Effects of whole body Vibration exercise combined with Forced weight bearing on balance and gait in patients with Stroke Hemiplegia

 

Yongwoong Nam¹, Jemyung Shim²*, Sung Joong Kim³, Seung Namkoong⁴

¹Department of Physical Therapy, Emergency Medical Rehabilitation, Kangwon National University, 346 Hwangjo-gil, Dogye-eup, Samcheok, 25945, Rebulic of Korea

²Department of Physical Therapy, Kangwon National University, 346 Hwangjo-gil, Dogye-eup, Samcheok, 25945, Rebulic of Korea

^3,4Department of Physical Therapy, Kangwon National University, 346 Hwangjo-gil, Dogye-eup, Samcheok, 25945, Rebulic of Korea

 

ABSTRACT:

Background/Objectives: Forced weight support and whole-body vibration exercise are being widely used in patients with stroke to improve balance and gait. Thirty patients with stroke participated in the experiment. Methods/Statistical analysis: A 10-mm insole underneath the non-affected lower foot and Galileo equipment were used in the experimental group. Only a 10-mm insole was provided underneath the shoe in the control group, and all activities of daily living were performed without the whole-body vibration exercise. The Berg balance scale (BBS), Timed up & go (TUG), and bio rescue balance tests before and after intervention were conducted in all subjects. Statistical analysis was performed using the SPSS version 22.0. Findings: There were statistically significant differences in the BBS test result, limit of stability (LOS), and 10 compared to comparator controls. However, there was no statistically significant difference in the TUG test result and foot print (FP). The experimental group displayed statistically significant differences between the BBS, TUG, FP, LOS, and 10mWT items in the before- and after-intervention comparisons. On the contrary, the control group displayed statistically significant differences in the BBS, TUG, FP, and 10mWT items; however, there was no statistically significant difference in the LOS. Improvements/Applications: In balance and gait, the forced weight support and whole-body vibration exercise yielded symmetrical body weight support and improved the walking speed of the patients with stroke.

 

 

 

1. INTRODUCTION:

Stroke is a neurological disorder that presents functional impairments due to local damage of the brain tissues. Damage to the brain causes impairments in motor function, sensation, cognitive function, perception and mental function, intellectual ability, and language ability, and among these, physical therapy specifically targets motor function and sensory impairment¹.

 

For patients with stroke who have difficulties in postural control and balance and motor function impairment may present difficulties in gait and upright standing due to abnormal body balance, asymmetric posture, deterioration of weight transfer ability, and deterioration of motor components that perform delicate movements². Such a deterioration of balance ability impairs functional movements, which may lead to problems with activities of daily living (ADL)³.

 

For patients with stroke with such impairments, the useful intervention methods that are currently used in clinical practice as objective indicators include muscle training and muscle strengthening training⁴. Among them, the interventional theory on gait training for typical patients with stroke involves properly regulating muscle tension and achieving the range of motion for each joint. As a result, functional and proper movements in a given environment can be improved, and the ability to control posture is learned via interactions. Accordingly, bodily movements can be controlled via stimulations of the proprioceptive senses and motor learning in the joints and muscles, and in addition, balance is maintained to improve gait ability⁵.

 

Balance is a fundamental element of gait and ADL performance. Therefore, balance must be maintained properly to allow a normal gait. Exercise methods for improving such a balance ability include standing up, walking, climbing stairs, and changing directions, which are effective and important^6,7. Among patients with stroke, those with hemiplegia exhibit asymmetric and individualized balance ability when in the standing posture or performing functional movements⁸. Such an asymmetric posture is associated with diminished balance and gait abilities⁹. Improvement in balance ability for the recovery of motor function has been reported to occur most often up to 6 months¹⁰.

 

Patients with hemiplegia have a gait pattern of long swing phase on the affected side, and weight bearing on the affected side is also difficult, which causes the stance phase to be short. As a result, there is a difference in the step length between the affected and unaffected sides, while the gait cycle and speed tend to be slower¹¹. Moreover, because of the diminished balance ability during gait, compensatory movements are triggered in various parts of the body, resulting in an inefficient gait that requires more energy than that in healthy individuals¹². Such diminished balance and gait abilities in patients with hemiplegia act as disabling factors in performing ADLs that compromise the independence of each individual, which ultimately becomes a limiting factor in their social activities¹³. Consequently, various physical therapy exercise and training methods have been suggested for patients with hemiplegia, which can promote greater use of the affected side than the unaffected side and induce voluntary movements that can trigger reorganization of the locally damaged brain. To improve the gait ability of patients afflicted with stroke-induced hemiplegia, various training methods have been studied, including gait training using an electro-mechanical gait trainer¹⁴, gait training on ground surface and treadmill¹⁵, gait training using proprioceptive neuromuscular facilitation¹⁶, task-oriented progressive resistance strength training¹⁷, and backward walking training¹⁸.

 

Among various training methods, the balance training method that placed an insole beneath the unaffected foot of a patient with hemiplegia to force the patient to shift the body weight to the affected side and support the weight improved the stride length and gait speed, while also affecting the symmetry of weight bearing¹⁹. Moreover, applying force weight bearing in patients with acute stroke for 2 weeks improved the weight bearing distribution and gait speed²⁰; conversely, applying it in patients with chronic stroke for 6 weeks showed long-term and continuous effect on weight bearing and gait speed even after 3 months²¹.

 

Another training method uses the Galileo tilting table, which can continuously provide whole-body vibration (WBV) cross-training. WBV cross-training has been used for a long time for increasing muscle strength and enables systematic and focused training²². The principle behind the Galileo tilting table involves stimulation and activation of the proprioceptive senses. Amplitude, vibration, and frequency are important parameters, and the Galileo tilting table that provides WBV cross-training stimulates not only the lower back muscles, but also the leg muscles in a physiologically similar manner to an actual gait^{23, 24}. Recent studies have reported that it is also effective in improving biomechanical functions of the damaged musculoskeletal system, nerves, and muscles²⁵. Moreover, WBV cross-training has also been reported to promote the activation of the motor neurons through the pathway of the central nervous system²⁶. Mulder et al.²⁷ demonstrated changes in skeletal muscle length in the leg after 8 weeks of vibration exercise. Other studies also showed that it was effective in improving balance ability^28,29. Accordingly, the present study aimed to investigate the effects of WBV exercise using the Galileo equipment with forced weight bearing (FWB) before and after gait training on the dynamic and static balance and gait speed of patients with stroke.

 

2. MATERIALS AND METHODS:

2.1. Subjects:

The present study was conducted for 6 weeks between March and May 2017 at “G” National Rehabilitation Clinic located in Yangpyeong County, Gyeonggi Province. The study included 30 patients with hemiplegia who were diagnosed with stroke, understood the objective of the present study, and consented to participate in the study. The participants were assigned to the WBV with FWB (WBV-FWB; experimental) group (n=15) and only FWB (FWB; control) group (n=15) via random drawing. As shown in Table 1, there were no statistically significant differences in the disease duration, sex, and age among the participants.

The selection criteria were as follows:

1.    ≥3 points on the 10-m walking test (10mWT)

2.    Ability to stand on their own without support

3.    No other neurological diseases

4.    No musculoskeletal disorders

5.    Ability to communicate on their own

 

Table 1. General characteristics of the participants

	Experimental group	Control group	t	p
	Mean±SD	Mean±SD
Disease duration (y)	13.46±4.43	13.73.00±5.88	-0.14	0.89
Men/Women	11/4	11/4	0.00	1.00
Age(y)	49.93±14.87	48.53±15.24	0.25	0.80

 

2.2. Instrument and intervention:

Both the WBV-FWB (experimental) and FWB (control) groups were provided with 10-mm insoles¹⁸ made of ethylene vinyl acetate with medium hardness, FWB was applied in both groups, while WBV was applied additionally only in the experimental group. According to previous studies on FWB, the intervention period was set to 6 weeks¹⁸, and the patients in both groups were instructed to wear the insole on the bottom of the shoe on the unaffected side while performing their ADLs during the intervention period. The experimental group performed three sets of WBV exercise, 5 min per set with a frequency of 25 Hz. One-minute rest periods were provided in between sets. The patients in both groups received 60-min physical therapy for five times per week.

 

All participants underwent the BBS, TUG, and bio rescue balance tests and 10mWT prior to the start of intervention for the measurement of balance ability, left-right distribution of the center of the mass (foot print [FP]), distance travelled (limit of stability [LOS]), and gait speed. In the experimental group, 10-mm insoles made of ethylene vinyl acetate were placed on the bottom of the shoe on the unaffected side, and the Galileo equipment was used to apply WBV exercise (25 Hz, 5 min, three sets; with 1-min rest in between sets) with the participants placing their heels 8.4 cm apart from the normal range of 2-4 in and 9° from the normal angle of the toe-out range of 7-9° on the vibrating plate.³⁰ In the control group, 10-mm insoles made of ethylene vinyl acetate were placed on the bottom of the shoe on the unaffected side, and the participants performed their ADLs without any WBV applied. After 6 weeks, the insoles were removed in both groups, and the BBS, TUG, and bio rescue balance tests, and 10mWT were performed to measure balance ability, left-right distribution of the center of the mass, and distance travelled, with the latter test used to measure gait speed.

 

2.3. Statistical analysis:

Statistical analysis between the groups was performed using the IBM SPSS ver. 22.0 (IBM Co., Armonk, NY, USA). Differences between the WBV-FWB and FWB groups were tested via the independent samples t-test, while differences between pre- and post-intervention in each group were tested via the paired samples t-test. Statistical significance level was set to 0.05.

3. RESULTS AND DISCUSSION:

The present study included 30 patients with hemiplegia who had been diagnosed with stroke. As shown in Table 2, the results showed that the experimental group had statistically significant differences in the BBS test result, LOS, and 10mWT result compared with the control group, but no statistically significant differences in the TUG test result and FP. Moreover, as shown in Table 3, the experimental group showed statistically significant differences in the BBS and TUG test results, FP, LOS, and 10mWT results in the pre- and post-intervention comparisons, whereas the control group showed statistically significant differences in the BBS and TUG test results, FP, and 10mWT results, but no statistically significant differences in the LOS.

 

Table 2. Comparison before and after intervention in each group

(BBS = Berg balance scale, TUG = Timed up & go test, FP = Foot prints, LOS = Limit of stability, 10mWT = 10-m walking test)

	Experimental group	Control group	t	p
	Mean±SD	Mean±SD
BBS	47.40±6.19	42.00±8.13	2.04	0.05*
TUG	15.83±5.98	19.83±7.72	-1.58	0.12
FP	45.18±4.28	47.18±3.12	-1.45	0.15
LOS	5668.20±2839.25	3562.66±2490.08	2.15	0.04*
10mWT	14.28±4.74	18.89±7.67	-1.97	0.05*

 

Table 3. Comparison before and after intervention in both groups

(BBS = Berg balance scale, TUG = Timed up & go test, FP = Foot prints, LOS = Limit of stability, 10mWT = 10-m walking test)

Experimental group	Pre-test	Post-test	t	p
	Mean±SD	Mean±SD
BBS	37.20±8.96	47.40±6.19	-6.67	0.00*
TUG	22.47±9.00	15.83±5.98	5.75	0.00*
FP	39.58±6.43	45.18±4.28	-4.79	0.00*
LOS	3739.20±	5668.20±	-6.44	0.00*
10mWT			6.65	0.00*

 

Control group	Pre-test	Pro-test	t	p
	Mean±SD	Mean±SD
BBS	39.66±8.32	42.00±8.13	-6.24	0.00*
TUG	22.56±8.74	19.83±7.72	4.31	0.01*
FP	42.56±4.04	47.18±3.12	-4.67	0.00*
LOS	3156.20± 2394.55	3562.66±2490.08	-1.39	0.18
10mWT	21.21±7.81	18.89±7.67	7.56	0.00*

 

4. CONCLUSION:

Applying the WBV exercise using the Galileo equipment and FWB with the insole placed under the foot on the unaffected side had an effect on the balance and gait of the patients with stroke. The two intervention methods were associated with an improved mobility for movements and stability for clinically maintaining balance of the inpatients. Moreover, the BBS test result, LOS, and 10mWT result differed between the two intervention methods in association with the improvement in dynamic balance ability and gait speed. The WBV-FWB group showed effect in all items measured, whereas FWB group showed such an effect in all items, except for the LOS.

A study by Aruin et al. in 2000 showed that their intervention using 10-mm insoles influenced weight transfer to the affected side of patients with stroke, with the posture maintained when the Galileo equipment was being applied and the application method followed in an objective and similar manner as that of Van Nes et al. in 2004: the heels were placed 8.4 cm apart from the normal range of 2-4 in and 9° from the normal angle of the toe-out range of 7-9° on the vibrating plate, and WBV exercise was applied at 25 Hz for 5 min per set for three sets, with 1-min rests in between sets.

 

The study by Mohapatra et al. and Aruin et al. both in 2012 reported that FWB had an positive effect on the balance and gait of patients with acute and chronic stroke, respectively. With respect to WBV exercise, a study by Tankisheva et al. in 2014 reported that it had an effect on posture control and balance; however, that by Van Nes et al. in 2006 reported that it did not have any significant effect. In the present study, WBV exercise had an effect on the balance and gait of the patients with stroke; however, additional future studies on this subject are needed.

 

In the present study, FWB and WBV exercise improved symmetric weight bearing and gait speed of the patients with stroke. Moreover, applying both FWB and WBV was more effective in improving the dynamic balance and gait speed of patients with stroke than applying FWB alone.

 

5. REFERENCES:

1.     Laufer Y, Sivan DO, Schwarzmann R, Sprecher E. Standing balance and functional recovery of patients with right and left hemiparesis in the early stages of rehabilitation. Neurorehabil Neural Repair, 2003, 17(4), pp. 207-213.

2.     Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther, 1985, 65(2), pp. 175-178.

3.     Winstein CJ, Cardner ER, McNeil DR, Barto PS, Nicholson DE. Standing balance training: effect on balance and locomotion in hemiparetic adults. Arch Phys Med Rehabil, 1989, 70, pp. 755-762.

4.     Bohannon RW. Muscle strengthening and muscle training after stroke. J Rehabil Med, 2007, 39, pp. 14-20.

5.     Hyun-ok L. Observational gait analysis. Yeongmun Publisher, 2008, http://www.ymsbook.net/

6.     Eng JJ, Chu KS. Reliability and comparison of weight-bearing ability during standing tasks for individuals with chronic stroke. Arch Phys Med Rehabil, 2002, 83(8), pp. 1138-1144.

7.     Carr JH, Shepherd RB. Stroke rehabilitation guidelines for exercise and training to optimise motor skill. Oxford, UK: Butterworth Heinemann, 2003.

8.     Tyson SF, Hanley M, Chillala J, Selley A, Tallis RC. Balance disability after stroke. J Phys Ther, 2006, 86, pp. 30-38.

9.     Wall JC, Turnbull GI. Gait asymmetries in residual hemiplegia. Arch Phys Med Rehabil, 1986, 67, pp. 550-553.

10.   Carson RG. Neural pathways mediating bilateral interactions between the upper limbs. Brain Res Rev, 2005, 49(3), pp. 641-662.

11.   Wagenaar RC, Beek WJ. Hemiplegic gait: a kinematic analysis using walking speed as a basis. J Biomech, 1992, 25(9), pp. 1007-1015.

12.   Granat MH, Maxwell DJ, Ferguson AC, Lees KR, Barbenel JC. Peroneal stimulator; evaluation for the correction of spastic drop foot in hemiplegia. Arch Phys Med Rehabil, 1996, 77(1), pp. 19-24.

13.   Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke, 1995, 26(6), pp. 982-989.

14.   Tong RK, Ng MF, Li LS. Effectiveness of gait training using an electromechanical gait trainer, with and without functional electric stimulation, in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil, 2006, 87(10), pp. 1298-1304.

15.   Ada L, Dean CM, Hall JM, Bampton J, Crompton S. A treadmill and overground walking program improves walking in persons residing in the community after stroke: a placebo-controlled, randomized trial. Arch Phys Med Rehabil, 2003, 84, pp. 1486-1491.

16.   Wang RY. Effect of proprioceptive neuromuscular facilitation on the gait of patients with hemiplegia of long and short duration. Phys Ther, 1994, 74(12), pp. 1108-1115.

17.   Yang YR, Wang RY, Lin KH, Chu MY, Chan RC. Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil, 2006, 20(10), pp. 860-870.

18.   Yang YR, Yen JG, Wang RY, Yen LL, Lieu FK. Gait outcomes after additional backward walking training in patients with stroke: a randomized controlled trial. Clin Rehabil, 2005, 19(3), pp. 264-273.

19.   Aruin AS, Hanke T, Chaudhuri G, Harvey R, Noel R. Compelled weightbearing in persons with hemiparesis following stroke: the effect of a lift insert and goal-directed balance exercise. J Rehabil Res Dev, 2000, 37(1), pp. 65-72.

20.   Mohapatra S, Eviota AC, Ringquist KL, Muthukrishnan SR. Compelled body weight shift technique to facilitate rehabilitation of individuals with acute stroke. ISRN Rehabilitation, 2012, 328018, pp. 7.

21.   Aruin AS, Rao N, Sharma A, Chaudhuri G. Compelled body-weight shift approach in rehabilitation of individuals with chronic stroke. Top Stroke Rehabil, 2012, 19(6), pp. 556-563.

22.   Cardinale M, Wakeling J. Whole body vibration exercise: are vibrations good for you? Br J Sports Med, 2005, 39 (9), pp. 585-589.

23.   Abercromby AF, Amonette WE, Layne CS, McFarlin BK, Hinman MR, Paloski WH. Vibration exposure and biodynamic responses during whole-body vibration training. Med Sci Sports Exerc, 2007, 39(10), pp. 1794-1800.

24.   Wilcock IM, Whatman C, Harris N, Keogh JW. Vibration training: could it enhance the strength, power, or speed of athletes? J Strength Cond Res, 2009, 23(2), pp. 593-603.

25.   Rees SS, Murphy AJ, Watsford ML. Effects of whole body vibration on postural steadiness in an older population. J Sci Med Sport, 2009, 12(4), pp. 440-444.

26.   Griffin L, Garland SJ, Ivanova T, Gossen ER. Muscle vibration sustains motor unit firing rate during submaximal isometric fatigue in humans. J Physiol, 2001, 535(3), pp. 929-936.

27.   Mulder ER, Stegeman DF, Gerrits KH, Paalman MI, Rittweger J, Felsenberg D, de Haan A. Strength, size and activation of knee extensors followed during 8 weeks of horizontal bed rest and the influence of a countermeasure. Eur J Appl Physiol, 2006, 97(6), pp. 706-715.

28.   Runge M, Rehfeld G, Resnicek E. Balance training and exercise in geriatric patients. J Musculoskelet Neuronal Interact, 2000, 1(1), pp. 61-65.

29.   Bautmans I, Van Hees E, Lemper JC, Mets T. The feasibility of whole body vibration in institutionalised elderly persons and its influence on muscle performance, balance and mobility: a randomised controlled trial. BMC Geriatr, 2005, pp. 5-17.

30.   Van Nes IJW, Geurt ACH, Hendricks HT. Short-term effect of whole-body vibration on postural control in unilateral chronic stroke patients: preliminary evidence. Am J Phys Med Rehabil, 2004, 83, pp. 867-873.

 

 

 

 

 

Accepted on 08.06.2019          © RJPT All right reserved

Research J. Pharm. and Tech 2019; 12(9):4117-4120 .