The effect of balance training on clinical balance performance in obese patients aged years old undergoing sleeve gastrectomy

Transcription

1 Eur Surg : DOI /s The effect of balance training on clinical balance performance in obese patients aged years old undergoing sleeve gastrectomy Z. Rojhani-Shirazi S. Azadeh Mansoriyan S. V. Hosseini Received: 31 August 2015 / Accepted: 13 November 2015 / Published online: 15 January 2016 Springer-Verlag Wien 2016 Summary Background It is estimated that over 1.9 billion people suffer from overweight worldwide, among whom 600 million people are classified as obese. Obesity can result in many health problems. One of them is balance control insufficiency. Obesity treatment and management may include a combination of diet modification, appropriate physical activity, behavior modification, drug consumption, and sometimes surgery. However, to the best of our knowledge the effect of balance training exercises on postural stability has not been examined among the obese individuals undergoing sleeve gastrectomy. This study aimed to assess the effect of weight loss and balance training on clinical balance performance. Methods This clinical trial was conducted on 32 subjects selected through convenience sampling. The subjects were divided into two groups by random allocation (16 in the intervention group and 16 in the control group). Both groups underwent bariatric surgery. The intervention (case) group attended balance exercise sessions for 4 weeks (4 sessions per week), whereas the control group did not attend any balance exercise sessions. Before and after the intervention, the static, dynamic, and functional clinical balance tests were done in the S. V. Hosseini, MD ( ) Colorectal Research Center, Shiraz University of Medical Sciences, colorectal2@sums.ac.ir; colorectal92@yahoo.com Z. Rojhani-Shirazi, PhD Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, S. Azadeh Mansoriyan, MSc Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, intervention group. The tests were also performed in the control group twice with a 4-week interval. Results After 4 weeks of balance training exercise, a significant difference was found between the intervention and the control groups regarding static, dynamic, and functional balance tests. Conclusion Attending balance exercises program for 4 weeks can improve the balance among obese individuals undergoing sleeve gastrectomy. Keywords Obesity Balance training Clinical balance performance Sleeve gastrectomy Introduction It is estimated that over 1.9 billion people suffer from overweight worldwide, 600 million of whom are classified as obese depending on WHO report [1]. Obesity has been increasingly cited as a major health issue in the USA and other countries all over the world [2, 3]. Body mass index (BMI) is a good indicator of obesity. According to reference study results, BMI > 25 is considered as overweight, BMI > 30 as obese, and BMI > 35 as morbid obese [4]. Obesity can interfere with daily activities, which may result in different injuries and falls [5 7]. One of the daily activities altered among obese individuals is balance control. Balance control is a key factor in prevention of the related injuries [3, 5, 8, 9]. Management of obese patients may include a combination of diet modification, appropriate physical activity, exercise, behavior modification, drug consumption, and sometimes surgery to reduce excessive weight. Bariatric surgery has increased over the last four decades and the efficiency of this weight-loss technique has been approved. This surgery is an appropriate option for the individuals who excessively need to lose weight and their life is in risk [10]. The effect of balance training on clinical balance performance in obese patients 105

2 Sleeve gastrectomy is one of the rapid growing methods as a restrictive procedure in the field of bariatric surgery [11]. Sleeve gastrectomy not only acts as a restrictive procedure but also it abolishes the Ghrelin hormone act as a malabsorptive procedure in some parts. Most of the cases underwent laparoscopic surgery with resection of about 75 % stomach. Overall, three sensory stimuli are needed for balance control. These stimuli include somatosensory, visual, and vestibular afferents. Integrity of such systems data is vital to sustain a proper posture. Sensory data are adjusted dynamically and changed according to the environmental changes [12]. The relationship between body weight and postural control was first suggested by some researchers in Waist circumference, endomorph, and body weight are considered as the key factors affecting postural tests among individuals with excessive weight. Size and shape of the body significantly affect the static postural condition due to the center of body mass changes [13]. Good balance is a key factor in daily activity. When an obese individual moves forward in an oscillating motion manner, the specific abnormal adipose tissue distribution in the abdomen increases the need for ankle torque to establish balance. In other words, when obese individuals are under various disturbances and stresses, they must establish ankle torque quite faster with larger ankle torque degrees [5]. Previous available studies have mostly focused on the effect of weight loss on postural stability without balance training. Also, most of these studies have been conducted on the relationship between balance training and balance improvement. Moreover, they have mostly targeted elderly individuals [6, 7, 14]. However, to the best of our knowledge, the effect of balance training exercises on postural stability has not been examined among the obese individuals undergoing bariatric surgery. Thus, the present study aimed to assess the effect of weight loss and balance training on clinical balance performance. Methods This clinical trial was conducted on 32 obese individuals referred to Mother and Child Ghadir Hospital, Shiraz, Iran. The participants were divided into intervention and control groups by random allocation. It should be noted that participation in the study was voluntary. An informed consent was taken from all the patients. All of them confirmed that their participation was voluntary. The study design was approved by the ethics committee of Shiraz University of Medical Sciences (No. CT ). The inclusion criteria of the study were years of age, BMI over 35 kg/m 2, and being candidate for bariatric surgery. On the other hand, the exclusion criteria of the study were any reports of lower limb injuries such as fractures, dislocations, muscle, and articular lesions; soft tissue injury; any condition resulting in non-weight bearing on the leg that lasted for longer than 24 h during the past 6 months; musculoskeletal and neuromuscular disorders such as rheumatoid arthritis, diabetes, myopathy, and neuropathy; any surgery on the muscles, joints and bones in the lower limb; daily regular exercise (at least 3 times a week, min each time); middle ear disorders; and flexion contracture of the knee joint. Their performance was examined using star excursion balance test (SEBT), single leg stance (SLS) test, and get up and go (GUG) test. Moreover, their waist circumference and thigh circumference were measured by a meter. Also, a questionnaire, including age, weight, height, BMI, was filled out for each participant. Afterwards, balance exercise sessions started for the patients 5 days after the surgery, and the patients were evaluated by specific tests after 4 weeks. In the control group, the tests were repeated with a 4-week interval. Tests techniques In this study, the clinical tests were used to assess the balance. The previous studies showed that the clinical method is a reliable and valid method used for assessing postural stability [15 17]. SLS In this static balance test, patients stand barefooted on one leg without support of the upper extremities or bracing of the unweighted leg against the stance leg with eyes open and closed. During the test with eyes open, they were looking at the point on the front wall which was at the eye level and in 2 m distance. The time period that the patients could maintain this posture was measured by chronometer. Then the test was repeated with eyes closed repeated for eye closed condition [18]. SEBT SEBT is a dynamic balance test that incorporates single-leg stance on one leg with maximum reach of the opposite leg. SEBT is performed with subjects standing at the center of a grid placed on the floor, with 8 lines extending at 45 increments from the center of the grid. Patients were instructed to touch the anterior (A), posteromedial (PM), and posterolateral (PL) lines consecutively with their feet. The three distances in each direction were measured, normalized to leg length (from ASIS to medial malleolus), and multiplied by 100 [19]. GUG This functional balance test requires patients to stand up from a chair, walk a short distance (3 m) toward a wall, turn around without touching the wall, return, and sit down again. The time needed for this procedure is measured [18]. Static and dynamic exercise instructions Balance training included standing on one leg, standing in tandem mode (one should gradually increase the duration of the current practice), standing on one leg with closed, walking in a tandem mode (one foot in front of the other), 106 The effect of balance training on clinical balance performance in obese patients

3 walking on toes and heels, side walk, standing while one upper extremity and the opposite lower extremity were up, rotating the head from side to side, walking backwards for four steps, and shifting weight from one foot to the other. [14]. Periodic exercises were frequently performed for 45 min without rest among workouts. No balance training exercises were conducted in the control group. Data analysis Clinical balance indicators were reviewed again in both groups after the end of the intervention. The data were analyzed using the SPSS statistical software, version 19. Paired t test was used to compare the variables in the two groups before and after the training. Independent t test was also used to compare the two study groups. The level of significance was considered less than 0.05 in this study. Results Before the intervention, no significant difference was observed between the intervention and control groups regarding age, height, weight and waist circumference thigh circumference ratio (Table 1). Table 2 showed no significant difference between the two groups in clinical balance at first. Accordingly, the intervention group showed a significant improvement in static, dynamic, and functional balance compared with the control group after the inter- Table 1 Pretest result of baseline characteristics of the participants Variables Intervention (mean ± SD) Control (mean ± SD) P-value Age (years) 36.1 ± ± Height (cm) ± ± Weight (kg) ± ± Wc/RTc 1.78± ± Wc/LTc 1.79± ± Wc waist circumference, RTc right thigh circumference, LTc left thigh circumference vention. The results showed that there was no significant correlation between weight loss and improvement in balance control with respect to clinical balance tests in the intervention and control groups (P > 0.05). The results of the control groups clinical balance performance in pre- and posttests showed no significant difference between the variables in pretest and posttests (Table 3). The ability of the obese individuals significantly improved in static, dynamic, and functional balance after the training (Table 3). Discussion Obesity negatively affects the individuals daily activities and increases the risk of injuries [20, 21]. Table 2 Comparison of the case and control groups clinical balance performance and BMI in Pre- and Post-test Variables Intervention (Mean ± SD) Control (Mean ± SD) P-value Intervention (Mean ± SD) Control (Mean ± SD) P-value Post test Post test Pre test Pre test R SEBT (cm) 48.3 ± ± ± ± L SEBT (cm) ± ± ± ± R SLS (s) 31.5 ± ± ± ± L SLS (s) 17.6 ± ± ± ± GUG (s) 8.78 ± ± ± ± BMI (kg/m2) 36.9 ± ± ± ± R Right leg, L Left leg, SEBT Star excursion balance test, SLS Single leg stance test, GUG Get up and go test, Post test after the intervention, pretest before the intervention, BMI body mass index Table 3 Posttest and pretest results of clinical balance performance and BMI in the intervention and control groups Variables Control P-value Intervention P-value Pretest (mean ± SD) Posttest (mean ± SD) Pretest (mean ± SD) Posttest (mean ± SD) R SEBT (cm) 37.3 ± ± ± ± L SEBT (cm) 39.2 ± ± ± ± R SLS (s) 15.3 ± ± ± ± L SLS (s) ± ± ± ± GUG (s) 13.7 ± ± ± ± BMI (kg/m 2 ) 44.0 ± ± ± ± R right leg, L left leg, SEBT star excursion balance test, SLS single leg stance test, GUG get up and go test, Post test after the intervention, Pretest before the intervention, BMI body mass index The effect of balance training on clinical balance performance in obese patients 107

4 The findings of this study showed that BMI significantly reduced 4 weeks after the bariatric surgery (Table 3), but the clinical indicators of static, dynamic, and functional balance performance were improved only in the intervention group. Zamanian et al. [14] conducted a similar study on 40 elderly women who were able to ambulate 6 m or more without an assistive device. These women were randomly allocated to intervention and control groups. The intervention group took part in 1 h balance training exercises performed three times a week for 8 weeks. On the other hand, no balance training was performed in the control group. Based on the results, balance control improved in the intervention group [14]. Besides, Clemson et al. [22] conducted Lifestyle integrated Functional Exercise (LiFE) program, which included balance and strength activities, among individuals with the mean age of 70 years for 12 months. The findings of that study showed an improvement in static balance among these individuals [22]. Moreover, Hauer et al. [23] investigated 57 women with the mean age of 82 years. Balance training was performed three times a week for 3 months. The results showed an improvement in balance control and fall risk after 3 months [23]. Similar to the present study, the abovementioned investigations revealed that balance training had a positive effect on improvement of balance control. Also, Binder et al., Campbell et al., King et al., and Gao et al. in their studies mentioned that activities and exercises including balance training improve balance control [24 27]. There are three important systems used for the control of posture. Balance is assessed by somatosensory, visual, and vestibular systems [28, 29]. Vestibular and visual systems were kept stable in the present study. Thus, it can be concluded that the most important factor affecting balance is the somatosensory system that is stimulated by specific balance exercises. So, this system may be responsible for better performance in postural control during clinical tests. Balance training that was used in this study included unusual activities such as walking on toes and heels, side walk, walking while one upper extremity and the opposite lower extremity are up. Participants performed these activities for 4 weeks, so these kinds of training could affect and improve somatosensory system significantly. In contrast, Hortobágyi et al. investigated obese individuals above 60 years of age with BMI > 25 kg/m 2 before and 6 months after the surgery in terms of walking patterns, Ground Reaction Force (GRF), and kinetic and kinematic knee joint parameters. They found that after the surgery, the speed and length of each step were increased; also, the vertical GRF and knee adduction torques in the frontal plate were decreased [30]. Teasdale et al. also examined obese individuals with BMI > 40 kg/m 2 who had undergone bariatric surgery. They found that measures of postural stability, including center of pressure speed and the peak magnitude of both anterior/posterior (AP) and medial/lateral (ML) direc- tions with open and closed eyes, were improved with weight loss after 12 months [25, 31]. These two studies indicated that weight loss improved the balance control without doing balance training; this was incompatible with the findings of the current study. This may be due to the different variables to assess postural control (force plate in the previous studies and using clinical balance performance tests in current study) and longer duration of follow-up (6 12 months) in previous studies compared with the current study (4 weeks). In addition, BMI in participants in the previous studies and current study was different. Also, Handrigan et al. and Matrangola et al. showed that the weight loss was more efficient at improving the balance control than enhancing the muscle strength [32, 33]. Matrangola et al. only investigated nine participants and their methodology was dependent on mathematical issues with different evaluations. In the study of Handrigan, the mean of weight loss was about 66 kg (45 % of weight) during 3 12 months compared with the current study, less weight loss during 4 weeks. In addition, we used clinical test but they used force plate. The findings of the present study showed a significant difference between the intervention and control groups regarding clinical balance performance. Accordingly, balance performance improved significantly in the patients attending balance training sessions for 4 weeks after sleeve gastrectomy. In fact, the present study showed that, regardless of weight loss, balance training exercises after bariatric surgery could enhance balance performance that may be due to stimulation of somatosensory system. However, one of the limitations of this study was lack of somatosensory system measurements before and after the balance exercises. Conclusion This study showed that, regardless of weight loss, attending balance training sessions for 4 weeks after sleeve gastrectomy could improve the balance performance among obese individuals. Recommendations Further studies with more patients are recommended to assess individuals with respect to the quality of life after attending balance exercise sessions. Moreover, clinical indicators as well as quantitative indicators, such as variables derived from force plate, are highly recommended to be taken simultaneously with clinical balance tests. Acknowledgments This article was extracted from the MSc thesis written by Seyedeh Azadeh Mansoriyan and supported by Shiraz University of Medical Sciences (proposal No. 6756). Hereby, the authors would like to thank the participants for contribution of their time and support to this study. They are also grateful for Ms. A. Keivanshekouh at the 108 The effect of balance training on clinical balance performance in obese patients

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