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Effect of Bobath Concept Combined with Task-Oriented Exercises on Improving Postural Stability in Chronic Stroke Patients: A Randomized Controlled Trial

Shreen I. Taha, Mahmoud Y.Elzanaty, Shaima M.Abdelmageed, Abdel El-Hamied I.El. Sherbini, Wanees M. Badawy
International Journal of Clinical and Experimental Neurology. 2018, 6(1), 8-11. DOI: 10.12691/ijcen-6-1-2
Received April 02; Revised May 06; Accepted May 16, 2018

Abstract

Background: Stroke patients often experience higher postural sway, asymmetry in weight distribution, and disrupted equilibrium reactions. Objective: To examine the effects of applying the Bobath concept combined with task-oriented exercises on improving postural stability in chronic stroke patients. Methods: 30 stroke cases randomly allocated to 2 groups as study & control. Study group which exposed to specific Bobath-based exercises plus task-oriented exercises while the control group received the task-oriented exercises only. Training regime was 3 times / week for 8 successive weeks. Outcome of training regime either Pre or post were: Berg Balance Scale, Timed Up and Go test and trunk and pelvis malalignment detecting by using Formetric II device. Results: Positive increasing in all measurments in both groups while study group seen better than control. Conclusions: It was suggested that combining both Bobath-based training and task-oriented exercises were beneficial in improving postural stability in chronic stroke patients.

1. Introduction

Postural instability in stroke patients was reported previously to increase liability to imbalance and gait deviations 1. As there is imbalance between the paralyised and unaffected sides which leads to malalignment of the spinal column 2. Movement performance especially during arbitrary activities depends on stable posture 3. The most influence contributor affecting stroke patients’ lack of participation in daily life activities is motor impairment. Stroke patients have higher postural sway, asymmetry in weight distribution, and disrupted equilibrium reactions 4.

Different approaches were applied in order to encourage stroke patients to increase their body weights on the affected side. These approaches concentrated on motor performance using task-oriented training 5, dual-task training 6, and proprioceptive neuromuscular techniques aiming to improve functional level or balance 7, 8, 9.

Bobath concept or neurodevelopmental treatment (NDT) is one of the preferred approaches for stroke rehabilitation 10. Proximal stability of the trunk is important for enhancing the movement of the head and the four peripheral extremities through increased co-contraction of the trunk flexors and extensor muscles 11, 12, 13.

Our aim is examine applying Bobath concept effects combined plus task-oriented exercises on improving postural stability in chronic stroke patients.

2. Methods

2.1. Selection of the Subjects

This study was conducted from April 10, 2016 to May 28, 2017. All cases were having stroke. Inclusion criteria of volunteers in our study were subjects who have illness duration of six months or longer, able to maintain a standing position without assistance for at least five minutes, capable of walk 10 m independently by use aid or orthotic with / without supervision or aid, and capable of go after simple verbal commands. Subjects with recurrent strokes, communication problems, and by orthopedic or neurological disorders other than strokes eliminated. The enrolled subjects consented to the content and purpose of this study. The study setup and protocol were approve by ethics committee, according to Declaration of Helsinki.

Finally 30 patients were selected and randomly assigned equally to either group I (the study group) received specific Bobath-based exercises plus task-oriented exercises or group II (the control group) who received the task-oriented exercises only. Schedules were computer using generated an basic random number generator. Subjects in both groups were involved in the exercises for 60 minutes per day; three days a week for eight consecutive weeks.

2.2. Interventions

The Bobath-based program that was applied is developed by Kılınc et al. 12 in form of: A: latissimus dorsi muscle stretching; B: functional use and latissimus dorsi strengthening; C: functional strengthening for abdominal muscles; D: placing exercises; F: trunk extended practicing rotations and counter-rotations of hips; G: lumbar spine stabilizers strengthening; H: shoulder functional reach, anterior, right, and left sides.

Task-oriented training used developed by Dean et al. 14. The training consists of: 1) sitting at a table and reach forward; 2) sit-to-stand from different chair heights; 3) step-ups with different heights; 4) heel lifts; 5) tandem walking; 6) treadmill; 7) walking over various surfaces and obstacles;(8) stairs climbing.

2.3. Outcome Measurements

1. BBS for assessment postural stability 15,

2. Timed Up and Go test for functional stability evaluation 16

3. Rasterstereography (DIERS Formetric II, Diers Medical Systems, Chicago, IL) was used for 3 dimensional quantification of posture 17.

2.4. Statistical Analysis

All data analyzed by SPSS / 19. Use non parametric tests such Wilcoxon Signed-ranks, Mann Whitney and Chi-squared tests. Using ANOVA one way for comparing between variables among groups. P < 0.05.

3. Results

There were no significant differences for age and gender or clinical variables at detected inclusion among groups. (Table 1)

No statistically differences were found in Initial measurements among groups were not differ significantly (Table 2), while all variables either pre or post training were differ significantly, results of study group clarified positive increasing in proportion comparing to control (Table 3 and Table 4).

4. Discussion

Postural stability improved in chronic stroke cases seen in our study. Bobath-based exercises when combined with the task-oriented training upgrade trunk functions and influenced on balance, walking abilities and posture correction. Even the control group who received the task-oriented training showed also significant improvement in the measured variables but gained less improvement than the study group.

Previously Bobath approach was studied by Langhammer and Stanghelle 18 in the acute stroke comparing it with motor relearning program (MRP) through practicing task-specific motor activities as sitting, standing, or walking. They found that MRP is preferable than Bobath based technique in the acute rehabilitation of stroke patients with no differences between the groups in the life quality in follow up after three months. Also Dean et al. 19 showed that stroke patients with duration of illness less than three months improved in sitting balance, reaching forward and standing up tasks within two weeks interventions. This can be explained by Swayne et al. 20 who reported that during the acute phase of stroke corticospinal integrity contributes poststroke recovery and changes in local motor cortex circuitry would influence on recovery potential. As continuous practicing in the acute phase of stroke helps relearning of lost motor function.

It was obvious in the initial measurements of all participants that stroke patients assume asymmetrical posture; trunk lateral flexion towards the hemiplegic side and anterior pelvic tilt. These postural deviations in stoke patients results from improper muscular activity associated with spasticity and weakness in the trunk and extremities. Coordination between proximal hip muscles and lower trunk muscles yields pelvic stability which is reflected on static and dynamic tasks 21.

Latissimus dorsi muscle is a huge muscle extends from the inferior 3-4 ribs, lower thoracic spine, all the lumbar spines and iliac crest to be inserted in the intertubercular groove of the humerus. Post-stroke latissimus dorsi become spastic causing pelvic elevation coronally and anterior tilting sagittally. In addition the trunk become laterally flexed, the shoulder adducted and internally rotated in the hemiplegic side. This abnormal activity of the latissimus dorsi muscle affects trunk control, balance and gait 22.

The Bobath-based exercises in combination with the task-oriented training reduced the imbalance between the hemiplegic musculature and the unaffected side. The more improvement seen in the measured outcomes can be attributed to improving trunk and lower extremity performance which could be seen in achieving good posture, balance, and walking 23.

5. Limitations

The study was limited to eight weeks intervention period and the long-term effect was not tested. Also the strength of trunk and lower extremities were not tested in this study.

6. Conclusions

In accordance to the present findings, it was suggested that combining both Bobath-based training and task-oriented exercises were beneficial in improving postural stability in chronic stroke patients. Future researches on larger randomized controlled trials are recommended to investigate the benefits of combining different physical therapy interventions in stroke rehabilitation.

References

[1]  Karatas M, Cetin N, Bayramoglu M, Dilek A. Trunk muscle strength in relation to balance and functional disability in unihemispheric stroke patients. Am J Phys Med Rehabil. 2004; 83(2): 81-87.
In article      View Article  PubMed
 
[2]  Brown SH, Vera-Garcia FJ, McGill SM. Effects of abdominal muscle coactivation on the externally preloaded trunk: variations in motor control and its effect on spine stability. Spine (Phila Pa 1976). 2006; 31(13): E387-E393.
In article      View Article  PubMed
 
[3]  Ahn S-N. Differences in body awareness and its effects on balance function and independence in activities of daily living for stroke. J Phys Ther Sci. 2018; 30(11): 1386-1389.
In article      View Article  PubMed
 
[4]  Sawacha Z, Carraro E, Contessa P, Guiotto A, Masiero S, Cobelli C. Relationship between clinical and instrumental balance assessments in chronic post-stroke hemiparesis subjects. Journal of NeuroEngineering and Rehabilitation. 2013; 10: 95.
In article      View Article  PubMed
 
[5]  Kim, Bo Hyun & Lee, Suk & Bae, Young & Yu, Jae & Kim, Tae. (2012). The Effect of a Task-oriented Training on Trunk Control Ability, Balance and Gait of Stroke Patients. Journal of Physical Therapy Science. 24. 519-522.
In article      View Article
 
[6]  Ghai S, Ghai I, Effenberg AO. Effects of dual tasks and dual-task training on postural stability: a systematic review and meta-analysis. Clin Interv Aging. 2017; 12: 557-577. Published 2017 Mar 23.
In article      View Article  PubMed
 
[7]  Hwangbo PN, Don Kim K. Effects of proprioceptive neuromuscular facilitation neck pattern exercise on the ability to control the trunk and maintain balance in chronic stroke patients. J Phys Ther Sci. 2016; 28(3): 850-853.
In article      View Article  PubMed
 
[8]  Sharma V, Kaur J. Effect of core strengthening with pelvic proprioceptive neuromuscular facilitation on trunk, balance, gait, and function in chronic stroke. J Exerc Rehabil. 2017; 13(2): 200-205. Published 2017 Apr 30.
In article      View Article  PubMed
 
[9]  Seo K, Park SH, Park K. The effects of stair gait training using proprioceptive neuromuscular facilitation on stroke patients' dynamic balance ability. J Phys Ther Sci. 2015; 27(5): 1459-1462.
In article      View Article  PubMed
 
[10]  Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence?. Stroke. 2009; 40(4): e89-e97.
In article      View Article  PubMed
 
[11]  Verheyden G, Vereeck L, Truijen S, Troch M, Lafosse C, Saeys W, Leenaerts E, Palinckx A, De Weerdt W. Additional exercises improve trunk performance after stroke: a pilot randomized controlled trial. Neurorehabil Neural Repair. 2009; 3(3): 281-86.
In article      View Article  PubMed
 
[12]  Kılınç M, Avcu F, Onursal O, Ayvat E, Savcun Demirci C, Aksu Yildirim S. The effects of Bobath-based trunk exercises on trunk control, functional capacity, balance, and gait: a pilot randomized controlled trial. Top Stroke Rehabil. 2016; 23(1): 50-58.
In article      View Article  PubMed
 
[13]  Cabanas-Valde´s R, Cuchi GU, Bagur-Calafat C. Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. NeuroRehabilitation. 2013; 33(4): 575-592.
In article      View Article  PubMed
 
[14]  Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000; 81(4): 409-417.
In article      View Article  PubMed
 
[15]  Blum L, Korner-Bitensky N: Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Phys Ther, 2008, 88: 559-566.
In article      View Article  PubMed
 
[16]  Morris S, Morris ME, Iansek R: Reliability of measurements obtained with the timed ‘up and go’ test in people with Parkinson disease. Phys Ther, 2001, 81: 810-818.
In article      View Article  PubMed
 
[17]  Zakaria Y, Rashad U, Mohammed R. Assessment of malalignment of trunk and pelvis in stroke patients. Egypt J Neurol Psychiat Neurosurg 2010; 47: 599-604.
In article      
 
[18]  Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clin Rehabil. 2000; 14(4): 361-369.
In article      View Article  PubMed
 
[19]  Dean CM, Channon EF, Hall JM. Sitting training early after stroke improves sitting ability and quality and carries over to standing up but not to walking: a randomised controlled trial. Aust J Physiother. 2007; 53(2): 97-102.
In article      View Article
 
[20]  Swayne OB, Rothwell JC, Ward NS, Greenwood RJ. Stages of motor output reorganization after hemispheric stroke suggested by longitudinal studies of cortical physiology. Cereb. Cortex. 2008; 18: 1909-1922.
In article      View Article  PubMed
 
[21]  Garland SJ, Gray VL, Knorr S. Muscle activation patterns and postural control following stroke. Motor Control 2009; 13: 387-411.
In article      View Article  PubMed
 
[22]  Li S, Francisco GE, Zhou P. Post-stroke Hemiplegic Gait: New Perspective and Insights. Front Physiol. 2018; 9: 1021. Published 2018 Aug 2.
In article      View Article  PubMed
 
[23]  Dubey L, Karthikbabu S, Mohan D. Effects of Pelvic Stability Training on Movement Control, Hip Muscles Strength, Walking Speed and Daily Activities after Stroke: A Randomized Controlled Trial. Ann Neurosci. 2018; 25(2): 80-89.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2018 Shreen I. Taha, Mahmoud Y.Elzanaty, Shaima M.Abdelmageed, Abdel El-Hamied I.El. Sherbini and Wanees M. Badawy

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Shreen I. Taha, Mahmoud Y.Elzanaty, Shaima M.Abdelmageed, Abdel El-Hamied I.El. Sherbini, Wanees M. Badawy. Effect of Bobath Concept Combined with Task-Oriented Exercises on Improving Postural Stability in Chronic Stroke Patients: A Randomized Controlled Trial. International Journal of Clinical and Experimental Neurology. Vol. 6, No. 1, 2018, pp 8-11. http://pubs.sciepub.com/ijcen/6/1/2
MLA Style
Taha, Shreen I., et al. "Effect of Bobath Concept Combined with Task-Oriented Exercises on Improving Postural Stability in Chronic Stroke Patients: A Randomized Controlled Trial." International Journal of Clinical and Experimental Neurology 6.1 (2018): 8-11.
APA Style
Taha, S. I. , Y.Elzanaty, M. , M.Abdelmageed, S. , Sherbini, A. E. I. , & Badawy, W. M. (2018). Effect of Bobath Concept Combined with Task-Oriented Exercises on Improving Postural Stability in Chronic Stroke Patients: A Randomized Controlled Trial. International Journal of Clinical and Experimental Neurology, 6(1), 8-11.
Chicago Style
Taha, Shreen I., Mahmoud Y.Elzanaty, Shaima M.Abdelmageed, Abdel El-Hamied I.El. Sherbini, and Wanees M. Badawy. "Effect of Bobath Concept Combined with Task-Oriented Exercises on Improving Postural Stability in Chronic Stroke Patients: A Randomized Controlled Trial." International Journal of Clinical and Experimental Neurology 6, no. 1 (2018): 8-11.
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[1]  Karatas M, Cetin N, Bayramoglu M, Dilek A. Trunk muscle strength in relation to balance and functional disability in unihemispheric stroke patients. Am J Phys Med Rehabil. 2004; 83(2): 81-87.
In article      View Article  PubMed
 
[2]  Brown SH, Vera-Garcia FJ, McGill SM. Effects of abdominal muscle coactivation on the externally preloaded trunk: variations in motor control and its effect on spine stability. Spine (Phila Pa 1976). 2006; 31(13): E387-E393.
In article      View Article  PubMed
 
[3]  Ahn S-N. Differences in body awareness and its effects on balance function and independence in activities of daily living for stroke. J Phys Ther Sci. 2018; 30(11): 1386-1389.
In article      View Article  PubMed
 
[4]  Sawacha Z, Carraro E, Contessa P, Guiotto A, Masiero S, Cobelli C. Relationship between clinical and instrumental balance assessments in chronic post-stroke hemiparesis subjects. Journal of NeuroEngineering and Rehabilitation. 2013; 10: 95.
In article      View Article  PubMed
 
[5]  Kim, Bo Hyun & Lee, Suk & Bae, Young & Yu, Jae & Kim, Tae. (2012). The Effect of a Task-oriented Training on Trunk Control Ability, Balance and Gait of Stroke Patients. Journal of Physical Therapy Science. 24. 519-522.
In article      View Article
 
[6]  Ghai S, Ghai I, Effenberg AO. Effects of dual tasks and dual-task training on postural stability: a systematic review and meta-analysis. Clin Interv Aging. 2017; 12: 557-577. Published 2017 Mar 23.
In article      View Article  PubMed
 
[7]  Hwangbo PN, Don Kim K. Effects of proprioceptive neuromuscular facilitation neck pattern exercise on the ability to control the trunk and maintain balance in chronic stroke patients. J Phys Ther Sci. 2016; 28(3): 850-853.
In article      View Article  PubMed
 
[8]  Sharma V, Kaur J. Effect of core strengthening with pelvic proprioceptive neuromuscular facilitation on trunk, balance, gait, and function in chronic stroke. J Exerc Rehabil. 2017; 13(2): 200-205. Published 2017 Apr 30.
In article      View Article  PubMed
 
[9]  Seo K, Park SH, Park K. The effects of stair gait training using proprioceptive neuromuscular facilitation on stroke patients' dynamic balance ability. J Phys Ther Sci. 2015; 27(5): 1459-1462.
In article      View Article  PubMed
 
[10]  Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence?. Stroke. 2009; 40(4): e89-e97.
In article      View Article  PubMed
 
[11]  Verheyden G, Vereeck L, Truijen S, Troch M, Lafosse C, Saeys W, Leenaerts E, Palinckx A, De Weerdt W. Additional exercises improve trunk performance after stroke: a pilot randomized controlled trial. Neurorehabil Neural Repair. 2009; 3(3): 281-86.
In article      View Article  PubMed
 
[12]  Kılınç M, Avcu F, Onursal O, Ayvat E, Savcun Demirci C, Aksu Yildirim S. The effects of Bobath-based trunk exercises on trunk control, functional capacity, balance, and gait: a pilot randomized controlled trial. Top Stroke Rehabil. 2016; 23(1): 50-58.
In article      View Article  PubMed
 
[13]  Cabanas-Valde´s R, Cuchi GU, Bagur-Calafat C. Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. NeuroRehabilitation. 2013; 33(4): 575-592.
In article      View Article  PubMed
 
[14]  Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000; 81(4): 409-417.
In article      View Article  PubMed
 
[15]  Blum L, Korner-Bitensky N: Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Phys Ther, 2008, 88: 559-566.
In article      View Article  PubMed
 
[16]  Morris S, Morris ME, Iansek R: Reliability of measurements obtained with the timed ‘up and go’ test in people with Parkinson disease. Phys Ther, 2001, 81: 810-818.
In article      View Article  PubMed
 
[17]  Zakaria Y, Rashad U, Mohammed R. Assessment of malalignment of trunk and pelvis in stroke patients. Egypt J Neurol Psychiat Neurosurg 2010; 47: 599-604.
In article      
 
[18]  Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clin Rehabil. 2000; 14(4): 361-369.
In article      View Article  PubMed
 
[19]  Dean CM, Channon EF, Hall JM. Sitting training early after stroke improves sitting ability and quality and carries over to standing up but not to walking: a randomised controlled trial. Aust J Physiother. 2007; 53(2): 97-102.
In article      View Article
 
[20]  Swayne OB, Rothwell JC, Ward NS, Greenwood RJ. Stages of motor output reorganization after hemispheric stroke suggested by longitudinal studies of cortical physiology. Cereb. Cortex. 2008; 18: 1909-1922.
In article      View Article  PubMed
 
[21]  Garland SJ, Gray VL, Knorr S. Muscle activation patterns and postural control following stroke. Motor Control 2009; 13: 387-411.
In article      View Article  PubMed
 
[22]  Li S, Francisco GE, Zhou P. Post-stroke Hemiplegic Gait: New Perspective and Insights. Front Physiol. 2018; 9: 1021. Published 2018 Aug 2.
In article      View Article  PubMed
 
[23]  Dubey L, Karthikbabu S, Mohan D. Effects of Pelvic Stability Training on Movement Control, Hip Muscles Strength, Walking Speed and Daily Activities after Stroke: A Randomized Controlled Trial. Ann Neurosci. 2018; 25(2): 80-89.
In article      View Article  PubMed