The effects of balance training on rehabilitation of acute and subacute stroke patients

Abstract

Purpose: Aim of this study is to evaluate effects of balance education with Balance Trainer, according to clinical and laboratory measurements for locomotor performance and daily life acitivities when added to traditional rehabilitation program in stroke patients.
Materials and methods: This randomised controlled study included 30 stroke patients who hospitalized in our clinic between dates of January 2011-May 2012. At least six month after stroke were excluded from the study. Patients were randomly assigned into two groups, the control group and trained group. All patients evaluated with Brunnstrom stages of motor recovery, spasticity with modified Ashworth scale, sense of touch, sense of joint position, cerebellar findings, neglect phenomen with star erasing test, ambulation with Functional Ambulation Scale (FAS) and daily life activities with Functional Independence Measurement (FIM). Their balance was assessed clinically with Berg Balance Scale (BBS), Trunk Control Test (TCT) and Fugl-Meyer Assessment Scale (FMAS). Visual feedback balance training with the Balance Trainer was used in the trained group. Balance training consisted of a 15 minute training session three times a week for a 6 week period. The control group were exercized only conventional physical therapy. Data of patients in the trained group (1^st group) and control group (2^nd group) were collected before training and after completing the training program.
Results: In our study after the rehabilitation period, Berg Balance Scale and Trunk Control Test values in both groups improved significantly. In addition, FIM and FAS values were significantly higher in both groups. Compared top ast-treatment changes at BBS, TCT and FAS values were not different between the groups. It was found that both conventional stroke rehabilitation and additional balance training with Balance Trainer showed improvement in the parameters (balance and activities of daily living (ADL) However, they do not have a statistically significant advantage over each other.
Conclusion: We observed that both conventional stroke rehabilitation and Balance Trainer exercise program provides improvement in clinical parameters of balance but there was no statistically significiant difference between each other. And we have found that, patients with better Brunnstrom motor recovery score in lower extremity had better balance.

Keywords

• Stroke
• rehabilitation
• balance trainer

Akut ve subakut inmeli hastaların denge eğitiminin rehabilitasyon üzerine etkileri

Abstract

Amaç: Bu çalışmanın amacı; inmeli hastalarda konvansiyonel inme rehabilitasyonuna ek olarak denge egzersiz cihazı ile denge eğitiminin dengenin klinik ölçümleri ile lökomotor performans ve günlük yaşam aktivitesi üzerine etkilerini değerlendirmektir.
Gereç ve yöntem: Çalışmaya Ocak 2011-Mayıs 2012 tarihleri arasında kliniğimizde yatarak rehabilitasyon gören 30 inmeli hasta dahil edildi. Serebrovasküler olay (SVO) üzerinden en fazla altı ay geçmiş olan 30 hasta, çalışma (Grup 1) ve kontrol (Grup 2) grubu olarak 2’ye ayrıldı. Her iki gruptaki hastalar Brunnstrom’a göre motor iyileşme düzeyi, Modifiye Ashworth skalasına göre spastisite, yüzeyel duyu, eklem pozisyonu, serebellar testler, yıldız silme testi ile ihmal fenomeni, Fonksiyonel Ambulasyon Skalası (FAS) ile ambulasyon yeteneği ve Fonksiyonel Bağımsızlık Ölçütü (FBÖ) ile günlük yaşam aktivitesi açısından değerlendirildi. Denge ve postural kontrol klinik olarak Berg Denge Ölçeği (BDÖ), Gövde Kontrol Testi (GKT) ve Fugl Meyer Değerlendirme (FMD) ölçeğinin denge kısmı ile değerlendirildi. Çalışma grubuna (1. grup) altı hafta boyunca konvansiyonel egzersiz programına ek olarak haftada üç gün 15 dakika denge egzersiz cihazı ile egzersiz programı verildi. Kontrol grubu (2. grup) ise sadece konvansiyonel egzersiz programına alındı. Hastalar altı hafta sonra aynı testlerle tekrar değerlendirildi.
Bulgular: Çalışmamızda altı haftalık rehabilitasyon periyodundan sonra her iki grubun da kendi içlerinde BDÖ, GKT değerleri anlamlı olarak düzelmiştir. Ek olarak her iki grupta FBÖ ve FAS değerleri de anlamlı olarak düzelmiştir. Tedavi sonrasında BDÖ, GKT ve FAS değerlerinde oluşan değişimlere bakıldığında, iki grup arasında farklılığa rastlanmamıştır. Dolayısıyla konvansiyonel inme rehabilitasyonun ve denge egzersiz cihazı ile yapılan ek denge eğitiminin, denge ve günlük yaşam aktivitelerini (GYA) gösteren parametrelerde birbirlerine istatistiksel olarak anlamlı üstünlükleri olmadan düzelme gösterdikleri gözlenmiştir.
Sonuç: Konvansiyonel egzersizler ve buna ek olarak uygulanan denge egzersiz cihazı ile verilen denge eğitimi akut ve subakut dönemdeki inmeli hastaların denge rehabilitasyonunda katkı sağlar. Ancak bu yaklaşımların birbirine üstünlüğü saptanmamıştır. Çalışmamızda ayrıca; alt ekstremite Brunnstrom motor evrelemesi yüksek olan hastalarda dengenin daha iyi olduğu da bulunmuştur.

Keywords

• İnme
• rehabilitasyon
• denge eğitimi

References

1. 1. Swieten, J. C., Koudstaal, P. J., Visser, M. C., Schouten, H. J., & Gijn, J. (1998). Interobserver agreement for the assessment of handicap in stroke patients. Stroke, 19, 604-607. DOI: 10.1161/01.str.19.5.604
2. 2. Wade, D.T., & Collin, C. (1988). The Barthel ADL Index: a standard measure of physical disability? Disabil Rehabil, 10, 64–67. DOI: 10.3109/09638288809164105
3. 3. Altuğ, F., Kitiş, A., Tunçkır, S., Cavlak, U., & Şahiner, T. (2002). Hemiparetik hastalarda mental durum, mobilite ve depresyon düzeylerinin günlük yaşam aktiviteleri üzerine etkisi. Fizyoterapi Rehabilitasyon, 13(3), 135–139.
4. 4. Danckert, J., & Ferber, S. (2006). Revisiting unilateral neglect. Neuropsych, 44, 987-1006. DOI: 10.1016/j.neuropsychologia.2005.09.004
5. 5.Kurt, E. E., Delialioğlu, S. Ü., & Özel, S. (2010). İnmede denge ve denge değerlendirme skalaları. Turk J Phys Med Rehab, 56, 56–61.
6. 6. Günendi, Z., Özyemişci, Ö., Uzun, M. K., Öztürk, G. T., & Demirsoy, N. (2010). Reliability of quantitative static and dynamic balance tests on kinesthetic ability trainer and their correlation with other clinical balance tests. Turk J Phys Med Rehab, 13, 1-5.
7. 7. Şahin, E., Baydar, M., El, Ö., Söylev GÖ, Akpınar BA, Şenocak Ö, ve ark. (2012). İnmeli hastalarda omuz askısının statik dengeye etkisi. J Neurol Sci, 29(3),458-466.
8. 8. Mecagni C, Smith JP, Roberts KE, O'Sullivan SB. Balance and ankle range of motion in community-dwelling women aged 64 to 87 years: a correlational study. Phys Ther 2000;80:1004-11.

9. 9. Bohannon RW, Leary KM. Standing balance and function over the course of acute rehabilitation. Arch Phys Med Rehabil 1995;76:994-6. DOI: 10.1016/s0003-9993(95)81035-8
10. 10. Keenan MA, Perry J, Jordan C. Factors affecting balance and ambulation following stroke. Clin Orthop Relat Res 1984;182:165-71.
11. 11.Blum L, Korner-Bitensky N. Usefulness of the Berg Balance Scale instroke rehabilitation: a systematic review. Phys Ther 2008;88:559-66. DOI: 10.2522/ptj.20070205
12. 12. Measuring balance in the elderly: validation of an instrument. Can J Public Health 1992;83:7-11.
13. 13. Mao HF, Hsueh IP, Tang PF, Sheu CF, Hsieh CL. Analysis and comparison of the psychometric properties of three balance measures for stroke patients. Stroke 2002;33:1022-7. DOI: 10.1161/01.str.0000012516.63191.c5
14. 14. Chou CY, Chien CW, Hsueh IP, Sheu CF, Wang CH, Hsieh CL. Developing a short form of the Berg Balance Scale for people with stroke. Phys Ther 2006;86:195-204.
15. 15. Liston RA, Brouwer BJ. Reliability and validity of measures obtained from stroke patients using the Balance Master. Arch Phys Med Rehabil 1996;77:425-30. DOI: 10.1016/s0003-9993(96)90028-3
16. 16. Berg K, Wood-Dauphinee S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995;27:27-36.
17. 17. Stevenson TJ. Detecting change in patients with stroke using the Berg Balance Scale. Aust J Physiother 2001;47:29-38. DOI: 10.1016/s0004-9514(14)60296-8
18. 18. Wang CH, Hsueh IP, Sheu CF, Yao G, Hsieh CL. Psychometric properties of 2 simplified 3-level balance scales used for patients with stroke. Phys Ther 2004;84:430-8
19. 19. Salbach NM, Mayo NE, Higgins J, Ahmed S, Finch LE, Richards CL. Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil 2001;82:1204-12. DOI: 10.1053/apmr.2001.24907
20. 20. Collin C, Wade D. Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry 1990;53:576-9. DOI: 10.1136/jnnp.53.7.576
21. 21. Franchignoni FP, Tesio L, Ricupero C, Martino MT. Trunk control test as an early predictor of stroke rehabilitation outcome. Stroke 1997;28:1382-5. DOI: 10.1161/01.str.28.7.1382
22. 22. Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther 1966;46:357-75. DOI: 10.1093/ptj/46.4.357 23. Rankin A. Functional independence measure. Physiotherapy 1993;79:842-3.
23. 24. Küçükdeveci A, Yavuzer G, Elhan A, Sonel B, Tennant A. Adaptation of the Functional Independence Measure for use in Turkey. Clin Rehab 2001;15:311-9.
24. 25. Holden MK, Gill KM, Magliozzi MR, Nathan J, Piehl-Baker L. Clinical gait assessment in neurolgically impaired. Phys Ther 1984;64:35-40. DOI: 10.1093/ptj/64.1.35
25. 26- Hui-Fen Mao; I-Ping Hsueh, Pei-Fang Tang, Ching-Fan Sheu, PhD; Ching-Lin Hsieh, Analysis and Comparison of the Psychometric Properties of Three Balance Measures for Stroke Patients Stroke 2002;33;1022-1027 DOI: 10.1161/01.str.0000012516.63191.c5
26. 27- Hsieh CL, Sheu CF, Hsueh IP, Wang CH. Trunk control as an early predictor of comprehensive activities of daily living function in stroke patients. Stroke 2002;33:2626-2630 DOI: 10.1161/01.str.0000033930.05931.93
27. 28- Sarah F Tyson 1, Marie Hanley, Jay Chillala, Andrea Selley, Raymond C Tallis. Balance disability after stroke, . 2006 Jan;86(1):30-8. doi: 10.1093/ptj/86.1.30. Physical Therapy DOI: 10.1093/ptj/86.1.30
28. 29. Grant T, Balance Retraining Following Acute Stroke: A Comparison of Two Methods. A Thesis submitted to the School of Rehabilitation Therapy in conformoriy with the requirements for the degree of Master of Science. Queen’s University Kinsgton, Ontario. October, 1996
29. 30. Walker C, Brouwer BJ, Citlham EG. Use of Visual Feedback in Retraining Balance Following Acute Stroke Physical Therapy. Volume 80. Number 9. September 2000
30. 31. Barclay-Goddard R, Stevenson T, Poluha W, Moffatt MEK, Taback SP. Force platform feedback for standing balance training after stroke (Review). 2004 Cochraine Review DOI: 10.1002/14651858.CD004129.pub2