The Effect of Swiss Ball Therapy On Sit-To-Stand Function, Paretic Limb Weight Bearing and Lower Limb Motor Score in Patients With Hemiplegia

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Int J Physiother.

Vol 4(6), 319-323, December (2017) ISSN: 2348 - 8336

ORIGINAL ARTICLE
THE EFFECT OF SWISS BALL THERAPY ON SIT-TO-STAND
IJPHY
FUNCTION, PARETIC LIMB WEIGHT BEARING AND LOWER LIMB
MOTOR SCORE IN PATIENTS WITH HEMIPLEGIA
¹ Vadnagarwala Rasheeda
*2 Ramachandran Sivakumar

.
Methods: First-time stroke patients with hemiplegia were recruited from an acute stroke care set up in a University
teaching hospital and assigned to control (n=34) and experimental group (n = 33). Along with physiotherapy based
on impairments, patients in control group were trained for sitting to standing and sitting activities on a stool, and
from in the experimental group were trained with Swiss Ball. Both the groups underwent 40 minutes of training for
ten days. 30-second sit to stand, Percentage of weight bearing through the paretic limb and Brunnstrom stages were
recorded. Parametric and non-parametric tests were used based on the outcome tested.
Results: The baseline characteristics between the groups were similar statistically. Post-intervention experimental
group had better weight bearing ability and motor control of lower limb (p<0.05), than the control group. The differ-
ence in 30-second sit to stand did not reach statistical significance (p=0.059).
Conclusion: Training with Swiss ball results in greater improvement in weight - bearing ability and motor control of
paretic lower limb, compared to conventional training. The Swiss ball training does not enhance the sit to stand per-
formance more than conventional training.
Keyword: Hemiplegia, sit to stand, Swiss ball, Rehabilitation, Brunnstrom stages.

Received 19th August 2017, revised 28th November 2017, accepted 07th December 2017
Ethical clearance: University ethical committee (REF: CSP/11/AUG/18/50)

10.15621/ijphy/2017/v4i6/163917

www.ijphy.org
CORRESPONDING AUTHOR
*2 Ramachandran Sivakumar
Professor of Physiotherapy, Faculty of
¹Postgraduate research scholar, Faculty of Physiotherapy, Sri Ramachandra Medical
Physiotherapy, ri Ramachandra Medical College College and Research Institute (DU), Chennai,
and Research Institute (DU), Chennai, India. India**. email: rsivkumar@gmail.com
This article is licensed under a Creative Commons Attribution-Non Commercial 4.0 International License.

Int J Physiother 2017; 4(6) Page | 319


INTRODUCTION admitted to the stroke ward of inpatient facility of univer-
Instability Resistance training (IRT) is a new concept in sity teaching hospital was screened for inclusion criteria.
sports training and fitness regimes. IRT involves train-ing on Patients who met the following criteria were included: (1)
an unstable surface with the resistance offered by body mass first ever ischemic stroke; (2) presence of hemiplegia or pa-
or external objects such as dumb-bells [1]. This concept is resis; (3) within 5 days post stroke; (4) comprehension ad-
widely used in healthy individuals and sports personals. The equate to understand the command , (5) able to maintain
efficacy of this concept in the rehabilitation of neurological sitting on a stool; (6) able to stand for 30 seconds without
conditions is less studied. Studies related to use of unstable support; (7) orthopaedic problems in lower limbs, cardio-
surfaces is more in the rehabilitation of stroke than other pulmonary problems and any other neurological problems
conditions. The Swiss ball is common-ly used unstable limiting their sit to stand performance; (8) able to perform
surface in stroke rehabilitation. Effect of Swiss ball on trunk less than 3 sit to stand in 30 seconds; and (9) having lower
control and postural stability is widely studied and reported limb motor control in Brunnstrom stage 3 or less. Patients
to be effective in improving the pos-tural control in sitting who met inclusion criteria were randomly assigned to con-
[2-4]. Karthikbabu et al. (2011) state that trunk exercises trol group (n = 36) and experimental group (n = 38) using
performed on a Swiss ball is more ef-fective than exercises block randomization.
performed on a plinth in improving trunk control and Figure 1: Consort flow chart
functional balance in acute stroke pa-tients [2].
Literature by Davies (1990) and Carrière (2012) explores
the use of Swiss ball in improving various functions after
stroke [5,6]. However, the effect of Swiss ball training on
functions other than postural control in a sitting is not
clear from literature. In this study, we aimed to study the
effect of Swiss ball training on sit to stand performance,
weight bearing through the paretic lower limb and lower
extremity motor control. Earlier studies state that lower
extremity contributes to the postural control in sitting.
Dean et al. (1997) reported that sitting and reaching in pa-
tients with stroke facilitated lower extremity muscle con-
traction and weight bearing [7]. The study also revealed
an improvement in sit to stand performance, though it is
not part of the training. The authors state that
biomechanical similarities between reaching task and
early phase of sit to stand would have resulted in a
positive change in sit to stand in the study population. We
hypothesized that sitting activity on Swiss ball would
have a greater impact on lower limb muscle control and
thereby lower extremity function compared to a
conventional training on stable surfaces like stool.
The 30-second sit to stand the test, Brunnstrome stage of
motor recovery and weight bearing measured with weigh-
ing scale were considered as outcome measures for the
study. 30-second sit to stand is a commonly accepted tool PROCEDURE
for evaluation of the functional ability of lower body [8-
10]. We used it because it is an easy bedside examination Patients in both the group received conventional physio-
for sit to stand performance. Brunnstrom stages of motor therapy based on motor learning concept advocated by
recovery were widely accepted and used to group patient Carr and Shepherd, (2002) [15]. All the patients received
based on their motor control [11-14]. Using these 40 minutes physiotherapy session for ten days. Patients
outcome measures the study was aimed to identify the were blinded by the difference in the treatment provided.
effect of Swiss ball training on sit to stand performance, The first researcher handled the therapy sessions.
weight bearing through paretic extremity and motor The conventional physiotherapy was designed to improve
control of paretic ex-tremity. paretic lower extremity control with isolated lower ex-
MATERIALS AND METHODS tremity muscle contractions in supine and side-lying po-
sitions, turning in bed, supine to sitting, and weight shifts
Study design and setting
in sitting. In addition to these training sitting to in stand-
The study was approved by ethics committee of Sri Ram- ing training was given to both the group. The patients in
achandra University (CSP/11/AUG/18/50). Stroke patients control group received sit to stand training and sitting
activities using a stool, and experimental group received
Int J Physiother 2017; 4(6) Page | 320
sit to stand training and sitting activities using Swiss ball. test values. Post-training sit to stand number between the
The experimental group patients were not given training in groups did not reach statistical significance (p = 0.059).
stool in addition to Swiss ball to avoid additive effects of Table 1: Patient profile
training. In control group, the height of the stool was
Control group Experimental group
adjusted to have hip and knee in 90 degrees in sitting, with
Age(mean yrs, SD) 53 (8.9) 55 (9.1)
foot on the floor. Patients were trained to sit symmetrically,
Male 27 28
reach beyond arm’s length with normal and affected upper
Female 7 5
extremity in different directions, and sit to stand. Patients in
Right hemiplegia 18 18
the experimental group were given training with a Swiss
Left hemiplegia 16 15
ball. The exercise methods were chosen from earlier liter-
ature from Davies, (1990), Carrière (2012) and Karthikba-bu Table 2: Pre and post training values in control and
et al., (2011) [2,5,6]. Patients were trained to maintain the ex-perimental groups (Mean and SD)
sitting on the Swiss ball, reaching beyond arm’s length with * Independent t test, significant p≤0.05
normal and affected upper extremity in different di-rections,
Control Experimen-
controlling the ball in anteroposterior and later-al directions, Variables group tal group
and sit-to-stand training from the ball. The intensity of (n=34) (n =33)
training was increased using one or more of the following No. of STS/30 sec-
Difference
method: (1) reducing the manual guidance, between the p
onds, Mean(SD)
groups
(2) increasing the number of movement performed (3) in-
Pre training 1.5 (0.86) 1.39 (0.93) 0.13 0.539
creasing the limits of balance. Post training 5(1.4) 6(1.4)* 0.64 0.059
Outcome measures: % of weight
30-second sit to stand test, weight bearing through the pa- through paretic
lower limb,
retic lower limb and Brunnstrom stage of motor control in Mean (SD)
lower limb were the outcome measures in the study. The Pre training 26.62 (9.09) 29.56 (9.91) 2.89 0.216
second author (S.R) recorded the outcomes at first eval- Post training 34.73 (9.2) 40.48 (9.2) 5.75 0.013*
uation done during the time of inclusion into the study and
Weight bearing through paretic extremity improved in
after ten sessions of physiotherapy. Weight-bearing was
both the groups (Table 2). The improvement in the
measured by two weighing scale, one under each foot. The
experi-mental group was greater than the control group
total weight of the patient was calculated by adding the
(p=0.01). The mean difference between the groups was
weight recorded in both weighing scale and percentage of
5.75 %. The 95% confidence interval for the difference in
weight through paretic lower limb was derived.
the percent-age of weight shift between groups was
The number of sit to stand and percentage of weight bear-
1.27% to 10.23%. Effect size calculated with Cohen’s D
ing through paretic limb within and between the groups
(0.62) showed a mod-erate effect size.
were tested with independent and paired t-test respective-ly.
After the training patients who recovered isolated move-
Motor stage of lower extremity was dichotomized as good
ments out of synergy in the lower extremity (Brunnstrom
(stage 4 and above) and poor control (below stage 4).
stage 4 and above) in the experimental group was more
Brunnstrom stage 4 denotes the presence of isolated move-
compared to the control group. The difference reached sta-
ments and decrease in abnormal synergy. The data was
tistical significance (Fisher’s exact test, p = 0.002). Table 2
tested with Fisher’s exact test. Effect of side of hemiplegia
shows a number of patients in different Brunnstrom stages
on sit to stand performance and percentage of weight bear-
in control and experimental group. The side of hemiple-gia
ing in the post-training period was tested using unpaired t-
did not influence a number of sit to stand (p =.86) and
test. Alpha was set at 0.05 for statistical testing.
weight bearing through paretic lower extremity (p=.06).
RESULTS Statistical analysis was done using Openstat program.
Thirty-four patients in control group (out of 36) and thir- Table 3: Brunnstrom stage distribution in control and
ty-three patients in experimental group (out of 38) com- experimental group
pleted the study. Two patients in control group and three experimental
in experimental group discharged ahead of the control group group
completion of therapy sessions. Two patients in the (n = 34) (n = 33)

experimental group reported knee pain during the study,


Brunnstrom Pre post Pre post
hence excluded from the study.
stage of lower training training training training
In pre-training period patients in both the groups were limb# n, (%) n, (%) n, (%) n, (%)
similar statistically in 30-second sit to stand the test, the 1 14 (41%) 1 (3%) 8 (24%) 0
2 15 (44%) 2 (6%) 16 (48%) 0
percentage of weight bearing and Brunnstrom stage of the 3 5 (15%) 10 (29%) 9 (28%) 2 (6%)
paretic lower limb. Patients in control and experimental 4 0 16 (47%) 0 15 (45%)
group improved in 30-second sit to stand the test. Table 2 5 0 5 (15%) 0 16 (48%)
6 0 0 0 0
shows pre and post-intervention 30 seconds sit to stand

Int J Physiother 2017; 4(6) Page | 321


# 1- minimal movement, 2 – weak synergy, 3 – strong reaching activities. Though both groups showed statistical-
syn-ergy, 4 to 6 – synergy decreases and isolated ly significant improvement, Swiss ball training would have
movements improves provoked greater activity in the lower limb, as demand for
DISCUSSION postural control over the unstable surface will be greater
than the stable surface. The motor control based on Brunn-
The training with Swiss ball resulted in a statistically sig-
strom stage improved in both the group. Ninety-three per-
nificant difference in the percentage of weight transfer
cent of the patients in the experimental group showed iso-
through paretic lower extremity and lower extremity mo-tor
lated movements out of synergy in the experimental group,
control, compared to conventional training. Though 30-
whereas in control group 63% of the patients had isolated
second sit to stand performance improved in both the
movements in paretic lower extremity. The Brunnstrom
groups, the difference did not reach statistical significance.
stage 4 denotes a decrease in spasticity and recovery of iso-
Five-second sit to stand test was commonly used in the
lated motor control. The results of this study show Swiss
stroke population. Thirty-second sits to stand test was de-
ball therapy may be effective in normalizing the muscle
veloped as a measure of functional lower extremity strength
tone; hence resulting in the early development of normal
in older adults and to overcome the floor effect of the five
motor control. Controlling the Swiss ball movement in sit-
times sit to stand test [16]. This test measures the ability of
ting would have forced the use paretic lower limb resulting
the individual to rise to stand as many times as possi-ble,
in a better outcome in motor control in the experimental
reflecting their ability to control their lower extremity
group than control group. During literature review studies
muscles adequately, and also their ability to control the rate
on the impact of unstable surface sitting training on lower
of force production in the muscles. Minimally important
extremity muscle control following stroke was hard to find,
clinical improvement(MCID), identified for 30 seconds sit
to compare the outcome of this study.
to stand is equal to or greater than two repetitions of sit to
Use of unstable surface has been recognized as a tool to im-
stand [17]. In the present study, 98% of patients in control
prove strength and coordination in sports (1). Though the
and experimental group had shown an increase of sit to
use of unstable surface has been part of the rehabilitation of
stand repetitions more than two. The result of this study
neurological conditions, studies evaluating its efficacy are
shows that training with both stable and unstable surfaces
scarce. Patricia Davies (1990) in her literature advocates
resulted in clinically relevant improvement in sit to stand
Swiss ball as a therapeutic aid in improving the lower limb
performance. Dean & Shepherd (1997) evaluated the effect
control and trunk control in hemiplegics (5). The evidence
of sitting activities on the stable surface on sit to stand per-
related to use of unstable surfaces is limited compared to
formance and concluded that such training had a positive
effect on sit to stand [7]. We could not identify literature on other forms of interventions in stroke rehabilitation [22].
training with an unstable surface such as Swiss ball on sit to The present study could not prove the superiority of reha-
stand performance. The Cochrane review on interventions bilitation program with Swiss ball as a therapy aid in im-
for sit to stand did not list Swiss ball as a therapy aid [18]. proving sit to stand performance compared to a rehabil-
itation program without Swiss ball as a therapy aide. The
The weight bearing through paretic limb improved in both
the group. The Swiss ball therapy resulted in a better out- positive effect of Swiss ball on improving weight bearing
come. Dean et al. (1999) studied the relationship between ability through the paretic limb and motor control in lower
reaching in sitting and lower extremity contribution to the extremity can be supportive evidence identified for its use.
activity [19]. They concluded that vertical ground reac-tion The study was done with acute stroke patients, where the
force and electromyographic data demonstrated the spontaneous recovery can result in clinical improvement,
contribution of lower limb for reaching in a sitting. Kim et apart from treatment effect [23]. The therapy period was ten
al. (2015) found a correlation between lower extremity sessions in this study, though it seems to be shorter for a
muscle activity and forward reaching task [20]. Catherine M clinical change, we identified similar short-term training
Dean et al. (2007) reported that two weeks of sitting training resulting in significant change [7,24]. However, a longer
involving reaching beyond arm’s length, improved the peak training program can add value to the results of the similar
vertical ground reaction force under the paretic lower study. Future studies in a different stage of the post-stroke
extremity by around 13% of body weight [21]. These studies period or a long-term follow-up may provide more details
reveal the role of the lower extremity in maintain-ing on the effect of training with unstable surfaces like Swiss
postural control during sitting activities. In the present study, ball on sit to stand function, weight bearing and motor
there was a mean increase of around 8% and 10% weight control. Future studies adding information on lower ex-
transference through paretic extremity in exper-imental tremity muscle activity using electromyography can be of
group and control group respectively. The effect size value to know the impact of Swiss ball therapy in sitting on
calculated was moderate, supporting the effectiveness of the facilitation of lower extremity muscle activity.
therapy on weight shifting ability. These findings suggest CONCLUSION
that sitting training improved the weight bearing through The present study did not provide support for the superi-
paretic lower extremity, as the lower extremity is forced to ority of Swiss ball training in the stroke rehabilitation in
become a part of postural control system during improving sit to stand function. However, use of Swiss

Int J Physiother 2017; 4(6) Page | 322


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Citation
Rasheeda, V., & Sivakumar, R. (2017). THE EFFECT OF SWISS BALL THERAPY ON SIT-TO-STAND
FUNCTION, PARETIC LIMB WEIGHT BEARING AND LOWER LIMB MOTOR SCORE IN PATIENTS WITH
HEMIPLEGIA. International Journal of Physiotherapy, 4(6), 319-323.
Int J Physiother 2017; 4(6) Page | 323

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