A Study to Compare the Effect of Balance Training Exercises on Presbystasis: A Cross-Sectional Study

BACKGROUND OF THE STUDY Presbyastasis is a medical term for age related balance problems. Presby means elders and stasis means balance problem. Presbystasis can be defined as an aging disequilibrium. Elderly people often complain of dizziness and loss of balance. The main sign and symptoms of presbystasis are dizziness, loss of balance, increased fall risk, vertigo, postural instability which progressively increases loss of quality of life. An estimated 13 percent of adults report imbalance between the ages of 65 and 69. For people 85 and older, it increases to 46%. In addition, balance, and gait disorders are associated with an increased risk of falls13. The estimated annual fall rate for adults over age 65 is 28%. Balance is important for maintaining postural balance and thus preventing falls.


INTRODUCTION
Life expectancy is increasing worldwide, especially in the Indian subcontinents. The problems associated with ageing are now understood as the proportion of the population in this category is increasing 1 . The number of people aged 65 and over continues to grow at an unprecedented rate. India's current population is 1414940553 as of Tuesday, January 31, 2023 based on the latest UN data Worldometer revision. India's elderly population is now the world's first largest. With the rapid aging population, it is important to emphasize the need to maintain function and maintain quality of life into old age. There are an estimated 962 million people over the age 60 in the world, representing over 13% of the total population. Age related changes in vestibular function include a decline in vestibulo-ocular reflex, which is responsible for stabilizing vision during head movements, as well as the vestibulospinal reflexes, which is used to maintain upright posture 3 Balance and gait are important considerations in the health of the elderly. Maintaining balance depends on the information the brain receives from the three organs: eye, muscles and joints, and vestibular system. All three of these sources send signals to the brain in the form of nerve impulses from certain nerve terminals called sensory receptors. An estimated 13 percent of adults report imbalance between the ages of 65 and 69. For people 85 and older, it increases to 46%. 4 The prevalence of walking disorder among community-dwelling adults 70 years and older has been estimated 35% in elderly. Falls are associated with significant morbidity and mortality in the elderly: they are the most common cause of accidental death and nonfatal accidental injury in those 65 and older, accounting for 55.8% of accidental deaths 4,5,6,7,8 . One study reported that more than 10,000 seniors died from accidental falls 65 and older every year, and the risk increases with age 9 . Impaired postural stability is recognized as a major risk factor for falls in the elderly 10 . Some fall risk factors are irreversible, while others are potentially modifiable with appropriate interventions 11 . Balance is important for maintaining postural balance and thus preventing falls. According to WHO fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level 12 . Many people who experience falls are immobilized by fear of falling, which in turn increases the risk of pressure ulcers, pneumonia, weakness, and falls 13 The presence of dizziness in elderly is a strong augury of fall. Dizziness is a frequent occurrence in the elderly and it carries substantial health and quality of life consequences for elders 14 . Multifactorial balance dysfunction and dizziness that occur in an individual age is also called Presbyastasis. 15 Presbyastasis is a medical term for age related balance problems. Presby means elders and stasis means balance problem 16 . Presbystasis can be defined as an aging disequilibrium. It is dizziness and imbalance caused by the aging of the sensory systems, the aging of the central nervous system and motor system 15 . Elderly people often complain of dizziness and loss of balance. Elderly people with dizziness are found to have significant disabilities that require assistance. According to Agrawal et al., the likelihood of falling increases 12-fold in people affected by vestibular dysfunction 17 . Age-related vestibular degeneration is a condition that leads to unsteady gait, dizziness, and an increased risk of falling in the elderly which interferes with daily activities and life.
Presbyastasis summarizes these terms and can be defined as an age-related imbalance of peripheral and central balance systems (vestibular, visual, somatosensory) involved in striking the right balance 18 . The main sign and symptoms of presbystasis are dizziness, loss of balance, increased fall risk, vertigo, postural instability which progressively increases loss of quality of life 2,16 . People who suffer with other vestibular conditions are more prone to Presbyastasis. Age related conditions of reduced vestibular functions that can manifest in the elderly increases the chances of presbystasis 19 .
Vestibular rehabilitation therapy (VRT) is a specialized treatment primarily aimed at reducing problems caused by vestibular disorders such as dizziness and vertigo, gaze instability and/or loss of balance and falls 20 . People with vestibular disorders often experience problems such as dizziness, vertigo, visual disturbances, and/or imbalance 21 . VR aims to use a problem-oriented approach to facilitate compensation 22 . This is done by customizing exercises to address each individual's specific problems. Depending on the identified vestibular problem, three main exercise strategies can be prescribed: 1) habituation, 2) gaze fixation, and/or 3) balance training 24 .

METHOD and METHODOLOGY
This study is a prospective cross-sectional study, and the subject were recruited from a tertiary Neurootology Clinic. Participants who fulfil the inclusion criteria were included in the study. The purpose of the study was explained to the subjects. And the participants were instructed regarding treatment protocol in detail. The written consent was taken from the subjects before starting the treatment protocol. Patients with presbyastasis randomly assigned into 2 groups; Group A and Group B. Subjects fill the FHI questionnaire and TUG test was done. The following protocol was followed: -    Within the group analysis of FHI was conducted using Paired t-test test, with level of significance, p set at 0.05. The comparison of the readings for FHI of the two groups namely, Group A and B was found to be statistically significant (0.0001).   Between the group analysis of TUG was conducted using Independent t-test test, with level of significance, p set at 0.05. The comparison of the readings for TUG of the two groups namely, Group A and B was not found to be statistically significant (0.0001).

Fall Handicap Inventory (FHI)
The Fall Handicap Inventory (FHI)is the measure of handicapped associated with repeated falls. It is measured using a self-administered 18 item scale. The post-test mean values for FHI for participants in the Group A came out to be 25.12±2.386 and that for Group B came out to be 16.16±3.508.
Between the group analysis of FHI was conducted using Paired t-test test, with level of significance, p set at 0.05. The comparison of the readings for FHI of the two groups namely, Group A and B was not found to be statistically significant (0.0001).

DISCUSSION
In this prospective study we tried to evaluate presbystasis patients and assess the effect of balance training exercises on fall efficacy and dizziness. This study also compares the two balance training approaches that is Rhythmic weight shift and limit of stability. The study was carried out at a tertiary Neuro-Otology clinic. 50 patients between the age group of 65 to 80 years of age were included in this study. Our overall result agrees with those reported in the literature that the balance training exercises are helpful in decreasing the falls in older adults and improves the ADL and confidence.
Both the groups showed significant improvement in balance and fall risk, but group B shows better improvement than group A, suggesting better clinical outcomes in those treated with Limit of stability exercise protocol.

CONCLUSION
The study concluded that Rhythmic weight shift and Limit of stability exercises are both effective in reducing falls and improving balance in patients with presbystasis. But the participants of group B, who have received Limit of stability exercise protocol have better clinical outcomes when compares the FHI and TUG score of both groups. Hence, we concluded and accepted the experimental hypothesis which stated that Limit of stability exercises have a significant effect in balance and fall in individuals having presbystasis.