Abstract
Background/Objective
The aim of this study was to assess whether a program of exercise specifically designed to target the vestibular organ improved the postural stability of female participants over 60 years old.
Methods
Twenty-eight healthy female volunteers aged from 60 years to 76 years were assigned to a group (n = 15) engaging in vestibular-stimulating exercises, or to a control group (n = 13) engaging in traditional training exercises. Training sessions (∼45 minutes each) occurred twice a week over the course of 3 months. The following parameters were analyzed before and after training for both groups: stabilogram ellipse area and radii, total length of stabilogram, and visual-inspection indicator (eyes open).
Results
Results in terms of stabilogram ellipse area and radius without visual control (eyes closed) revealed statistically significant differences in the experimental group between the values before and after the training regimen (74.8 ± 51.6 − 54.5 ± 42.5 for area of ellipse, 6.6 ± 2.8 − 5.8 ± 2.8 for axis minor, 13.2 ± 4.3 − 11.1 ± 3.3 for axis major, respectively). No significant changes were observed in the control group.
Conclusion
Exercises stimulating the vestibular organ, such as those described herein, should be a part of efforts to improve balance in older people.
Keywords: Aging, Postural stability, Training, Vestibular organ
Introduction
As people's lives are growing longer and elderly people constitute an ever-increasing share of the population, there is a growing need to develop and implement effective exercise programs to help alleviate some of the problems associated with aging. Aging brings about a lowered integrity of many physiological systems, leading to mobility and stability problems.1 Balance difficulties are one of the factors that have a negative impact on the daily activity of elderly people, which in turn lower their quality of life. Reduced postural stability, associated with increasing age,2, 3 has been found to be a good predictor of falls,4 whereas good posture control plays an important role in compensating for an unexpected body movement. Falls and faints, in turn, have a major impact on health care costs.5, 6
The complex and diverse etiology of balance problems makes them a difficult diagnostic and treatment problem. One of the main goals of research in this field is to find an optimal training regimen to improve balance control, and increase resistance to endogenic and exogenic disturbances.
Physical activity brings about many favorable changes in the bodily system, such as increased muscle mass and improved muscle strength,7, 8 as well as better balance control.6, 9 Studies have identified a positive impact of various forms of exercise on stability in elderly individuals.10, 11, 12 At the same time, systematic physical exercise is of huge significance for mental health, as it affects the complex functions of the central nervous system (CNS) that are related to emotional reactions. As a result, physical activity is an effective factor contributing to improved quality of life for elderly individuals, which is the most important component of life satisfaction—which means enjoying a good-quality, independent life.13
Various studies have reported a positive impact of vestibular rehabilitation on postural stability in individuals suffering from dizziness,14, 15, 16 as well as patients suffering from disorders, such as multiple sclerosis.17 These findings suggested the viability of developing a similar experimental program of exercise for individuals not suffering from such vestibular disorders.
Most training regimens aimed at improving balance in the elderly seek to activate the entire vestibular system via traditional training exercises, with particular emphasis on proprioception. However, elderly individuals are not always eager to engage in long and strenuous exercise programs, and as such, it can be difficult to motivate them. That is why we hypothesized that a simple set of exercises targeted to have an impact on the main components of the balance system, performed to a background of relaxing music, should be easier to promote among elderly individuals and should therefore be of broader application.
The objective of this study was to test whether such a simple and targeted program of exercise stimulating the vestibular organ (involving cyclical movements of the head and whole body in low positions, performed to music) would have a positive impact on postural stability in the elderly (in participants older than 60 years, against a control group engaging in traditional training exercises), and, secondarily, whether it would furthermore be successful in encouraging elderly individuals to engage in a physical activity.
Methods
Participants
The study began with a total of 57 female participants older than 60 years (Figure 1), all of them were enrolled participants in the University of the Third Age at the Józef Piłsudski University of Physical Education in Warsaw, Poland. Based on medical assessment, the volunteers were assigned to two training groups: 20 individuals to a group in which specific exercises were used to stimulate the vestibular organ, and 20 individuals to a control group in which traditional training was combined with certain elements of balance control. Fifteen individuals were disqualified from the study for medical reasons (most commonly due to untreated hypertension and balance problems), while a further two people refused to participate. An approval was obtained from the institute's Research Ethics Commission, and all the participants provided a written informed consent.
Figure 1.
Flow diagram of participants.
A total of 40 women began participating in the exercise regimens, but the full training cycle was completed by 15 participants from the experimental group and 13 participants from the control group. This relatively low final attendance rate was at least partly the consequence of an adopted rule, whereby participants were excluded from the program if they missed two sessions. There were no significant differences between the groups of program-completing participants [analysis of variance (ANOVA)] in terms of age, height, weight, or body mass index (BMI; Table 1).
Table 1.
Participants' demographics and baseline measures.
| Group 1 (n = 15)a | Group 2 (n = 13)b | F | p | |
|---|---|---|---|---|
| Age (y) | 68.9 ± 7.1 | 67.3 ± 7.1 | 0.3682 | 0.6179 |
| Height (cm) | 161.0 ± 7.0 | 159.5 ± 7.6 | 0.3107 | 0.8469 |
| Weight (kg) | 71.3 ± 12.1 | 69.8 ± 9.5 | 0.1293 | 0.7541 |
| BMI | 27.5 ± 4.6 | 25.5 ± 3.9 | 0.0001 | 0.8601 |
| Sway path length with eyes open (mm) | 549.3 ± 128.9 | 560.0 ± 151.2 | 0.9184 | 0.3632 |
| Sway path length with eyes closed (mm) | 599.3 ± 124.9 | 636.5 ± 122.0 | 0.6307 | 0.4499 |
| Area of ellipse with eyes open (mm2) | 55.2 ± 41.5 | 37.2 ± 21.8 | 1.9862 | 0.1852 |
| Area of ellipse with eyes closed (mm2) | 74.8 ± 51.6 | 51.3 ± 30.3 | 2.0610 | 0.1774 |
| Axis minor with eyes open (mm2) | 5.7 ± 2.9 | 4.9 ± 1.8 | 0.9524 | 0.3546 |
| Axis minor with eyes closed (mm2) | 6.6 ± 2.8 | 5.0 ± 1.7 | 3.3532 | 0.0887 |
| Axis major with eyes open (mm2) | 11.2 ± 3.4 | 9.2 ± 2.6 | 3.1549 | 0.0982 |
| Axis major with eyes closed (mm2) | 13.2 ± 4.3 | 12.6 ± 5.7 | 0.1091 | 0.7522 |
| Speed with eyes open (mm/s) | 18.3 ± 4.3 | 20.0 ± 5.0 | 0.9184 | 0.3632 |
| Speed with eyes closed (mm/s) | 20.0 ± 4.2 | 21.2 ± 4.1 | 0.6307 | 0.4499 |
Data are presented as mean ± standard deviation.
*Analysis of variance, p < 0.05.
BMI = body-mass index.
Group 1: training stimulating the vestibular organ.
Group 2: control.
According to the BMI norms adopted by the World Health Organization,18 the arithmetic mean of this value indicates that the participants were slightly overweight (27.5 ± 4.2).
Training
Training sessions (∼45 minutes each) were held twice a week over the course of 3 months. In the experimental group, stimulation of the vestibular organ was achieved by means of a series of easy-to-perform nonstrenuous exercises performed in low body positions, having the participants rotate their heads and bodies in the sagittal, transverse, and frontal planes.
In designing this exercise program, we anticipated that, by triggering sensory conflict, such activities would force the correct responses from the ocular, vestibular, and proprioceptor organs, leading to an improved relationship between them, which in turn should improve balance control. Stimulation caused by movements of the head and body is perceived as a nonspecific impulse. When the stimuli are repeated regularly and not followed by a loss of balance, the response is inhibited, which in turn leads to the formation of a new image of the vestibular position in the CNS. This method aims to improve the perception and verification of information originating from the external and internal environments. The exercises started with gentle, slow movements of the head with visual control in various low positions (lying position), such as body bent at 30°, with the participants lying on their backs or sides.
For example, after first lying on their back, the participants shifted to lying on their right side, then to their left side, repeating these ∼10 times (in keeping with their individual capabilities). After all the repetitions were performed, the participants stopped moving for ∼3 minutes while lying on their right side. The cycle was then repeated, this time stopping on the left side. Another exercise involved sitting with legs extended straight, then performing side bends to rest the arms on the mat behind the body, alternatingly on the left and right sides. After several repetitions were performed, movement was halted for ∼3 minutes in the side-bend position with upper limbs bent and with head held motionless, alternatingly on the left side and the right side. Following relaxation to music, the next exercise involved gentle, slow movements of the head with the participants keeping their eyes closed and maintaining the final position for ∼3 minutes. Once in the final positions, the participants performed breathing and relaxation exercises with their heads kept motionless. All the exercises were then repeated without visual control to achieve better stimulation of vestibular receptor cells (because vision compensates for equilibrioception).
These exercises were further supplemented with additional auditory stimuli (soothing music), intended to help create an appropriately positive mood, calm the participants, and make the motor exercises more attractive. The relevance of such music to attempts to boost vestibular performance may be justified by the close proximity and close interrelatedness of the auditory and vestibular organs,19 and the fact that receptor cells for both organs are situated in the inner ear and transmit information along the same eighth cranial nerve (the vestibulocochlear nerve).20
The exercises, with and without visual control, aimed to improve kinesthesia by stimulating signals from the vestibular organ through head and body movements. In the final phase of each movement, the participant was stopped in the corrective position and asked to maintain the set position. The purpose of this halting of movement for ∼3 minutes after performing each simple exercise movement was to equalize the flow (following head movement) of the endolymph in the semicircular canals and the otoliths of the saccule and utricle of the vestibular organ. As the exercise program progressed, the number of repetitions was gradually increased and the support plane was reduced. Each training session also involved games for improving memory and concentration. The maximum heart rate during exercise did not exceed 100 beats/min. Overall, the therapy for the experimental group aimed to encourage older people to take up some sort of physical exercise, improve their physical fitness, and particularly improve their balance control.
The women in the control group, in turn, engaged in traditional forms of exercise, consisting of various balance, coordination, and flexibility exercises in all positions, adapted to suit people aged 60 years and over, led by fitness instructors. This traditional training likewise took place twice a week for 45 minutes over 3 months. Sessions began with a 5–7 minute warm-up followed by the main part of the regimen, in which a series of traditional training exercises were performed on a stable floor. (Traditional training exercises are performed in high body positions, and employ integrated multifaceted motion in all the joints and all planes of motion.) These exercises included, for instance: (1) performing a squat, and then returning to a standing position, combined with various movements of the upper limbs; (2) lifting one lower limb and the upper limbs to one side (alternating left and right); (3) lifting one lower limb to the rear, while simultaneously performing a semisquat on the standing leg; (4) raising the second limb, bent at the knee and hip joint to a 90° angle; and (5) stretching to the rear the second limb, with the knee joint held straight.
Data recording and analysis
Qualification was conducted by a medical doctor, and included a medical-history interview (on history of falls, fractures, stumbling, and dizziness), analysis of medical records, electrocardiogram and assessment of the cranial nerves for any possible meningeal symptoms, cerebellar testing (finger-to-nose test, diadochokinesis, and pronator-drift test), and the results of static and dynamic tests, which assess the correctness of posture and gait (Romberg's test, Unterberger's test, the Babinski–Weil test, the Fukuda test, and the straight-line test), after which potential participants were excluded if required on this basis. Also taken were anthropometric measurements (basic body shape, height, weight, and BMI) and stabilometry measurements while the participants were standing, with and without visual control. The zebris FDM-T platform (zebris Medical GmbH, Isny, Germany), which registers foot pressure on a base, was used in order to characterize postural stability, with three 30-second trials in each measurement. The following parameters were analyzed: stabilogram ellipse area and radii [shifts of center of pressure (COP) sway in all planes (mm2)], total length and speed of stabilogram (mm), and visual-inspection indicator (VII) (eyes open) calculated on the basis of the equation described by Mraz et al.21
All tests were conducted twice, before commencing the exercise program and immediately after.
Statistical analysis
The registered data were analyzed statistically using STATISTICA version 10 (StatSoft Inc., Tulsa, OK, USA). A 2 (group) × 2 (test time) variance analysis (ANOVA) with repeated measurements of the test sway, area, speed, and adjustment for significant differences between the groups on baseline measures was used to examine the differences between the groups and pretraining sessions. In addition, Levene's test for equality of variances was performed, which did not show differences between the groups in the research before the exercise program.
The Wilcoxon nonparametric test was used to study post-training differences. The ethical committee of the Józef Piłsudski University of Physical Education in Warsaw granted approval for conducting the research.
Follow-up questionnaire
The participants in the experimental group were given a short written questionnaire to fill out, following the completion of the study, in which they reported their impressions of the experimental training program and its effects. A total of 15 responses were received.
Results
The stabilometric parameters obtained during the pretraining tests are shown in Table 1.
Prior to the training regimen, the mean values for stabilometric parameters obtained during the initial tests revealed no significant differences between the groups [ANOVA (p < 0.05)]. The ellipse area of the stabilogram with visual control was 55.2 ± 41.5 mm2 for the experimental group and 37.2 ± 21.8 mm2 for the control group; without visual control, the figures were 74.8 ± 51.6 mm2 and 51.3 ± 30.3 mm2, respectively (Table 2). An analysis of the mean values for the stabilogram ellipse area and its radii following the exercise program revealed significant statistical differences between the values without visual control in the experimental group alone (area p = 0.022; radii p = 0.041 and p = 0.04). This we see as confirming the first research hypothesis, showing that a simple and targeted program of exercise stimulating the vestibular organ has a positive impact on postural stability in participants older than 60 years.
Table 2.
Comparison of pre- and post-exercise values for center-of-gravity sways and speed parameters.
| Parameter | Group 1 (n = 15)a |
Group 2 (n = 13)b |
||||||
|---|---|---|---|---|---|---|---|---|
| Eyes open |
Eyes closed |
Eyes open |
Eyes closed |
|||||
| Pre-exercise | Post-exercise | Pre-exercise | Post-exercise | Pre-exercise | Post-exercise | Pre-exercise | Post-exercise | |
| Sway path length (mm) | 549.3 ± 128.9 | 537.9 ± 124.6 | 599.3 ± 124.9 | 580.9 ± 128.8 | 560.0 ± 151.2 | 511.0 ± 140.5 | 636.5 ± 122.0 | 595.4 ± 229.8 |
| Area of ellipse (mm2) | 55.2 ± 41.5 | 38.9 ± 17.6 | 74.8 ± 51.6* | 54.5 ± 42.5* | 37.2 ± 21.8 | 36.0 ± 20.6 | 51.3 ± 30.3 | 42.8 ± 24.5 |
| Speed (mm/s) | 18.3 ± 4.3 | 17.9 ± 4.1 | 20.0 ± 4.2 | 19.4 ± 4.3 | 20.0 ± 5.0 | 17.0 ± 4.7 | 21.2 ± 4.1 | 19.8 ± 7.6 |
| Axis minor | 5.7 ± 2.9 | 4.8 ± 1.5 | 6.6 ± 2.8* | 5.8 ± 2.8* | 4.9 ± 1.8 | 4.8 ± 2.1 | 5.0 ± 1.7 | 4.7 ± 1.8 |
| Axis major | 11.2 ± 3.4 | 10.1 ± 3.2 | 13.2 ± 4.3* | 11.1 ± 3.3* | 9.2 ± 2.6 | 10.6 ± 3.1 | 12.6 ± 5.7 | 11.5 ± 3.9 |
Data are presented as mean ± standard deviation.
*Wilcoxon test, p < 0.05.
Group 1: training stimulating the vestibular organ.
Group 2: control.
In order to determine the degree to which visual control is involved in compensating for lost balance, the VII value was calculated as the ratio of the stabilogram ellipse area with eyes open minus the ellipse area with eyes closed, to the stabilogram ellipse area with eyes open plus the ellipse area with eyes closed, multiplied by 100.
This index is usually positive, which suggests that, when the participants keep their eyes closed, the ellipse area increases. Higher VII values suggest that visual control plays a role in compensating for loss of balance, while lower VII values may suggest a reduced role played by visual control in maintaining postural stability or an absence of visual compensation when compensating for lost balance.
The VII values for both groups before and after training are shown in Table 3. Since the VII values in both groups do not follow a normal distribution, all normalization of stabilometric parameters was conducted on the basis of median and quartile values. The mean value for this index was 14 for the experimental group and 13 for the control group. Although a downward trend was noted in the mean values of this index following the training cycle, they did not show statistically significant differences. It is worth noting the reduction in the Q75 quartile value by 26% in the experimental group, and by 15% in the control group (from 32 to 27). It can be assumed that the number of participants for whom visual control plays a significant role in maintaining postural stability was lower.
Table 3.
Visual-inspection indicator values.
| Group | n | VII (mean ± SD) |
VII Q25 |
VII median |
VII Q75 |
||||
|---|---|---|---|---|---|---|---|---|---|
| Pre-exercise | Post-exercise | Pre-exercise | Post-exercise | Pre-exercise | Post-exercise | Pre-exercise | Post-exercise | ||
| 1a | 15 | 13.95 ± 28.58 | 11.64 ± 30.96 | −8.75 | −8.04 | 11.72 | 13.53 | 45.24 | 33.33 |
| 2b | 13 | 12.71 ± 28.98 | 8.97 ± 27.93 | −8.20 | −7.38 | 8.15 | 9.10 | 31.67 | 26.92 |
| Total | 28 | 13.37 ± 28.24 | 10.40 ± 29.08 | −8.47 | −7.71 | 11.50 | 11.31 | 33.08 | 32.25 |
SD = standard deviation; VII = visual-inspection indicator.
Group 1: training stimulating the vestibular organ.
Group 2: control.
As for the follow-up questionnaire concerning participants' opinions of the experimental program, the results indicate that 12 individuals saw an improvement in their day-to-day lives, whereas three patients did not notice any change. Of the seven individuals who declared they had experienced balance difficulties, six reported that their balance had improved, whereas six individuals without previous incidents stated that their balance improved, and two participants reported no change. The program received good reviews in terms of its attractiveness, in 14 cases, with only one participant dissatisfied that the exercises were not more intensive. Overall, 14 individuals gave the program of therapy a positive evaluation, most often citing improved physical fitness and balance control. We see these results as confirming our secondary research hypothesis, indicating that a simple and targeted program of exercise stimulating the vestibular organ would be successful in encouraging elderly individuals to engage in a physical activity.
Discussion
Balance problems have been the subject of numerous studies, which have aimed to devise and implement programs to help people improve their balance. Although the positive effects of exercise should be obvious to everyone, it can be difficult to encourage people who have never exercised regularly to take up training regimens. Researchers are particularly interested in finding optimal training methods to improve balance control in older people, which would be effective in minimizing the risk of falls. It is difficult to define a universal training regimen suitable for all people who are at risk of falls; such exercise should be versatile and affect all components of the balance-control system. As elderly people are frequently resistant to the idea of keeping fit, a set of simple exercises targeted to affect the main components of the balance system should therefore have broad applications.
The experiment described in this paper involves a simple exercise program that actuates the vestibular organ by means of movements of the head and body in all planes. This set of exercises does not require a lot of energy or time; instead, it focuses on relaxing techniques that also stimulate cognitive function. The experimental group, engaging in such an exercise program specifically designed to target the vestibular organ, did show positive changes to the COP sway ellipse area and radii (p < 0.05) in the test where participants stood up without visual control, whereas the control group, undergoing traditional training, which also included (but was not limited to) some elements of balance exercises, did not show significant differences in their stabilometric parameters before and after the exercise regimen. No changes were observed for either group in the ellipse area with visual control or COP sway path length.
These findings differ from those of Lichtenstein et al,22 who observed significant differences when the participants kept their eyes open, but not when they kept their eyes closed. Different results were also obtained by Morioka et al,23 who conducted tests of sensory perception of the soles of the feet in elderly participants, and noted a statistically significant difference in path-length values while the participants kept their eyes closed; no significant changes were noted in the stabilogram ellipse area changes. Hagedorn and Holm24 compared traditional training with computer training with feedback in elderly people. Their participants saw increased muscle strength and endurance, as well as a statistically insignificant improvement in static balance parameters. Wilson et al25 used orthopedic footwear in 40 participants aged ∼50 years over the course of 4 weeks, finding that wearing specialist shoes for 6 hours per day did not have a significant effect on postural stability. Sofianidis and Hatzitaki26 used traditional dancing training in elderly people, reporting a statistically significant difference in COP values when the participants had their eyes closed and open. The wide range of results obtained in these different studies may result from the types of training used, which may have an effect on other components of posture control.
In our study, many of the exercises in the experimental program were carried out without visual control. Our experimental program consisted of exercises specifically targeting the vestibular system, which were combined with relaxing music and did not require strenuous effort, and at the same time ensured safe rotation of the whole body. We sought to test whether such a regimen could improve postural stability in older individuals, and at the same time to serve as an introductory program encouraging them to become more physically active. The results proved encouraging on both counts: the experimental group showed improved balance with their eyes shut, which was not noted in the control group (whose regimen also included generally balance-related exercises), and the follow-up questionnaire showed positive feedback concerning physical activity.
Haibach et al27 showed that even minor visual disturbances can contribute to loss of balance in elderly people, therefore indicating that improved balance control while participants keep their eyes closed is useful. In our study, the arithmetic mean of the balance-control index did not change significantly at the end of the training cycle in either group. The only improvement to this index was noted in people who had high positive results to begin with, which suggests that, when the participants closed their eyes, it significantly increased the stabilogram ellipse area. Higher VII values (which measure the difference between the ellipse areas obtained when the participants keep their eyes closed and open) suggest that visual control plays a part in the compensation for loss of balance, while lower VII values may suggest a reduced significance of visual control in postural stability or an absence of visual compensation when dealing with lost balance; thus, the 26% reduction in the Q75 quartile may indicate that the therapy described herein reduces the share of visual control in balance.
There is evidence that vestibular rehabilitation has a positive effect on postural stability in people prone to dizziness.15, 28 Dizziness and other symptoms linked to balance problems are relatively common in elderly people and should be taken seriously, since they can lead to falls, injuries, loss of independence, and even death.29 The goal of this study was the prevention of vestibular disorders. The training program described herein aims to trigger sensory conflict, forcing correct responses from the ocular, vestibular, and proprioceptor organs, leading to an improved relationship between them, which in turn should improve balance control. Stimulation caused by movements of the head and body is perceived as a nonspecific impulse. When the stimuli are repeated regularly and they are not followed by a loss of balance, the response is inhibited, which in turn leads to the formation of a new image of the vestibular position in the CNS. This method aims to improve the perception and verification of information originating from the external and internal environments.
Research by Morozetti et al30 shows that rehabilitation of dizziness through various types of head movements resulted in a significant improvement in the otoneurological clinical assessment and in participants' self-perception. They excluded people suffering from dizziness or tinnitus. During intervention, the experimental group performed movements of the head and whole body, like during rehabilitation for dizziness, and this group reported improved balance assessed by measuring the stabilogram ellipse area without visual control. Although the expected results may not have been achieved following 12 weeks of observations with visual control, it is notable that a statistically significant improvement was found for results with eyes closed. This progress is important, because according to Radvay et al,31 stability is reduced as visual impulses are eliminated. These authors also found an even greater reduction of stability in their dynamic study. Similarly, Wong et al28 found differences between a group participating in Tai Chi Chuan exercises and a control group when performing more complex tasks with elements of swaying, with the Tai Chi Chuan group achieving significantly better results than the control group, but did not find differences in a static study of postural stability in elderly people. Further research is needed to define more precisely the effect of programs of exercise on stability, both statically and dynamically.
The training regimen described herein was found to have a positive effect on certain stabilometric parameters in people aged 60 years or over. We conclude on the basis of this relatively small study that, in order to delay involutional changes leading to balance problems, such nonstrenuous, easy-to-perform exercises specifically targeting the vestibular system, performed without visual control, should be a part of all efforts to improve fitness in older people, and moreover, that it will be easier to motivate older people to engage in such specifically targeted exercise than in traditional programs of general physical exercise.
Limitations
Our results may not be generalized to the overall older population owing to relatively small number of healthy participants, and due to the fact that only female participants were studied. Moreover, as anonymous reviewers have aptly pointed out, the relatively high dropout rate during the course of the program may represent a certain limitation on the interpretation of the results.
Conflicts of interest
The authors declare that the research described herein involves no conflicts of interest.
Funding/support
This study was supported by the Polish National Science Centre N404047339.
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