STUDY OF BALANCE TRAINING IN AMBULATORY HEMIPLEGICS

Transcription

1 The Indian Journal of Occupational Therapy : Vol. XXXVIII : No. 1 (April - July 2006) STUDY OF BALANCE TRAINING IN AMBULATORY HEMIPLEGICS *Snehal Bhupendra Shah, Co-Author : ** Smita Jayavant, M.Sc. (O.T.) Abstract : Objective : To study the effectiveness of balance training in ambulatory hemiplegics on stability trainer. Settings : Hospital based rehabilitation unit (Occupational Therapy Department) Materials and Equipments : Stability Trainers are oval shaped colour coded cell foam pad an anti slip ridged surface and oval foot fitting shape. It is available in 2 densities to provide a progressive system of balance training. 2 colours are Green with smaller surface are, firm density and more stable, Blue with larger surface area, soft ensity and less stable. Methods : 10 stroke patients (9 males, 1 female, 6 left hemiplegics and 4 right hemiplegics) between 40 yrs and 60 yrs and 60 yrs of age (mean 51.70) ranging between 4 mths to 180 mths post onset (mean 29.30) were included in the study. All subjects were community and functional ambulators. They were assessed on berg Balance Scale, Brunnstrom's stages of lower exteremity and routine functional evaluation. 14 exercises were performed on 6 challenge levels single green, single blue, green on green, blue on green, green on blue, blue on blue) of Stability Trainer depending on their performance. They were on weeks training programme. Results : After 4 weeks of training programme there was significant difference in pre and post assessment and training scores in balance. Improvement was seen on both affected and unaffected side. 2 patients stopped using their cane after the training programme. Conclusion : 1. Training on Stability Trainer in various postures, both static and dynamic, at appropriate challenge levels, helps to improve balance in ambulatory hemiplegics. 2. Training on stability Trainer can be generalized to functional activities such as ascending and descenfding staircase, going up and down ramp and walking on uneven surfaces. 3. Improvement in balance results in better patient satisfaction as they are socially more active. INTRODUCTION Stroke is one of the most common neurological disorders leading to chronic disability. It is an acute onset neurological dysfunction due to an abnormality in cerebral circulation with resultant signs and symptoms that correspond to involvement of focal areas of the brain. 5 Hemiplegia resulting from stroke has motor, sensory, balance, speech and perceptuo-cognitive deficits. Even if survivors of stroke are ambulatory, there is an increased risk of falling mainly on paretic side, difficulty in walking on uneven terrain and difficulty in using public transport. Bobath described, Walking as a constant losing and regaining of balance. * Occupational Therapist ** Lecturer (O.T.) Place of Study : All India Institute of Physical Medicine and Rehabilitation, Mumbai Period of Study : March July 2005 Correspondence : Dr. Snehal Bhupendra Shah 51, Avanti Apts, S.B. Marg, Dadar (W), Mumbai - 28 Tel. : / drsnehal3004@hotmail.com The recipient of Kailash Merchant Award for the Best Scientific Paper in Neurology presented in 43rd Annual National Conference of AIOTA at Aurangabad in January Balance is defined as a complex process involving the reception and integration of sensory inputs, planning and execution of movements, to achieve a goal requiring upright posture. 6 Hemiplegics have decreased trunk control, poor bilateral integration and impaired automatic postural control resulting in balance dysfunction. 3 Motor processes in balance control coordinate the action of trunk and leg muscles into discrete synergies that minimize sway and maintain the body s center of mass within its base of support. 16 Symmetry, steadiness and dynamic stability are three (3) elements of postural control. Impaired postural control is a key characteristic of the mobility problems in stroke patients and is caused by a complex interplay of motor, sensory and cognitive impairment thus leads to fall resulting in most common femoral neck fracture due to osteoporosis Sensory processes in balance control involve interaction among orientation inputs from somatosensory (proprioceptive, cutaneous and joints), visual and vestibular systems. 16 Proprioception is defined as interpreting stimuli originating in muscles, joints and other internal tissues that give information about the position of one body part in relation to another. (AOTA, 1994). Kinesthesia is defined as the perception of the direction and excursion of joint movement (AOTA, 1989).The ability to react to uneven 9

2 surfaces or changes in ground textures depends on this input and its impairment puts a patient at a higher risk of falling. 9 So for the hemiplegics to be really independent when moving around, the gait must be effective, safe and adaptable like walking on different terrains, to walk with other people around & avoid obstacles on the way. 4 Given this background of the dynamics of balance, postural control and adaptation and the deficits in these areas among ambulatory hemiplegics, it was postulated that the balance training in ambulatory hemiplegics on stability trainer may be a useful exercise and may result in better out comes of fall reduction and improved function. REVIEW OF LITERATURE Shin Chou (2003) in his study titled Postural control during sit to stand and gait in stroke patients. suggested that sit to stand and gait parameters correlated significantly with rising speed and maximal vertical force of both legs during rising. Tetsuo Ikai (2003) studied Dynamic postural control in hemiplegia and results indicated that hemiplegics tend to fall easily and risk of fall to paretic side is high. Maria Labi (1980) documented in her study that psychosocial factors and organic deficits are major determinants of psychosocial disability in physically restored long-term stroke survivors. Garland SJ, Willems (2003) reported that standing balance plays an important role in functional mobility after stroke. AIMS AND OBJECTIVES To study the effectiveness of balance training in ambulatory hemiplegics on stability trainer which results in better functional outcomes METHODOLOGY Balance dysfunction should be addressed in the treatment of independent ambulation, which is a prime area of concern in stroke rehabilitation. The study was conducted in the Department of Occupational Therapy, at All India Institute of Physical Medicine And Rehabilitation, on an outpatient basis, on a convenience sample. PARTICIPANTS: A total of 10 subjects (11 males, 1 female; 6 left hemiplegia, 4 right hemiplegia) secondary to unilateral cerebro vascular accident were tested. So finally 10 subjects (9 males, 1 female) were included for balance training. (Table 1) Subjects were of age ranging from 40 to 60 years (x = 51.7, S.D = 7.07) Times since the onset of hemiparesis ranged from 4 months to 180 months (x = 29.3, S.D = 53.89). Subjects were medically stable and their secondary illnesses such as hypertension and diabetes mellitus were under control. To qualify for this study hemiparetic subjects were required to meet the following criteria, 1) Understand instructions and be oriented to name, time and place. 2) No history of Orthopedic, Vestibular and other neurological conditions. 3) No perceptuo cognitive deficits like hemispatial neglect, attention, and memory deficits. 4) No wernicke s or global aphasia. 5) Voluntary movements at the hip, knee and ankle present at >3 of Brunnstrom s stages in affected lower limb. 6) Functional and community ambulators with or without ankle foot orthosis and cane. Before the investigation and assessment, the objectives and design of the study were explained to all subjects. All subjects gave informed consent and took part in the experiment on a voluntary basis. MATERIALS The materials used in the experiment included patients record sheets and stability trainers. Stability trainers are oval shaped color-coded closed cell foam It is available in two densities to provide a progressive system of balance training. Two colors are available the green which has a smaller surface area with firm density, more stable and Table 1 Sample characteristics No of Dropped Total No Males Female Left Right Mean Age Mean Duration of Pts. Out of Pts. Hemi Hemi in yrs. onset in mths

3 suitable for beginners, the blue which has a larger surface area with soft density, less stable and suitable for advance users. The stability trainer is used specifically to improve balance, postural stability proprioception and coordination. Research shows that balance training can reduce the incidence of falls in elderly. CLINICAL EVALUATION: Each participant underwent a clinical evaluation including the 1. Berg Balance Scale, 2. Brunnstrom s recovery stages of lower extremity 3. Routine functional evaluation. 1. Berg Balance Scale: Berg Balance Scale is a recommended assessment of balance for post stroke rehabilitation.the test consist of 14 balance items, common in everyday life and are graded on a five point scale ranging from 0 to 4, where 0 indicates the patients inability to perform the task & 4 represent independence. The test takes about 15 mins to administer & require only a watch & a ruler. 2. BRUNNSTROM RECOVERY STAGES OF LOWER EXTREMITY: It was the first systematic approach to the treatment of motor dysfunction after CVA. Following CVA resulting in hemiplegia, Brunnstrom observed that the patient progress through a series of recovery steps or stages in a fairly stereotypical fashion. Recovery may cease at any stage and is influenced by factors such as sensation, perception, cognition, motivation and concomitant medical problems. 3. FUNCTIONAL EVLAUATION: As Berg Balance Scale doesn t include the functional components, functional evaluation was added to see the effects of balance training. Functional evaluation includes, A = Ramp Up B = Ramp Down C = Staircase ascending (20 Steps) D = Staircase descending (20 Steps) E = Walking on uneven terrain (200 feet) Quality of gait that includes speed, balance, fear of falling, amount of assistance required were assessed. Functional evaluation was measured in terms of time and in terms of subjective rating of satisfaction. Subjective rating of satisfaction is divided into following four-point rating. Ratings are as follows, 0 = No Satisfaction 1 = 30% Satisfaction 2 = 70% Satisfaction 3 = >90% Satisfaction Subjective rating of satisfaction was selected as it measures patients perspective towards their level of independence and achievements as they all were ambulatory. Quality of life varied from person to person so subjective rating of satisfaction was used as all services are meant to increase quality of life. EXPERIMENTAL PROCEDURE: After completing the evaluation procedure, Balance training was provided on stability trainers, which has 4 green and 4 blue trainers. Stability trainers are oval shaped color-coded cell foam pads with anti slip-ridged surface. It s available in 2 densities, GREEN with smaller surface area and firm density, BLUE with larger surface area and soft density. Six levels of challenges in increasing order of difficulty were designed as follows, 1 = Only one Green stability trainer 2 = Only one Blue stability trainer 3 = Green on Green stability trainer 4 = Blue on Green stability trainer 5 = Green on Blue stability trainer 6 = Blue on Blue stability trainer A fix set of exercise was designed to be performed on the above-mentioned challenged level. Patient was evaluated to determine his level of functioning on the six-challenge level with each exercise performance. So each exercise will start from any one-challenge level and then proceed on to next level. It was a one-month protocol, 5 days for each challenge level. Patient can proceed on to next challenge level in <5 days if good performance is seen in terms of attaining and maintaining specific position. So all exercises will start at different challenge level and also end with different challenge level. 14 exercises are as follows, 1) Sit to stand 2) All four position 3) Kneel standing 4) Half kneeling 11

4 5) Standing 6) Bilateral calf raises 7) Unilateral standing with 90º knee flexion 8) Unilateral standing with hip in abduction 9) Unilateral standing with hip in adduction 10) Bilateral minisquats 11) Lunges 12) Step up 13) Walking 14) Spot marching All exercises were performed 5 times each and patients were allowed to take support whenever required. The training session lasted for about an average of 45 mins daily. All patients were on with other conventional therapy. DATA ANALYSIS AND RESULTS The data obtained from the experiment was then subjected to statistical analysis using student s paired t test, developed by W.S.Gosset. The student s paired t test is a parametric test and is applied to paired data of independent observations from one sample only when each individual gives a pair of observations. The student s paired t test is a parametric test and is applied to paired data of independent observations from one sample only when each individual gives a pair of observations. Table 2 BBS Score Mean Std. t test Significance Deviation (2-tailed) Pre Post S Table 2. shows mean scores on Berg Balance Scale pre training which was which changed to post training. On analysis, the difference in scores is significant at P < Table 3 Brunnstrom s Mean Std. t test Significance stages Deviation (2-tailed) Pre Post S Table 3. Shows statistical analysis on Brunnstrom s stages. Mean score on Brunnstrom s stages changed from 4.2 pre training to 4.6 post training so the difference in scores is significant at P < Table 4 Functional Mean Std. t test Significance Evaluation Deviation (2-tailed) A + B Pre A + B Post HS C + D Pre C + D Post HS E Pre E Post HS Table 4. shows combined mean values that is A + B, C + D, E as A & B are ramp up and down, C & D are staircase up and down and E is walking on uneven terrain. The mean score for A + B has changed from to , for C + D has changed from to and for E has changed from to On statistical analysis, the difference in scores is highly significance at P < Table 5 Functional Mean Std. t test Significance Evaluation Deviation (2-tailed) A + B Pre A + B Post HS C + D Pre C + D Post HS E Pre E Post HS Table 5. shows the statistical analysis where mean scores of A + B has changed from 2.8 to 4.8, of C + D has changed from 2.8 to 5.8, of E has changed from 1.6 to 2.5. The difference in scores is highly significant at P < Graph - 1 Comparison of Mean Scores of Subjective Rating of Satisfaction Before and After Balance Training. Mean score Functional Satisfaction A+B C+D E Pre Post

5 Mean score 0 Graph - 3 Comparison of Balance Before and After Training on Unaffected and Affected Side Expressed in Terms of Percentage 100% 80% 60% 40% 20% 0% A+B C+D E Pre Post Balance Unaffected Balance Pre Balance Affected Post Table 6 Paired Samples Test (N = 10, df = 9) Balance Intervention Mean Std. Deviation t test Significance (2-tailed) Unaffected Pre training Post training HS Affected Pre training Post training HS Table 6. shows that on statistical analysis, mean score for unaffected changed from to and for the affected it changed from to 85.80, thus stating that the difference is highly significant at P < Graph - 2 balance and there was significant difference between pre and Comparison of Mean Time Taken to Complete post scores on statistical analysis. Functional Evaluation Before and After Balance Training The difference seems to be due to 3 subtests that is standing Functional Evaluation on one leg, standing unsupported one foot in front and place alternate foot on step or stool while standing unsupported where subjects had lower score but for all other subtests, the score for all subjects was maximum that is So only these 3 subtests were sensitive to change in status; 50 the other tests being already at maximum level were unable to record progress. DISCUSSION Postural control, balance and functional mobility are the key focus areas for therapeutic intervention after stroke. Balance behavior is complex and is influenced by multiple factors. The primary goal of this study was to see effects of balance training in ambulatory hemiplegics which results in good functional outcome. 17 Berg Balance Scale (BBS) was used to assess patient s The Berg Balance Scale when used for such a sample may benefit from introduction of additional grades to be able to document change or introduction of a variety of supporting surfaces which will introduce the element of perturbation. 3 subtests exactly coincides with the 3 exercises in training on stability trainer, it may have resulted in higher post score on Berg Balance Scale due to the training effect. Change in the post training score on Berg Balance Scale is in agreement with the study by Garland, Willems in Recovery of standing balance and functional mobility after stroke where all subjects showed an improvement in functional balance (BBS) over the course of 1 month of rehabilitation resulting in an increased gait speed. 18 Brunnstrom s stages of lower extremity were evaluated on all patients prior to and after training. Only 4 out of 10 patients showed changed in stage after 4 weeks of training program. (3 patients changed from stage 4 to 5, 1 patient changed from stage 5 to 6). As Berg Balance Scale doesn t include assessment of ramp up and down, staircase up and down, walking on uneven terrain. So functional evaluation was included in this study. Functional evaluations are measured in terms of time in seconds and subjective rating of satisfaction. On statistical analysis there was significant difference between pre and post scores. Patients are not actually trained in terms of ramp up and down, staircase up and down, walking on uneven terrain, 13

6 but are trained for postural control, postural adaptation trunk alignment on stability trainer which has increasing order of destabilizing effect. So there is probably a transfer of learning, which refers to a person s ability to carry out the same task in a different environment. Most subjects in the study had sedentary lifestyles, had reduced social activity, could not fulfill their hobbies and interests, felt isolated from friends, were restricted to home due to fear of fall, could not use public transport, could not walk in crowded places which is supported by Maria labi, Philips in the study of psychosocial disability in physically restored long term stroke survivors. 15 After training, patients were more confident about their upright postures and its control, so became more social outside and inside home, and 2 discontinued use of cane. This is based on generalization, which occurs when the person is able to apply the newly learned strategy to a new task in a new environment. 3 Balance training for 1 month, on stability trainer had a significant difference in the scores obtained by the subjects both on unaffected and affected side. It is thought that training on stability trainer provided the patient with proprioceptive feedback at each challenge level. This is supported by the study Relationship of Sensory Organization to Balance Function in Patients with Hemiplegia by Richard Fabio, Mary Badke who found that balance behaviour can be influenced by somatosensory, visual and vestibular system. The study also says that in stroke, proprioception is often compromised which may lead to increased risk of falling and subsequent fear of falling. The results are also in agreement with the study by Anne Cook, Fay Horak on Assessing the Influence of Sensory Interaction on Balance which says that standing, walking, swaying and functional movements on foam may be practiced by patients as a therapeutic treatment approach to improve flexible use of all senses for postural control. 9 They also say that the preferred sensory input for the control of balance is somatosensory information from the feet in contact with support surface. Vision also contributes to providing inputs for postural correction. In one exercise i.e. sit to stand, patients took time to get up & then balance themselves on stability trainer & thus had a fear of fall which concurs with the study by Pao Tsai Cheng, Mei-Yun Liaw in sit to Stand Movement in Stroke Patients & its Correlation with Falling, which says that the stroke fallers had significant lower rates of rise in force thus greater postural sway which increases the risk of falling. 14 In all exercises, patients had to maintain position for few seconds with good postural control & alignment which was the deficit area in hemiplegics, supported by Ikai Kanni in the study Dynamic Postural Control in Patients with Hemiparesis which says that decreased postural stability is the common problem which increases the risk of falling on paretic side. 8 Trunk control allows the body to remain upright, to adjust to weight shifts, to control movement against the constant pull of gravity. The training protocol which provides increased postural & trunk control thus may have improved balance. During all training sessions, patients were given feedback about their posture, trunk alignment by the therapist. Patients simultaneously were getting intrinsic feedback from stability trainer. So it shows that feedback also can enhance or interfere with learning. Therapist had provided initially extrinsic feedback on performance which builds in their confidence but ultimately facilitated the development of intrinsic feedback. Intrinsic feedback which is received through their own senses helps them to incorporate self monitoring & self estimation enabling patients to create mechanism for self generated feedback. 3 Much more research is necessary to determine the precise consequences of cerebral lesions in the regulation of postural adjustments & movements. Because of the small size of the subject group & the variety of lesion, the results of this preliminary study are somewhat limited when attempting to generalize balance training in ambulatory hemiplegics. The most promising application of the study would be to implement balance training on stability trainer in the early phase of rehabilitation to provide a reduced risk of falling. CONCLUSION 1) Training on stability trainer in various postures both static and dynamic at appropriate challenge levels helps to improve balance in ambulatory hemiplegics. 2) Training on stability trainer can be generalized to functional activities such as staircase ascending and descending, going up and down ramp and walking on uneven surfaces. 3) Improvement in balance results in better patient satisfaction, as they are socially more active. ACKNOWLEDGMENT We would like to take this opportunity to thank Dr. B.D. ATHANI, Director A.I.I.P.M.R for permitting me to conduct the study in this institute. We wish to express our thanks and gratitude to 14

7 Mrs. PRATIBHA.V. REGE. Chief Occupational therapy Department for her valuable suggestions We sincerely thank all the Staff members of Occupational Therapy Department, A.I.I.P.M.R. for their support and help. Thanks to all friends for immense support and encouragement when we needed the most. We also thank all our subjects and their family members for their cooperation. REFRENCES 1. Occupational Therapy- Willard and Spackman s ; Helen Hopkin, 8 th Edition. J. P. Lippincott Company. 2. Occupational Therapy Practice Skills for Physical Dysfunction- Lorraine Williams Pedretti, 4 th Edition. MOSBY. 3. Occupational Therapy for Physical Dysfunction- Catherine A. Trombly, 5 th Edition. William and Wilkins. 4. Promoting Independence Following A Stroke WHO. 5. Physical Rehabilitation : Assessment and Treatment; Stroke Susan B. O Sullivan. 6. Neurological Rehabilitation Darcy A. Umphred, 4 th Edition. 7. Right in the middle Patricia M. Davies. 8. Ikai, Kanni. Dynamic postural control in patient with hemiparesis. Amer J Phys Med 2003 ; 82 ; Stroke rehabilitation Glen Gillen, Annburkhardt. 10. Adult Hemiplegia : Evaluation and Treatment Berta Bobath, 3 rd Edition. 11. Mirjam de Haart, MD Alexander C. Recovery of Standing Balance in Post Acute Stroke Patients. A Rehabilitation Cohort Study. Arch Phys Med Rehabil 2004 ; 85 : Au-Yeung SSY. Does Balance or Motor Impairment of Limbs Discriminate the Ambulatory Status of Stroke Survivors. Amer J Phys Med 2003 ; 82 : Chou SW Alice Wong. Postural Control during Sit to Stand and Gait in Stroke Patients. Amer J Phys MED 2003 ; 82 : Pao-Tsai Cheng, Mei-Yun Liaw. The Sit to Stand Movement in Stroke Patients and its correlation with Falling. Arch Phys Med Rehabil 1998 ; 79 : Marria Labi, Glen Gresham. Psychosocial Disability in Physically Restored Long Term Stroke Survivors. Arch Phys Med Rehabil 1980 ; 61 : Anne Cook, Fay Horak. Assessing the Influence of Sensory Interaction on Balance. Physical Therapy 1986 ; Richard Fabio, Mary Badke. Relationship of Sensory Organisation to Balance Function in Patients with Hemiplegia. Physical Therapy 1990 ; 70 : Garland, Willems. Recovery of Standing Balance and Functional Mobility after Stroke. Amer J Phys Med 2003 ; 84 : A.I.O.T.A. Membership Revised w.e.f. April 1, 2005 Subscription Details : Application Rs US $ (Overseas) Life Membership Rs Overseas Life Membership US $ (or equivalent to Indian Currency) Student Membership Rs (One time) Send your subscription by Demand Drafts only in favour of AIOTA, payable at Mumbai. Membership will only be released after approval of E.C. All correspondence regarding membership be referred to Dr. Mrs. Shashi Oberai, Hon. Treasurer, AIOTA, Tel. : , Mobile : , shashioberai@rediffmail.com The incentives for Student Members of the Recognised O.T. Education Programs, * Issues of the I.J.O.T. * Concession in the registration fees for the National Conferences of A.I.O.T.A. * Instant release of Life Membership after receiving the application and membership fee. 15