RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1 |Name of the Candidate and Address |joshi shivani ajay kumar |

| | |D/o mr. gakumar j joshi, |

| | |ss anand maal road surat 395009, gujarat |

|2 |Name of the Institution |Goutham College of Physiotherapy |

|3 |Course of Study and Subject |Master of Physiotherapy – |

| | |Musculoskeletal Disorder and Sports Physiotherapy |

|4 |Date of Admission to the Course | 26/06/2012 |

|5 |Title of the Topic: |

| |“EFFECTS OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION functional STRENGTHENING EXERCISES OVER BALANCE TRAINING IN IMPROVING |

| |selective GAIT PARAMETERS OF ELDERLY people” – a comparative study |

|6 |Brief Resume of the Intended Work: |

| |Need of the Study: |

| |Walking is one of the more frequently performed sensorimotor tasks in everyday life. It relies on a complex, simultaneous |

| |interaction of the motor system, sensory control, and cognitive functions. The diagnostic assessment of gait disturbances in old|

| |age requires a clear distinction of pathological findings from the normal, physiological changes of aging. Spontaneous walking |

| |speed normally decreases by about 1% per year from age 60 onward, and the observed decline of maximum walking speed is even |

| |greater. Gait and balance disorders are among the most common causes of falls in older adults and often lead to injury, |

| |disability, loss of independence, and limited quality of life. Gait and balance disorders are usually multifactorial in origin |

| |and require a comprehensive assessment to determine contributing factors and targeted interventions. Most changes in gait that |

| |occur in older adults are related to underlying medical conditions, particularly as conditions increase in severity, and should |

| |not be viewed as merely an inevitable consequence of aging. Early identification of gait and balance disorders and appropriate |

| |intervention may prevent dysfunction and loss of independence. |

| |At least 30 percent of persons 65 and older report difficulty walking three city blocks or climbing one flight of stairs, and |

| |approximately 20 percent require the use of a mobility aid to ambulate. In a sample of noninstitutionalized older adults, 35 |

| |percent were found to have an abnormal gait. The prevalence of abnormal gait increases with age and is higher in persons in the |

| |acute hospital setting and in those living in long-term care facilities. In one study, gait disorders were detected in |

| |approximately 25 percent of persons 70 to 74 years of age, and nearly 60 percent of those 80 to 84 years of age. |

| |Determining that a gait is abnormal can be challenging, because there are no clearly accepted standards to define a normal gait |

| |in an older adult. Studies comparing healthy persons in their 70s with healthy persons in their 20s demonstrate a 10 to 20 |

| |percent reduction in gait velocity and stride length in the older population. Other characteristics of gait that commonly change|

| |with aging include an increased stance width, increased time spent in the double support phase (i.e., with both feet on the |

| |ground), bent posture, and less vigorous force development at the moment of push off. These changes may represent adaptations to|

| |alterations in sensory or motor systems to produce a safer and more stable gait pattern. |

| |The term “senile gait disorder” has been used to describe disturbances in gait in older persons when an underlying disease |

| |cannot be identified. It is characterized by a slow, broad-based, shuffling, and cautious walking pattern. However, current |

| |understandings of gait disorders challenge this term because most major changes in gait and balance are attributable to one or |

| |more underlying conditions. Up to 20 percent of older adults maintain normal gait patterns into very old age, reinforcing that |

| |aging is not inevitably accompanied by disordered gait. Senile gait patterns may actually represent an early manifestation of |

| |subclinical disease, because their occurrence correlates with increased risk of cardiovascular disease, dementia, |

| |institutionalization, and death. |

| |When considering the preventive measures and treatment strategies in reducing or minimizing the gait abnormalities, regular |

| |exercises in order to increase the muscle strength and bone density, balance and coordination training, flexibility exercises, |

| |postural awareness and functional training plays an important role. Hence this study is an effort taken to analyse the |

| |effectiveness of proprioceptive neuromuscular facilitation lower extremity and trunk strengthening exercises and balance |

| |training in improving selective gait parameters among elderly people. |

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| |HYPOTHESIS |

| |Experimental Hypothesis: There will be a significant difference between proprioceptive neuromuscular facilitation functional |

| |strengthening exercises and balance training in improving selective gait parameters among elderly people. |

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| |Null Hypothesis: There will be no significant difference between proprioceptive neuromuscular facilitation functional |

| |strengthening exercises and balance training in improving selective gait parameters among elderly people. |

| |. |

| |Review of Literatures: |

| | |

| |Unlu E, Eksioglu E, Aydog E, Aydog ST, Atay G (2007): Evaluated the effect of home versus in-hospital exercise (under |

| |supervision) programmes on hip strength, gait speed and cadence in patients with total hip arthroplasty at least one year after |

| |operation.Twenty-six patients who had had a total hip arthroplasty operation 12-24 months prior to the study were enrolled. The |

| |patients were randomized into three groups: group 1 patients were assigned a home exercise programme, group 2 patients exercised|

| |under physiotherapist supervision in hospital, and group 3 served as the control group, with no specific intervention. The study|

| |duration was six weeks. Maximum isometric abduction torque of operated hip muscle, gait speed and cadence were measured before |

| |and after the study. Maximum isometric abduction torques of the hip abductor muscles improved in groups 1 and 2, but not in |

| |group 3 (30 +/- 12 to 38 +/- 11 ft.lb in group 1, 18 +/- 10 to 30 +/- 9.8 ft.lb in group 2). Gait speed improved from 67.8 +/- |

| |23 to 74.35 +/- 24 m/min in group 1, from 48.53 +/- 4 to 56.7 +/- 5 m/min in group 2 and from 58.01 +/- 12 to 59.8 +/- 14 m/min |

| |in group 3. Cadence also improved, from 97.7 +/- 18 to 111 +/- 17 steps/min in group 1, from 90.75 +/- 6 to 104.75 +/- 7 |

| |steps/min in group 2, and from 87 +/- 16 to 88.22 +/- 16 steps/min in group 3. When the three groups were compared, group 2 |

| |showed the best improvement (P = 0.006) only in maximum isometric abduction torque.Their findings suggest that both home and |

| |supervised exercise programmes are effective one year after total hip arthroplasty. Home exercise programmes with close |

| |follow-up could be recommended. |

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| |Lisa M. Shulman, M.D., of the University of Maryland School of Medicine, Baltimore (2012): conducted a randomized clinical trial|

| |of three types of physical exercise to compare the effectiveness of treadmill, stretching and resistance exercises in improving |

| |gait speed, strength and fitness for patients with PD. The study included 67 patients with PD who had gait impairment and were |

| |randomly assigned to one of three groups in the trial: a higher intensity treadmill exercise (30 minutes at 70 percent to 80 |

| |percent of heart rate reserve); a lower-intensity treadmill exercise (50 minutes at 40 percent to 50 percent of heart rate |

| |reserve); and stretching and resistance exercises (two sets of 10 repetitions on each leg on three resistance machines). |

| |Patients performed the exercises three times a week for three months.The effects of exercise were seen across all three exercise|

| |groups. The lower-intensity treadmill exercise resulted in the greatest improvement in gait speed. Both the higher- and |

| |lower-intensity treadmill exercises improved cardiovascular fitness. Only the stretching and resistance exercises improved |

| |muscle strength. Therefore, exercise can improve gait speed, muscle strength and fitness for patients with Parkinson disease, |

| |the study notes. According to the study results, all three types of exercise improved distance on the 6-minute walk: |

| |lower-intensity treadmill exercise (12 percent increase), stretching and resistance exercises (9 percent increase) , and |

| |higher-intensity treadmill exercises (6 percent increase). Both types of treadmill training improved cardiovascular fitness, |

| |whereas stretching and resistance had no effect. Only stretching and resistance improved muscle strength (16 percent increase) |

| | |

| |Laurence Z. Rubenstein, et al, Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, |

| |Sepulveda, California (2008): The randomized controlled trial studied the effects of a low- to moderate-intensity group exercise|

| |program on strength, endurance, mobility, and fall rates in fall-prone elderly men with chronic impairments. Fifty-nine |

| |community-living men (mean age [?] 74 years) with specific fall risk factors (i.e., leg weakness, impaired gait or balance, |

| |previous falls) were randomly assigned to a control group (n [?] 28) or to a 12-week group exercise program (n [?] 31). Exercise|

| |sessions (90 minutes, three times per week) focused on increasing strength and endurance and improving mobility and balance. |

| |Outcome measures included isokinetic strength and endurance, five physical performance measures, and self-reported physical |

| |functioning, health perception, activity level, and falls. Exercisers showed significant improvement in measures of endurance |

| |and gait. Isokinetic endurance increased 21% for right knee flexion and 26% for extension. Exercisers had a 10% increase ( p |

| |.05) in distance walked in six minutes, and improved ( p .05) scores on an observational gait scale. Isokinetic strength |

| |improved only for right knee flexion. Exercise achieved no significant effect on hip or ankle strength, balance, self-reported |

| |physical functioning, or number of falls. Activity level increased within the exercise group. When fall rates were adjusted for |

| |activity level, the exercisers had a lower 3-month fall rate than controls (6 falls/1000 hours of activity vs 16.2 falls/1000 |

| |hours, p .05). These findings suggest that exercise can improve endurance, strength, gait, and function in chronically |

| |impaired, fall-prone elderly persons. In addition, increased physical activity was associated with reduced fall rates when |

| |adjusted for level of activity. |

| | |

| |Racheal D.Seidler, Philip E. Martin,Department of Exercise Science and Physical Education, Arizona State University(2007): The |

| |purpose of this study was to determine and contrast the effect of five weeks of balance training on the postural stability of |

| |elderly adults with a history of falls (F) and those who have not previously fallen (NF). Twelve F subjects, 12 NF subjects, and|

| |14 control subjects participated. Balance training consisted of exercises designed to stress balance and coordination performed |

| |three times per week for five weeks. Postural stability was evaluated with an ADL test resembling activities of daily living and|

| |force-platform-based postural sway measurements. In general F and NF reflected similar improvements in postural stability |

| |following training. F and NF demonstrated small improvements (5–10%) on the ADL tests with respect to the control group. The |

| |postural sway measures provided only moderate support for the effectiveness of training, with the control subjects exhibiting |

| |improvements similar to those of the training groups (approximately 15–30%). Overall the data provide moderate support for the |

| |effectiveness of short term balance training for functionally independent elderly adults. |

| | |

| |Andrea Trombetti, MD, et al (2011): They conducted a randomized controlled trial to determine whether a 6-month music-based |

| |multitask exercise program (ie, Jaques-Dalcroze eurhythmics) would improve gait and balance and reduce fall risk in |

| |community-dwelling older adults at high risk of falling. Change in gait variability under dual-task condition from baseline to 6|

| |months was the primary end point. Secondary end points were to assess changes in other quantitative gait and balance measures, |

| |functional test performances, and falls and to determine through a 6-month postintervention follow-up whether the benefit due to|

| |the intervention could be maintained over time |

| | |

| |Ogaya S, Ikezoe T, Soda N, Ichihashi N,Department Rehabilitation, Kyorin University School of Medicine Hospital, Tokyo, |

| |Japan(2011): This study assessed the effects of wobble board balance training on physical function in institutionalized elderly |

| |people. This study examined 23 subjects (age 84.2 ± 5.9 years) who lived in a nursing home. The exercise program for the |

| |training group comprised balance training standing on a wobble board for 9 weeks, twice a week. In all, 11 training group |

| |subjects and 11 control group subjects completed this study. After 9 weeks, standing time on a wobble board, standing time on a |

| |balance mat, and maximum displacement distance of anterior-posterior center of pressure in the training group were significantly|

| |greater than those of the control group. Frequency analysis revealed that the power spectrum in 0.1-0.2 Hz significantly |

| |increased in the training group. These results suggest that wobble board training is effective for elderly people to improve |

| |their standing balance, by which they frequently control their center of gravity and maintain a standing posture on unstable |

| |surface conditions. |

| | |

| |Neil McCartney, Audrey L. Hicks, Joan Martin and Colin E. Webber, The Journals of Gerontology: They examined the effects of 42 |

| |weeks of progressive weight-lifting training on dynamic muscle strength, peak power output in cycle ergometry, symptom limited |

| |endurance during progressive treadmill walking and stair climbing, knee extensor cross-sectional areas, and bone mineral density|

| |and content in healthy males and females aged 60–80 years, currently enrolled in a 2-year resistance training program. Subjects |

| |were randomized into either exercise (EX) or control (CON) groups (60–70 years: 38 males and 36 females; 70–80 years: 25 males |

| |and 43 females). EX trained several muscle groups twice per week for 42 weeks at intensities ranging from 50–80% of the load |

| |that they could lift once only (1 RM); CON did usual daily activities. After the 10 months there was no change in 1 RM strength |

| |in CON, but significant gains (mean increases up to 65%) in EX (no independent age or gender effects); 30% and 47% of the |

| |increase in 1 RM had occurred by 6 and 12 weeks, respectively. In EX, the 7.1% increase in peak cycling power output was |

| |significantly greater than in CON (+1.1%). The 17.8% improvement in symptom limited treadmill walking endurance was also greater|

| |than in CON (+3.4%), but the difference between groups during stair climbing was not significant (EX + 57%, CON + 33%). The |

| |cross-sectional areas of the knee extensors increased significantly by 5.5% in EX but were unchanged in CON. There were no |

| |changes in bone mineral density or content in either group. We conclude that long-term resistance training in older people is |

| |feasible and results in increases in dynamic muscle strength, muscle size, and functional capacity. |

| |Mariane M. Fahlman, PhD, et al (2011): The purpose of the study was to determine the effects of 16 weeks of strength training on|

| |measures of functional ability in elderly who are functionally limited. Quasi-experimental trial in which elderly volunteers |

| |were assigned to either an exercise group or a control group. Eighty-seven participants (65–93 years) living independently but |

| |with some functional limitations. Thirteen different strength training exercises using Thera-Band resistive bands (Hygenic |

| |Corporation, Akron, Ohio). The program was 16 weeks in duration, and the frequency was three times per week. Participants |

| |exercised in a group setting one time per week and were given a home exercise book to follow for two additional sessions per |

| |week. Functional ability was operationalized to include a variety of measures related to functional ability that impact |

| |activities of daily living, morbidity, and mortality in the elderly, including upper- and lower-body strength and gait. |

| |Intervention effects were analyzed using a 2 (groups: exercise group vs. control group) × 3 (time: baseline vs. mid vs. post) |

| |analysis of variance.. The exercise group demonstrated significant improvements in upper-body strength as measured by biceps |

| |curl (F[2,140] = 39.870; p < .05) and lower-body strength as measured by chair sit-to-stand (F[2,124] = 25.887; p < .05). Gait |

| |velocity (F[2,140] = 37.317; p < .05) and step length (F[2,140] = 4.182; p < .05) both increased for the exercise group at week |

| |9, but this increase disappeared by week 17. Compared with minimal changes in the control group, the exercise group demonstrated|

| |significant improvements in upper-body strength as measured by biceps curl and lower-body strength as measured by chair |

| |sit-to-stand. |

| | |

| |A. Benaka, et al (2005): The purpose of this study was to determine whether a high intensity (HI) versus a moderate (MI) or |

| |low-intensity (LI) training program would be more effective in improving the isokinetic knee extension muscular performance in |

| |healthy inactive men and women. Sixty-four participants, men and women, were randomly assigned to one of four groups: control |

| |group (C), LI (50% of 1RM), the MI group (70% of 1RM) and the HI (90% of 1RM). Participants exercised on three resistance |

| |exercise machines: leg extension, leg curls and leg press. The isokinetic testing method (concentric mode) applied prior to and |

| |at the end of the training period (16 weeks, three 3 times per week) to assess the knee muscular performance. MANOVA repeated |

| |measures revealed that the HI group demonstrated the most strength gains following a speed specificity pattern (most |

| |considerable improvement occurred at or near slow speeds from 7.3% to 11.2% for male and from 2.3% to 15.2% for female). In |

| |addition, males demonstrated a greater improvement of knee extension power output than females. In conclusion, HI strength |

| |training is proposed for elderly men and women as the most effective protocol. Furthermore only at low-velocity testing, women |

| |of the HI showed a greater change than men (p ................
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