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INTRODUCTION

Stroke is one of the most common neurological disorders leading to chronic disability with resultant signs and symptoms that correspond to the involvement of focal areas of the brain. ₍₁₃₎ Two-thirds of the survivors have difficulty walking immediately after suffering a stroke, and 6 months later over 30%. ⁽¹⁸⁾ Clinically a variety of focal deficits are possible after stroke. It may include changes in the level of consciousness, impairments of sensory, motor, perceptual, cognitive, and language. ⁽¹³⁾ Globally stroke is the second leading cause of  death. ⁽¹²⁾ The estimated adjusted prevalence rate of stroke range is, 84-262/100,000 in rural and 334-424/100,000 in urban areas in India. On recent population-based studies, the incidence rate of stroke is 119-145/100,000. Many patients with stroke suffer from significant motor and cognitive impairments, such as visual spatial impairments, aphasia, hemi-neglect, dyspraxia, gait disorders, and poor sitting and standing balance control. ^{(19, 23)} Stroke is the greatest risk factor for falls among the elderly. ^(6,10)

Following stroke, patients lose functions of the motor, sensory, and cognition which lead to diminished balance. Hemiplegic or hemi paretic stroke patients have some common features. Posture sway, impaired weight bearing, ability decreased stability capability ^(1,3,16) and other deficits like decreased muscle strength, range of motion, abnormal muscle tone, motor coordination, sensory organization, cognitive and multisensory integration can contribute to balance disturbance at a different level^.(1,3,22)  As balance problems are common after stroke and are of importance in mobility and activities of daily living (ADL), so far treatment of balance continues to be the standard of care in stroke rehabilitation. ^(21,22)

Even if the survivors of stroke are ambulatory, there is an increased risk of falling mainly on the paretic side, difficulty in walking on uneven terrain, and difficulty in using public transport. In addition to the lack of accessible and appropriate exercise programs, impairments resulting from chronic disease (e.g., reduced mobility or pain); could lead to further sedentary lifestyle, which may decline functional status. ⁽¹¹⁾ Stroke patients have a two-fold higher risk of falling than other patients of the same age or gender^{. (20) (6)}

Balance is defined as a “complex process involving the reception and integration of sensory input, planning, and execution of movement” to achieve a good upright posture. ⁽¹⁷⁾ Mostly people with stroke and also have impaired balance or fallen in hospital are at risk of recurrent falls when they return home. ⁽⁸⁾ Therefore, it is necessary to respond to the early evaluation appropriately for balance failure for successful rehabilitation and recovery functions and provide treatment to improve the balance capacity.

Various physical therapy interventions like balance training, task–oriented training, wobble board exercise program, Otago Exercise Program (OEP), and Fitness and Mobility Exercise (FAME) program have been previously used for improving ADLs, balance, and mobility in patients with chronic stroke. The Otago exercise program is one of the most recent exercise training programs which was first introduced in New Zealand. ⁽²⁰⁾ Otago exercise programme is a strength and balance retraining program, combined with walking. The OEP is an evidence-based fall prevention program developed and designed by physical therapists. Past studies show the effect of OEP which was proven to be effective for the improvement of balance ability of the normal elderly individuals. The FAME Program was developed in Vancouver, Canada. ⁽²⁾ the Fitness and Mobility Exercise (FAME) Program has been designed to improve mobility, fitness, and fall risk. A loss of joint range is common following a stroke due to weakness, muscle stiffness, spasticity, and inactivity.

However, lack of literature finds the effect of OEP and FAME Programs on balance and mobility in chronic stroke patients over Indian stroke patients. The study has been conducted to find the effect of OEP and the FAME Program on improving balance and mobility in chronic stroke patients in developed countries. Even there is very scarce literature that compares the effect of the OEP vs. FAME Program on balance and mobility in chronic stroke patients. Hence, the result of this study would implicate a better intervention in improving balance and mobility in patients with chronic stroke.

MATERIALS AND METHODS

An experimental study was conducted by obtaining ethical clearance from an institutional ethical committee. Different OPDs in Surat were contacted for the patients. Sample size was calculated using G power 3.1.9.2 with effect size 0.8 and α = 0.05. The total number of sample size was 58. With a dropout chance of 10%, Calculated Sample size was 52. First attacked stroke patients (stroke duration 6-18 months) between the age group of 55 to 75 years, Brunnstorm’s stage of recovery ≥3, mini mental status examination scale score ≥24, Berg Balance Scale ≥ 30, and ability to walk 10 meters with or without assistive devices were set as inclusion criteria for the study. People with any psychosomatic or perceptual disorder, recent surgery, or other neurological disorder other than stroke/ cardiac diseases were excluded from the study.

After getting the written informed consent from all the patients, clinical history and a complete physical physiotherapy examination were done. They were randomly allocated into two groups using the chit method by using purposive sampling. Group A received the OEP & conventional Physiotherapy whereas, Group B received the FAME Program along with conventional physiotherapy.

Otago exercises include flexibility exercises, strength exercises, and balance exercises. FAME 18 includes a warm-up, stretching, functional strengthening, balance, agility fitness, and cool down. Conventional physiotherapy ^{(20, 24)} treatment was given by physiotherapists for both groups which includes stretching of spastic muscles (hold for 30 seconds, 3 repetitions), ankle toe movement, supine hip–knee flexion & extension, hip abduction-adduction in side lying, knee extension in high sitting, affected side upper limb ROM exercises, hand grip strengthening exercises, bridging exercise, trunk rotation (side to side), reach outs toward affected side, and weight shifting side to side. Each exercise was repeated 10 times. Conventional physiotherapy was given for 20 minutes, 5 days a week, for 8 weeks for both groups. The number of repetitions and intensity of each exercise were increased based on the patient’s performance. The study was carried out in various physiotherapy OPDs in Surat including SPB Physiotherapy College OPD. Pre- and post-intervention assessments were done for balance and mobility by using the Berg Balance Scale (BBS) ⁽⁸⁾ and the POMA ⁽¹⁵⁾ scale respectively. All patients were given treatment sessions for 1 hour, 3 days per week for 8 weeks. 58 patients were included in the analysis.

RESULTS & DATA ANALYSIS

Statistical analysis was performed using SPSS version 15.00 software. Kolmogorov-Smirnov test was applied to check the normality of data. All quantitative data of this study follow the normality (<0.05).

Gender and affected side were qualitative variables. Baseline characteristics were compared between intervention groups using independent t test for quantitative variables like age, MMSE Score, post stroke duration, Brunnstorm’s stage of recovery and homogeneity of dependent variables i.e. BBS score and POMA score before the training and the chi-square test for qualitative variable like gender. Paired t test was used to analysed the differences between pre and post training within each group and independent t test for between group comparisons. The level of significance for all statistical data was set at <0.05.   

Table 1 shows patient’s baseline characteristics with mean and SD. All two groups were matched in term of age, post stroke duration, brunnstorm’s stage of recovery, MMSE, Pre BBS-Score and pre-POMA score. The baseline characteristics were equivalent across the intervention groups (p>0.05).

The results show that there was no significant difference (p=0837) in the BBS value of two groups’ comparison. So, there is no any difference in BBS score between Otago exercise program and FAME program. But there is significant difference in POMA score between Otago exercise program and FAME program. (p=0.021) Hence, alternate hypothesis of there is significant difference between the effect of OEP and FAME Program can be accepted on mobility in patients with chronic stroke.

VARIABLE	GROUP A (OEP) Mean ± SD	GROUP B (FAME) Mean ± SD	p- Value
Age (in years)	59.03±3.47	60.59±5.81	0.222
Post stroke duration (In months)	9.86±3.15	8.89±2.33	0.191
Brunnstorm’s Recovery stage	4.69±0.471	4.66±0.484	0.784
Gender	M=61.54% F=38.46%	M=76.92% F=23.07%	-
MMSE	29.03±0.823	29.00±0.845	0.875
Pre BBS	36.10±2.76	35.90±1.97	0.744
Pre POMA	19.31±1.71	19.55±1.52	0.532

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 1: Baseline characteristics of patients

Test	Value	Degree of Freedom	P value
Pearson chi -square	5.586	1	0.018

Table 2: Gender distribution for homogeneity

As the p values obtained is 0.018 which is significant even at 95% confidence limits. It can be said that gender distribution is not homogenous.

Within group comparison

Groups	Outcome scale	Pre value (0 week)	Post value (8 week)	P-value
A	BBS	36.27±2.750	46.46±1.794	0.000
	POMA	19.42 ± 1.677	24.04±0.871
B	BBS	35.96±2.068	46.04±1.536
	POMA	19.62 ± 1.203	25.31 ± 1.123

 

 

 

 

 

 

 

 

 

Table 3: Within group comparison of BBS and POMA

 

 

 

 

 

 

 

 

 

 

Between group comparison

Variable	Group A	Group B	P- value
	Mean ± SD	Mean ± SD
BBS	10.19±2.136	10.08±1.875	0.837
POMA	4.61±0.871	5.69±1.123	0.021

 

 

 

 

 

 

 

Table 4: Between group comparison of BBS & POMA

 

 

 

 

 

 

 

 

 

 

DISCUSSION

In this study, conventional physiotherapy was only given to improve ROM, decrease muscle tone, improve flexibility and joint integrity, improving strength and upper extremity function by training in functional activities like sitting, standing, reaching, and transfers. OEP (specialized exercise program that includes flexibility exercises, strength exercises, and balance exercises) was given to group A for the duration of 8 weeks and the FAME program (which includes warm-up, stretching, functional strengthening, balance, agility, and fitness and cool down exercises) was given to group B for the duration of 8 weeks.

The result of the within-group comparison shows a highly significant improvement in balance and mobility in patients with chronic stroke in both groups. In the Otago exercise program group, the mean improvement in the BBS score was 10.19 (36.27 to 46.46) with a standard deviation of 2.136 (p<0.05), and the mean improvement in the POMA score was 4.61(19.42 to 24.04) with standard deviation 0.871 (p<0.05), which shows it is highly significant and suggests that there is a noticeable improvement in balance and mobility.