Three-Dimensional Balance Training Using Visual Feedback on Balance and Walking Ability in Subacute Stroke Patients: A Single-Blinded Randomized Controlled Pilot Trial

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Abstract

Background: Trunk-activating exercises for balance are important because trunk weakness is relevant to the functional performance of individuals with stroke. This study aimed to explore the effects of three-dimensional balance training using visual feedback on balance and walking ability in subacute stroke patients. Methods: Twenty-four participants with subacute stroke were randomly assigned to the experimental or control group. Each group underwent twenty sessions (30 min/day, 5 days/week for 4 weeks). Patients were assessed using the Berg balance scale, gait parameters (gait speed, cadence, step length, and double-limb support period) using GAITRite, and activity-specific balance confidence score, before and after the intervention. Results: The three-dimensional balance training using visual feedback exhibited greater changes in the Berg balance scale, gait speed, cadence, step length, double-limb support period, and activity-specific balance confidence compared with the control group. Statistical analyses showed significant differences in Berg balance scale (P = .012; 95% CI, 2.585-6.415), gait speed (P = .001; 95% CI, .079-.155), cadence (P = .001; 95% CI, 1.622-4.392), step length (P = .003; 95% CI, 1.864-3.908), double-limb support period (P = .003; 95% CI, −3.259 to −0.761) and activity-specific confidence (P = .008; 95% CI, 6.964-14.036) between groups. Conclusion: Three-dimensional balance training using visual feedback may be more effective than conventional training in improving balance, walking ability, and activity-specific balance confidence in patients with subacute stroke.

Introduction

Gait is typically preceded and accompanied by a sequence of anticipatory postural control that stabilizes posture to allow the stepping leg off the floor.1 Anticipatory postural control accelerates the center of mass forward and toward the stance limb by shifting the center of pressure backward and toward the stepping leg while stepping and stance legs.2 Impairment of these functions are associated with decreased gait velocity, step length, and increased fall risk.3 Impairments in postural control can be a consequence of changes in the sensory and integrative aspects of motor control.4 Stroke survivors typically have difficulties in balance, mobility, activities of daily living (ADLs), and task performance caused by loss of anticipatory postural control.5

Loss of balance decreases ADLs, particularly in gait ability, and it can be caused by various factors, such as stroke, spinal cord injury, or traumatic brain injury.6 Anticipatory postural control is the ability to selectively control the trunk muscles such that the body can be held upright in a vertical line and exert appropriate control over weight shift and is related with trunk control.7 In most stroke patients, appropriate trunk control ability should precede functional recovery.8 A systematic review has reported that balance training may be a viable strategy for improving trunk control and dynamic sitting balance, standing balance and gait in stroke patients.8 Fear of falling in these survivors reduce their activity level and make daily ADLs difficult.5 Therefore, improvement in balance and anticipatory posture control are important rehabilitation goals.

Three-dimensional (3D) balance training using visual feedback has been used in rehabilitation to improve postural control and balance of individuals poststroke, as well as to reduce the risk of falling.9 A combination training of several factors, including vestibular, visual, somatosensory, and trunk control, may improve functional ability. Therefore, comprehensive and objective training methods are needed. However, few studies have reported on the functional ability (balance and gait) of this method. Given the importance of balance, this study aimed to investigate the effect of 3D balance training using visual feedback to conventional therapy on improving balance and walking ability in sub-acute stroke patients.

Section snippets

Experimental Design

This study was a single-blinded randomized controlled pilot trial and reported according to the CONSORT statement.10 A blinded assessor was experienced and well qualified in the use of the tests. Patients were recruited from the Wonkwang University Medical Center (Iksan, Republic of Korea) between January 2016 and April 2017. A 4-week training were designed to evaluate the effect of 3D balance training using visual feedback on balance and walking ability. The Berg balance scale (BBS), gait

Results

The patients were randomized into two groups: experimental (n = 12) and control groups (n = 12) (Fig 1). Table 1 shows the characteristic of both groups at baseline. No differences were found between the two groups for the collected demographic variables. Comparisons between the groups at baseline also showed no difference for any physical outcome measure (P > .05).

The mean age of the participant was 56.5 (6.39) years and 56.33 (5.55) years in experimental and control groups, respectively. The

Discussion

This study highlights the importance of balance training in patients with stroke. The major findings of this study were that the balance training using visual feedback showed a more significant improvement compared with the control group in the BBS, gait parameter, and ABC over time. Our study provided evidence of the benefit of 3D balance training using visual feedback in improving balance function (BBS), walking ability (gait speed, cadence, step length, and double-limb support period), and

Conclusion

The 3D balance training using visual feedback led to significant improvement in balance (BBS) and walking ability (gait speed, cadence, step length, and double-limb support period) compared with the control group. The results of our study indicate that 3D balance training using visual feedback improved balance and walking ability, suggesting the applicability of this method for clinical rehabilitation. Improving balance and walking ability in stroke patients are important for independent and

Author Contributions

The roles of the authors in this study are as follow: Hyun-Jeong Noh – primary author, experimental procedure, manuscript writing; Soon-hyun Lee – cooperation authors, experimental procedure, and management of study; Dae-hyouk Bang – corresponding author, critical discussion, interpretation of the results, manuscript writing, and management of the study.

Declaration of Interest

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Acknowledgments

We would like to express their appreciation to all the subjects and their families for their co-operation and participation in this study.

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    Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

    Conflicts of interest: None.

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