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Research Article | Open Access2024|Volume 2|Issue 1| https://doi.org/10.37191/Mapsci-JRPM-2(1)-020

Comparative Study to Assess the Effect of Gaze Stability Exercises and Perturbation Based Balance Exercises on Balance for Stroke Patients

Rakshith BR1* and Prem Kumar BN2

1Post-Graduate Student, Kempegowda Institute of Physiotherapy, Bengaluru

2Associate Professor, Kempegowda Institute of Physiotherapy, Bengaluru

*Corresponding Author: Rakshith BR, Post-Graduate Student, Kempegowda Institute of Physiotherapy, Bengaluru.

ReceivedApr 1, 2024RevisedApr 19, 2024AcceptedApr 25, 2024PublishedMay 10, 2024
Abstract

Background: Impairment in perception of sensory input disturbs static and dynamic balance in patients with stroke. Gaze stability exercises and perturbation-based balance exercises (PBBT) have shown results in improving balance and reducing risk of falls. However, the effect of these interventions has not been assessed and compared for balance in stroke patients. This study aims to assess and compare the effect of gaze stability exercises and PBBT for balance in stroke patients.

Methods:  Forty stroke patients were recruited in the study. Patients were divided into group A and group B and they received gaze stability exercises and PBBT respectively. Berg Balance Scale (BBS), Timed Up and Go test (TUG) and Stroke Impact Scale (SIS) were the outcome measures. The pre and post intervention scores were recorded and assessed respectively.

Results: The analysis of BBS, TUG and SIS showed improvement in both group A and group B with p<0.05 significance. In comparison to Gaze stability exercises group and PBBT group, both performance oriented and clinical measures of balance was better improved in PBBT group than in gaze stability group (8.55 ± 6.85 and 5.10 ± 5.67 respectively) and (2.7 ± 5.43 and 1.15 ± 4.32 respectively) with respect to the scores of BBS and TUG respectively. Health- related quality of life improved better in PBBT group than in gaze stability group (15.45 ± 11.54 and 7.4 ± 9.11 respectively) with respect to the scores of SIS.

Conclusion: Gaze stability exercises and PBBT are effective for balance training and improving health- related quality of life in patients with stroke. However, in this study PBBT showed better results for balance and health-related quality of life in patients with stroke in comparison to Gaze stability exercises.

Keywords

Stroke, balance, Gaze stability exercises, PBBT

Introduction

Acute ischemic stroke, due to occlusion of blood vessels, has inability to maintain static and dynamic balance results in balance disorders [1-4]. Muscle weakness, paralysis, damage to the areas of the brain that control balance leading to Loss of balance [3,4]. Stroke also leads to increased postural instability [5]. The vestibular system controls postural stability [5].

Chronic motor impairments and limitations in activities of daily living are observed in 41- 45% of patients with stroke [6]. Gaze stability exercises have been found to resolve the sensory mismatch among visual, vestibular, and somatosensory inputs being beneficial for postural control in stroke patients [5]. PBBT during stroke rehabilitation has shown improvement in reactive balance responses, performance-based measures of balance [7]. Gaze stability exercises and PBBT have shown results in improving balance in patients with stroke. However, the effect of Gaze stability exercises and PBBT are not compared. Hence, the current study aimed to assess and compare the effect of gaze stability exercises and PBBT for balance in stroke patients.

Materials and Methods

The study was conducted in KIMS hospital, Bengaluru. 40 stroke patients who met the inclusion criteria were randomly divided into two groups. performance oriented and clinical measures of balance in Ischemic Stroke patients were assessed by BBS and TUG respectively and health-related quality of life was assessed by SIS [8,9] on the first day of treatment and the end of 4th week.

Ischemic Stroke patients within 45 days of occurrence, with a score of 26 points or higher of the Montreal cognition assessment, positive Romberg test and having the ability to walk at least 3 meters alone with or without an assistive device were included. Subjects with terminal illness or medically unstable, severe cardiopulmonary disease, visual and auditory disorders, perceptual and cognitive deficits, balance impairment and orthopedic or any other neurological disorders which impair balance were excluded in study.

Group A patients received Gaze stability exercises and Group B patients received PBBT. The patients of both groups received conventional exercises such as active assistive exercises, active exercises, resistive exercises, exercises in different functional positions, weight bearing exercises, weight shifting exercises, reaching exercises in sitting, standing. The treatment lasted for 45 minutes per day, 5 days per week, for 4 weeks.

Results

The baseline characteristics of subjects were analysed. The mean age of Group A was 57.3 and Group B 56.9, with standard deviation of 10.15 and 10.2 respectively. The Z value and P value of the age group was 0.54 and 0.82 respectively (Table 1 and Fig.1). Group A included 17 male subjects (85%) and 3 female subjects (15%), and Group B included 16 male subjects (80%) and 4 female subjects (20%) (Table 2 and Fig.2).

Group A-Gaze stability Exercise

Group B-Manual Perturbation Exercise

Z value (Mann Whitney U test)

P Value

Age

Mean

57.35

56.9

0.54

0.82

SD

10.15

10.2

Table 1: Distribution of subjects based on age in both the groups. P<0.005 is statistically (Shapiro Wilkinson Test, p<0.05).

Picture 1.png

Figure 1: Distribution of subjects based on age in both the groups.

Group A Gaze Stability Exercise

Group B Manual Perturbation Exercise

X2 Value

P Value

Gender

Male

17(85%)

16(80%)

0.29

0.83

Female

3(15%)

4(20%)

Table 2: Distribution of subjects based on gender in both the groups. *P<0.005 is statistically significant.

Picture 2.jpg

Figure 2: Distribution of subjects based on gender in both the groups.

The analysis of BBS, TUG and SIS showed improvement in both group A and group B with p<0.05 significance. The PBBT group than the gaze stability group showed better improvement in performance-oriented measures of balance in accordance with BBS with the standard deviation of 8.55 ± 6.85 and 5.100 ± 5.67(Table 3 and Fig.3) respectively, clinical measures of balance with the standard deviation of 2.7 ± 5.43 and 1.15 ± 4.32 (Table 4 and Fig.4) respectively and Health-related quality of life with the mean difference and standard deviation of 15.45 ± 11.54 and 7.4 ± 9.11 (Table 5 and Fig.5) respectively between Pre and Post test. Data was analysed using the statistical package SPSS 26.0 (SPSS Inc., Chicago, IL) and level of significance was set at p<0.05.

Group A-Gaze stability Exercise

Group B- Manual Perturbation Exercise

Z value (Mann Whitney U Test)

P Value

Berge balance Scale

PRE

34.15 ± 5.85

33.2 ± 7.15

0.56

0.77

POST

39.05 ± 6.27

41.75 ± 6.20

1.96

0.16

Z Value

2.55

4.04

 

P value (Wilcoxon Pair Test)

0.0001*

0.0003*

Difference

5.10 ± 5.67

8.55 ± 6.85

Table 3: Comparison of Berg Balance Scale (For 54 Points). *P<0.05 is statistically significant (Shapiro Wilkinson test, p<0.05).

Picture 3.png

Figure 3: Comparison of berg balance scale.

Group A-Gaze Stability Exercise

Group B-Manual Perturbation exercise

Z value (Mann Whitney U Test)

P Value

Timed Up and Go Scale

PRE

21.05 ± 4.38

21.95 ± 5.08

0.49

0.69

POST

19.9 ± 4.77

19.25 ± 5.40

0.25

0.77

Z value

0.79

1.62

P value (Wilcoxon Pair test)

0.43

0.11

Difference

1.15 ± 4.32

2.7 ± 5.43

Table 4: Comparison of Timed Up and Go scale (seconds). *P<0.05 is statistically significant (Shapiro Wilkinson test, p<0.05).

Picture 4.png

Figure 4: Comparison of timed up and go scale.

Group A- Gaze Stability Exercise

Group B-Manual Perturbation Exercise

Z value (Mann Whitney U Test)

P value

Stroke Impact Scale

PRE

54.95 ± 9.08

55.75 ± 12.54

1.86

0.06

POST

62.35 ± 9.36

71.2 ± 9.24

0.8

0.42

Z Value

2.53

4.41

P value (Wilcoxon pair Test)

0.01*

0.0001*

Difference

7.4 ± 9.11

15.45 ± 11.54

Table 5: Comparison of Stroke impact scale (%). *P<0.05 is statically significant (Shapiro wilkinson test, p<0.05).

Picture 5.png

Figure 5: Comparison of stroke impact scale (%).

Discussion

Stroke alters the weight distribution and loading on affected and unaffected lower limbs, followed by loss of balance [10,11]. complex integration and coordination of multiple body systems includes the vestibular, visual, auditory, motor, and higher-level premotor systems achieves balance [12]. Gaze stability exercises, the adaptation exercises to modify the magnitude of the vestibulo-ocular reflex (VOR) of the vestibular system are found to be effective for postural stability and dynamic visual acuity [13,14]. PBBT, a task specific intervention improves reactive balance control after loss of balance in a safe and controlled environment [7,15]. A randomized control study (2018) showed that gaze stability exercises are a short-term intense rehabilitation help resolve the sensory mismatch among visual, vestibular, and somatosensory inputs [5]. A randomized controlled trial (2021) has results which show that gaze stability exercises are efficient strategies to improve balance and reduce the risk for falls in patients with stroke [16]. A single-subject design study (2011) concluded that PBBT improved time to stabilization, improved balance and reduced the risk for falls [17]. The present study was done to assess and compare the outcomes of Gaze stability exercises and PBBT.

The present study was done on 40 stroke subjects randomly divided into two groups. Patients were assessed with BBS, TUG and SIS to evaluate performance-oriented measure of balance, clinical measure of balance and health-related quality of life respectively.

Gaze stability exercises and PBBT being for balance training, PBBT showed better results for balance and health-related quality of life in patients with stroke in comparison to Gaze stability exercises.

This study could provide better evidence with a greater sample size. The inclusion of Brunnstrom stages of recovery would have given a clear result of the interventions applied. Since the interventions were administered at the acute stage of stroke, further studies can be done on chronic stroke patients.

Conclusion

This study intended to assess and compare the outcomes of Gaze stability exercises and PBBT. Improvement was shown in both the groups. Greater improvement in performance- oriented measure of balance, clinical measure of balance and health-related quality of life was observed in patients who received PBBT than in those who received Gaze stability exercises.

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