Ef icacy Of Core Strengthening Exercises On Swissball Versus Conventional Exercises For Improving Trunk Balance In Hemiplegic Patients Following Stroke

Subrat N. Samal*1, Snehal S. Samal2, Neha Ingale Chaudhary3, Sachin Chaudhary4, Vasant Gawande5 1Department of Musculoskeletal Physiotherapy, Datta Meghe College of Physiotherapy, Wanadongri, Nagpur, India 2Department of Neuroscience Physiotherapy, Ravi Nair Physiotherapy College, Sawangi (M) Wardha, India 3Department of Neurosciences Physiotherapy, Datta Meghe College of Physiotherapy, Wanadongri, Nagpur, India 4Department of Cardio respiratory Physiotherapy, Datta Meghe College of Physiotherapy, Wanadongri, Nagpur, India 5Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences Sawangi (Meghe), Wardha, India

In stroke, there is paralysis or weakness of one side of the body including upper limb, trunk and lower limb leading to the disturbances in the trunk muscles. Trunk is often neglected part in the stroke rehabilitation, trunk training exercises and Swiss ball exercises results in better recruitment of trunk muscles thus improving sitting balance. To compare the effect of core strengthening exercises on Swiss ball and Conventional exercise, to improve trunk balance in hemiplegic patients following stroke. A total number of 70 subjects were screened as per inclusion and exclusion criteria. The subjects were divided into two groups, Group-A received core strengthening exercises on Swiss ball along with conventional treatment and Group-B received core strengthening exercises along with conventional treatment. Subjects showed improvement in trunk balance following 6 weeks of core strengthening exercises.Post-intervention the TIS, BBA and MBI score of both groups improved but the Group-A improved more signi icantly than Group-B. The level of signi icance was P<0. 0001. This study concluded that both the interventions have improved the trunk balance and activity of daily living by making the patient functionally independent.

INTRODUCTION
The "American Heart Association/American Stroke Association"(2016), stated that on a normal, every 3 minutes 42 seconds, somebody dies of a stroke (Benjamin and Muntner, 2019). World Health Organization (WHO) de ined stroke as: "rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin" (Sheikh et al., 2020). Among the non-communicable illnesses as assessed by Indian council of medical research, the mortality rate is resulted in 41% of cases, and differentlyabled is observed in 72% of stroke (Viswaja, 2015).Throughout the United States, roughly 1 of each 19 expiries (Benjamin and Muntner, 2019), and more than 7,95,000 individuals consistently experience the ill effects of a stroke (Dhakate and Bhattad, 2020). The trunk muscles are impaired on both ipsilateral and contra lateral side of the body to that of the site of the lesion because the trunk muscles of the two sides of the body function in synchrony (Das, 2016).The back extensors and the abdominal muscles are the two group of muscles which are essentially important for moving and controlling the trunk (Chaudhary et al., 2020). The pelvic movement originates from trunk muscles, as pelvis is a part of a trunk that supports further extremity movements (Shinde, 2014).
Balance is de ined as the ability to maintain functional equilibrium (Taly et al., 1998). Balance is a complex process which includes the integration and reception of sensory inputs and (Das, 2016), the visual, proprioceptive and vestibular system, along with the central functions of planning and execution of movement (Sathe et al., 2018).Anticipatory postural adjustments (APA) predicts the level of balance impairment and related danger of mobility, as well as falls and, are signi icant neuromuscular biomarkers (Lee and You, 2018).
Core stability is regarded as a recovery of balance after perturbation, by utilizing the capability of the lumbo-pelvic-hip complex to prevent buckling of the vertebral column (Cabanas-Valdes and Bagur-Calafat, 2016). A "core" comprising of the abdominals anteriorly, backside gluteal and paraspinal muscles, diaphragm as the roof, and hip girdle and pelvic loor muscles at the bottom, is referred to as a box (Chung and Kim, 2013). Bergmark (1989) (Bergmark, 1989) had differentiated the muscles as "local" muscles and "global" muscles, on the basis of the activity on the lumbosacral spine. The local muscles are actively involved in segmental stability of the trunk, whereas the global muscles modulate the spine and trunk movement (Haruyama et al., 2016).
Swiss ball (physioball), also known as Pezzi ball, was created in 1963 by Aquilinocosani, an Italian plastic manufacturer (Muniyar and Darade, 2018). Before testing the patient's balance on the Swiss ball, the balance during static and dynamic condition is checked on rigid and steady support in sitting and standing posture (Carriere and Tanzberger, 1998).
The Conventional program includes the patient in exercises that combines both movement and stability (Adler et al., 2014).Functional exercises are planned dynamically for improving the patient's independence (Hollis, 1999).
As a primary and secondary outcome measures, the results are estimated for the control of trunk by using the Trunk Impairment Scale (TIS), and the Brunel Balance Assessment (BBA),and Modi ied Barthel Index (MBI) for assessing functional balance after the stroke.

Methods
The study was conducted after taking approval from the institutional research ethics committee, approval no. (DMIMS(DU)/IEC/2018-19/7197)in Department of Neuro Physiotherapy, Ravi Nair Physiotherapy College, Acharya VinobaBhave Rural Hospital, Sawangi (Meghe), Wardha. Inclusion criteria were atients suffered from the irst episode of stroke within 1-3 months of duration, age between 40 to 60 years, tage 2, on the Modi ied Ashworth Scale, no visual and sensory de icits, ability to communicate verbally. Exclusion criteria were the existence of any other neurological or orthopaedic diseases, haemorrhagic stroke, patients having cognitive problems. Of each of the 70 subjects composed pre-informed consent, marked or with thumb impression was taken and they were told about the conceivable result of the intercessions. Pre and post-TIS score, BBA score and MBI score were taken. Patients were distributed in two groups with 35 subjects in each group respectively and were chosen randomly.
Subjects in a Group-A received core strengthening exercise on Swiss ball along with conventional treatment and subjects in the Group-B received core strengthening exercise along with conventional treatment. The total duration of exercises was almost approximately 45 minutes to one hour. Subjects had permitted to take rest for 2 minutes in the middle of each new exercise or as and when he/she wished. Also, for core strengthening the patient had to ask to draw-in the abdominal muscles for 5 counts or 5 seconds.
Conventional physiotherapy was received for 15 minutes by both groups which include, Active assisted range of motion exercise of upper limb (15 times each movement)-Shoulder, Elbow and Wrist and inger range of motion exercise.
Lower limb(15 times each movement)-Hip, knee and ankle range of motion exercise.
Core strengthening exercises on a Swiss ball(GROUP-A) was given in supine-lying position, with upper trunk lexion, and with lateral upper trunk lexion.
Sitting exercises: Static sitting balance, Forward trunk lexion, lateral trunk lexion, Trunk rotations in sitting, Weight shifts, Forward reach, Lateral reach, Perturbations, sit to stand.

Core strengthening exercises (Group-B)
Supine-lying position-Core strengthening exercise was done in crook lying position, Upper trunk in lexion, Upper trunk diagonal rotation.

Data Analysis
Statistical analysis was done by using descriptive and inferential statistics using chi-square test, Wilcoxon Signed Rank Test and Mann Whitney U test as well as SPSS version 22.0 and GraphPad Prism 7.0 version. The p<0.05 is considered as the level of signi icance.

Mann Whitney U Test
According to Table 1, based on the Mann Whitney U test, the mean difference of total Trunk Impairment Scale score in Group-A and Group-B was compared. The P-value was 0.0001 (P<0.05), which was found to be signi icant and represented graphically.

Mann Whitney U Test
According to Table 2, based on the Mann Whitney U test, the mean difference of Brunel Balance Assessment Scale in Group-A and Group-B was compared at 1 week and 1 month. The P-value was 0.62 (P> 0.0001), which is found to be non-signi icant at 1 week in both groups respectively while the P value 0.0001(P<0.05) was found at 1 month which was found to be signi icant and represented graphically.

Mann Whitney U Test
According to Table 3, based on the Mann Whitney U test, the mean difference of the Modi ied Barthel Index score in Group-A and Group-B was compared. The P value was 0.0001 (P<0.05), which was found to be signi icant and represented graphically.

Discussion
Regain of the trunk balance or proximal and distal stabilization is an important part of stroke rehabilitation, as trunk balance is related to a marked improvement of functional activity of daily living (Hariharasudhan and Balamurugan, 2016). Usually, the functional exercises of everyday living require the co-ordination between the limb and the trunk. The goal of the current study was to analyze the impact of core strengthening exercises on Swiss ball combined with conventional treatment and core strengthening exercises combined with conventional treatment for increasing the strength of core muscles to improve trunk balance in subacute stroke patients (Sahu and Naqvi, 2020).
Static sitting balance assesses the capacity to sit upright in a sitting position within the normal base of support or when the base of support has been decreased. Results indicated noteworthy improvement in the two groups following an intervention. The mean pretest score was improved from 5.51 to 7.00 following 6 weeks of treatment in Group-A while the Group-B improved from 5.65 pretest score to 7.00 post-test score following intervention which was signi icant. Anyhow, when we correlate the mean difference in static sitting balance in Group-A and Group-B with the mean values of 1.48 and 1.34, there was no signi icant change found, the Pvalue was 0.22. The dynamic sitting balance domain assesses speci ic side lexion of upper and the lower part of the trunk. Over a 6week's time of treatment, the mean pre and post-test scores of the dynamic sitting balance domain of TIS in the Group-A enhanced from 4.77 to 9.94 while the Group-B improved from 4.91 to 10.00. But, when we compared the mean difference in dynamic sitting balance in Group-A and Group-B with the average values was 5.17 and 5.08, which shows that there was no signi icant difference found. The co-ordination domain of TIS assesses the upper and lower trunk rotations independently and checks for the symmetry in the rotations. Following intervention mean score of co-ordination in the Group-A improved from 2.00 to 6.00 and 1.88 to 5.22 in Group-B and after comparing the average difference of co-ordination scores in Group-A and Group-B with the mean values of 4.00 and 3.34, a signi icant enhancement was found in two groups, the P-value was less than 0.05.
Following a month of intervention, the mean pretest and post-test scores of BBA at baseline evaluation, one-week evaluation and following 1 month of evaluation changed from 5.62 to 6.00 and 10.51 respectively in Group-A and from 5.48 to 5.80 and 8.88 in Group-B. However, by comparing the mean difference of BBA at one week and one month, we found that the mean values were increased from 0.37 to 4.88 in Group-A and 0.31 to 3.40 in Group-B respectively.   Signi icant improvement of Modi ied Barthel Index scores in both the groups might be because of the common conventional treatment which was given to both the groups. Average pre-test grade of Modi ied Barthel Index in Group-A and Group-B was 6.05 and 6.41. Following 6 weeks of a treatment program, the average post-test grade in Group-A and Group-B stood at 17.71 and 15.80, which was found to be signi icant. Also, when we compare the mean difference in the Modi ied Barthel Index score in Group-A and Group-B, which was 11.65 and 9.65, respectively.

CONCLUSIONS
This research concluded that the trunk equilibrium and daily living behaviour were enhanced by both the treatments by making the patient functionally autonomous. This study concluded that core muscle strengthening exercise is an important recovery strategy for all chronic low back pain patients, irrespective of the length (chronicity) of their pain, along with lumbar lexibility and gluteus maximus strengthening. Findings suggest that when a patient has chronic non-speci ic low back pain, doctors have an option to either administer core stability exercise or general exercise.If the patient is more acceptable and will promote compliance, core stability exercise may be used as an alternative to general encourage-ment and stretching. However, by selecting core stability in terms of pain and function, clinicians do not expect a dramatic change, especially in the long run.