipedal stance time (UST) is a convenient clinical measure of static balance that evaluates frontal

plane postural control. Unipedal stance time is used as an indicator for falls in the elderly24. Single

stance stability significantly worsens with age both in eye open and eye close conditions, showing

significant gender differences in the older class of age. Single stance stability was significantly

decreased in the age group 75-84 years. It worsened significantly more in older women than in older

men27.

Given the established relationships between a diminished UST and frailty, activity level and falls,

strategies to increase UST have clinical relevance. In the frontal plane hip strength, ankle

proprioceptive threshold, and age are significant predictors of UST; they contribute 46%, 24% and 3%

of the variance, respectively24.

Several individual studies have been conducted to improve static balance in elderly population

through muscle strengthening and proprioceptive exercises but no studies have compared their effect

in the frontal plane. This study aims to compare the effect of hip strengthening versus ankle

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proprioceptive exercises in frontal plane to improve static stability among geriatric population

Hypothesis:

Ho: There will be no significant difference in the effect of hip strengthening versus ankle

proprioceptive exercises in frontal plane to improve static stability among geriatric population.

H1: There will be a significant difference in the effect of hip strengthening versus ankle proprioceptive

exercises in frontal plane to improve static stability among geriatric population.

6.2 Review of Literature:

Review on neuromuscular changes in elderly

Frontera WR et al (1985) conducted a study on the aging of skeletal muscle in a 12 year longitudinal

study. Twelve healthy men were evaluated for various muscle strength tests. The author concluded

that there was a loss in muscle cross sectional area that contributed to loss of muscle strength seen

with advancing age28.

Review on Balance impairment

I. Menzer et al (2004) Conducted a study to determine the ability of various biomechanical measures

of postural stability to identify fallers in the elderly population. Various balance measurements were

made and maximal isometric lower limb strength was measured in major muscle groups. Repeated

measures analysis of variance tests were performed to assess the mean differences between the two

groups (fallers and non-fallers). The findings show an increase in mediolateral sway in narrow base

stance in older people who experienced recurrent falls. Also, TPD appears to be impaired in elderly

fallers23.

ROGERS, M. W et al (2003) conducted a study on lateral stability and falls in older people. They

concluded that older individuals in general, and those who are at a greater risk of falling in particular,

may be especially vulnerable to instability in the lateral direction during protective stepping and other

balance-correcting functions. Specific impairments of neuro-musculoskeletal factors related to axial-

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trunk rotational mobility, postural control, and M-L hip muscle force and torque-time production

disrupt key control functions for maintaining effective lateral stability22.

Review on unipedal stance time

Lara Allet et al (2012) conducted a study on the relationship between unipedal stance time (UST) and

frontal plane hip and ankle sensorimotor function in subjects with diabetic neuropathy. UST,

quantitative measures of frontal plane ankle proprioceptive thresholds, and ankle and hip motor

function were tested in forty-one persons with a spectrum of lower limb sensorimotor function,

ranging from healthy to moderately severe diabetic neuropathy. Multivariate analysis identified only

composite hip strength, composite ankle proprioceptive threshold, and age to be significant predictors

of UST ; they explained 46%, 24% and 3% of the variance24.

Holly Roberts et al(2007) conducted a study was to generate normative values for repeated trials of

the UPST with eyes opened and eyes closed across age groups and gender. Mean and best of 3 UPST

times for males and females of 6 age groups (18-39, 40-49, 50-59, 60-69, 70-79, and 80+) were

documented and inter-rater reliability was tested. Results showed that there was a significant age

dependent decrease in UPST time during both conditions29.

Edward A et al (2000) conducted a study on unipedal stance time as an indicator of fall risk among

older out patients. Fifty-three subjects underwent a standardized history and physical examination and

three trials of timed unipedal stance. Twenty subjects (38%) reported falling compared with the

subjects who had not fallen; those who fell had a significantly shorter UST. The author concluded that

UST of <30sec in an older ambulatory outpatient population is associated with a history of falling,

while a UST of >30sec is associated with a low risk of falling30.

Review of literature on muscle strengthening.

Sarabon Nejc et al (2013) conducted a study to investigate the effects of two different types of

strength training programs on static balance in elderly subjects. Subjects older than 65 years of age

were enrolled and assigned to control group, electrical stimulation group and leg press group. Subjects

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in both the training groups were exposed to training (2-3x/week) for a period of 9 weeks. Before and

after the training period, static balance of the subject was tested using a quiet stance task. Average

velocity, amplitude and frequency of the center-of-pressure (CoP) were calculated from the acquired

force plate signal. The mean improvements were higher in the LP group than in the ES group31.

Glenn N Williams et al (2002) studied the effects of training on aging skeletal muscle. The author

suggested that regular exercise including strength and endurance training of adequate intensity can

reduce some of the physiologic effects of aging seen in skeletal muscle32.

Review of literature on proprioceptive training

Jiejiao Zheng et al (2013) conducted a study to evaluate the effectiveness of strategic targeted

exercise for preventing falls in elderly people. Elderly people were randomly allocated to either a

control group that received conventional exercise or training group that received conventional plus

proprioception and cognitive exercises. Subjects were asked to exercise three times a week (40 min

per session) for 8 weeks. All participants were assessed using a static postural control test with eyes

open and closed, the Berg Balance Scale (BBS) and the joint position sense test of the lower limbs.

Results showed significant improvements in the training group compared with the control group for

mediolateral sway distance with eyes open and eyes closed, anteroposterior sway distance with eyes

open but not with eyes closed BB scores and joint position sense test for left knee33.

Kelly P Westlake et al (2007) conducted a study to examine the effects of balance exercises on

proprioception. Participants were randomly assigned to a balance exercise group or a falls prevention

education group. Baseline, post intervention, and 8-week follow-up measurements of 3 proprioceptive

measures (threshold to perception of passive movement, passive joint position sense, and velocity

discrimination) were obtained at the ankle. Threshold to perception of passive movement and passive

joint position sense did not change as a function of the exercise intervention34.

Objectives of the study:

To study the effectiveness of frontal plane hip strengthening in improving static balance among

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geriatric patients.

To study the effectiveness of ankle proprioceptive exercises in improving static balance among

geriatric patients.

To compare their effects.

Materials and Methods:

7.1Source of Data:

Old age homes in and around Bangalore.

7.2 Method of collection of data:

Population :- Geriatric population

Sample design :- Convenience Sampling

Sample size :- 30

Study design : - Comparative study

Duration of the study :- 6 months

Inclusion criteria:

No routine exercise habits.

Age 75–85 years.

Weight < 136 kg.

Strength of ankle dorsiflexors, invertors, and evertors at least anti-gravity (grade ≥3 by manual

muscle testing).

A score of <22 for the Mini Mental Status Examination (MMSE), to show that subjects had no

cognitive impairment.

Independent in activities of daily living according to the Barthel index.

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Exclusion criteria:

Cardiovascular pathologies (such as symptomatic cardiovascular diseases )

Angina or angina-equivalent symptoms with exercise

Cognitive impairments, as revealed by the MMSE.

History or evidence of any significant central nervous system dysfunction (i.e.hemiparesis,

myelopathy or cerebellar ataxia)

Any musculoskeletal disease of lower limbs (such as low back pain, serious arthritis or

ankylosing spondylitis).

Symptomatic postural hypotension.

Evidence of vestibular dysfunction.

Any pathology affecting lower extremity balance (such as diabetes mellitus); any other

disabling neurological illness.

Materials used :

1. Rocker board

2. foam

3. Footstool

4. Stopwatch

5. Paper

6. Pen

7. Mini mental score examination

8. Barthel index

Methodology:

After taking consent 30 patients will be randomly selected based on inclusion and exclusion

criteria, sociodemographic data and medical history will be taken into consideration.

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These 30 patients will be randomly allocated into two groups. 15 in group A and 15 in group B.

Group A: In this group frontal plane hip strengthening will be administered. UST will be

assessed pre and post.

Group B: In this group ankle proprioceptive exercises will be administered. UST will be

assessed pre and post.

Results will be compared between all the groups.

PROCEDURE

Group A: This group will receive hip abductor strengthening exercises for six weeks. Three sets of

fifteen repetitions were given for three days in the first two weeks. This was progressed during weeks

3 to 6 so that the total training volume per week came to 2.5-times of the initial.

(1) Position: - Side-lying. Pelvis in neutral position. The top hand will be placed on the floor to

ensure that there is no forward leaning.

Motion: - The subject will be asked to raise the top leg up and hold it in that position for 3 sec

and slowly return it to the start position.

(2) Position: - The subject will be asked to stand on a foot stool with one leg over the edge.

Motion: - Subject will then be asked to do a hip drop without bending the knee of the stance

limb.

Group B: - This group will receive ankle proprioceptive exercises. These tasks will include standing

or walking on various support surfaces (e.g., a rocker board, foam) and standing in a tandem or

semitandem position, standing on one leg, or standing with feet together. To alter visual cues,

participants were instructed to close their eyes or to engage vision with a reading. To modify

vestibular cues, participants were instructed to tilt their head backward or quickly move the head side

to side and up and down to focus on a target. Each lesson incorporated a similar general plan: 10-

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minute warm-up, four 10- minute sensory-specific activities, and 10 minutes of cool-down.

Outcome measures:

Unipedal Stance Time in seconds

Statistics:

Data analysis will be performed by spss (Ver. 17) for windows. Alpha value will be set as 0.05.

Descriptive statistics will be performed to find out mean range, standard deviation for demographic

variable and outcome variables.

Chi-square test will be performed to find out gender differences among both groups.

Unpaired t-test will be used to find out the significant difference among demographic variables such

as age, duration and baseline variables such as Unipedal stance time.

Unpaired t-test will be used to find out significant differences between groups for Unipedal

stance time.

Microsoft word and excel will be used for plotting graphs and tables.

7.3 Does the study require any investigation or interventions to be conducted on patients or

other humans or animals? If so please describe briefly.

YES. Frontal plane hip muscle strengthening and proprioceptive exercises will be given to geriatric

population.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, the ethical clearance been obtained from the institution.

8List of References:

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plane hip and ankle sensorimotor function, not age, predicts unipedal stance time,Muscle Nerve. 2012

April ; 45(4): 578–585

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Matthew R. Dixon, MD, Unipedal Stance Testing as an Indicator of Fall Risk

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9 Signature of the candidate :

10 Remarks of the Guide :

11 Name and Designation of :

11.1 Guide : Mrs. P. Maheshwari

Associate Professor

11.2 Signature

11.3 Co-Guide : Mr. Pravin Aaron

Professor

11.4 Signature

11.5 Head of Department : Mr. Nagaraj S.

Associate Professor

11.6 Signature

1212.1 Remarks of the Principal : Mr. Pravin Aaron

Professor

12.2Signature

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