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Bobathtrunkfull 1945511915 Y
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Hacettepe University
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Muhammed Kılınç, Fatma Avcu, Ozge Onursal, Ender Ayvat, Cevher Savcun
Demirci & Sibel Aksu Yildirim
To cite this article: Muhammed Kılınç, Fatma Avcu, Ozge Onursal, Ender Ayvat, Cevher Savcun
Demirci & Sibel Aksu Yildirim (2016) The effects of Bobath-based trunk exercises on trunk
control, functional capacity, balance, and gait: a pilot randomized controlled trial, Topics in Stroke
Rehabilitation, 23:1, 50-58, DOI: 10.1179/1945511915Y.0000000011
Objective: The aim of this study was to investigate the effects of Bobath-based individually designed trunk
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exercises on trunk control, upper and lower extremity function, and walking and balance in stroke patients.
The main aim of treatment was to eliminate individual trunk impairments during various patient functions.
Methods: The study was planned as an assessor-blinded, randomized controlled trial. A total of 22 patients
volunteered to participate in the study. Trunk function, functional capacity, and gait were assessed with the
Trunk Impairment Scale (TIS), stroke rehabilitation assessment of movement (STREAM), and a 10-m
walking test, respectively. The Berg Balance Test (BBT), functional reach (FR), and timed up-and-go
(TUG) tests were used to evaluate balance. After the initial assessment, the patients were divided
randomly into two groups, the study group (12 patients) and the control group (10 patients). The mean
age of the patients in the study group was 55.91 years (duration of stroke 58.66 months) and that of the
control group was 54.00 years (duration of stroke 67.20 months). Individual training programs were
determined for the patients in the study group, taking into consideration their evaluation results; and
strengthening, stretching, range of motion, and mat exercises were determined for the control group
according to their functional level. The participants in both groups were taken into the physiotherapy
program for 12 weeks, 3 days a week for 1 hour a day.
Results: In group analyses, both groups showed improvement in STREAM, TIS, and TUG tests. Only the
study group produced significant gains in the BBT, FR, and 10 m walking tests (Pv0.05). According to the
pre- and post-treatment results, no significant difference was observed in any of the evaluated parameters
between the two groups (Pw0.05).
Conclusion: Individually developed exercise programs in the Bobath concept improve trunk performance,
balance, and walking ability in stroke patients more than do conventional exercises.
Keywords: Stroke rehabilitation, Trunk training, Bobath concept, Individually designed exercises
In the literature, there is moderate evidence regard- by Hacettepe University. All patients diagnosed by
ing the effectiveness of trunk training in stroke a neurologist as having had a stroke were invited to
patients.4 In a study conducted by Mudie et al.,5 participate in the study. The diagnoses were made
the effectiveness of three different physiotherapy based on the patients’ history and signs and con-
approaches (NDT, specific reaching tasks, and bal- firmed by computed tomography (CT) or magnetic
ance training) were compared and the Bobath resonance imaging (MRI). The inclusion criteria for
method was reported to be the most effective for the study were:
trunk development. However, in another study con- N patients in the subacute and chronic stages associ-
ated with stroke hemiparesis (time since stroke
ducted by Pollock et al.,6 which was similar in
onset v6 months)
design, trunk training with the Bobath concept was
reported to have no effect on sitting balance. In a
N patients with an affected trunk (those who did not
have full points in the Trunk Impairment Scale, TIS)
study performed by Verheyden et al.,7 it was stated N adults 18 years or older,
that 10 sessions of trunk range of motion exercises N patients who could sit and walk independently (or
those who used an aid for walking).
in addition to conventional therapy increased the lat-
eral flexion movements of the trunk, but that func- Exclusion criteria were:
tionally based activities are necessary for more (1) patients with recurrent strokes
effective trunk control. Karthikbabu et al.8 investi- (2) patients with communication problems
gated the effects of both unstable and stable surfaces (3) patients with orthopedic or neurological disorders
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on trunk control and observed that unstable surfaces (other than strokes) that might affect their motor
were more effective in improving control. In another performance.
study by the same researchers, trunk training was The study design is shown in Fig. 1. A total of 87
found to improve walking speed, cadence, and gait stroke patients were followed up in the outpatient
symmetry.9 Saeys et al.,10 in a randomized controlled clinic during the 16-month study period. Of the 32
study in 2012, reported that trunk training in patients who met the inclusion criteria, 22 volun-
addition to conventional methods had positive effects teered to participate in the study.
on trunk function, balance, and mobility.
According to the literature, improving muscle Design
strength and stability, increasing trunk range of The study was planned as an assessor-blinded ran-
motion, and improving static and dynamic trunk domized controlled trial. After the initial assessment,
control form the basis of current post-stroke treat- patients were divided randomly into two groups
ments.4 Although the importance of trunk control using a random numbers table. One of the authors
in post-stroke physiotherapy is emphasized in the lit- (EA) was made the randomization by using a compu-
erature, the relationship between functional disability ter-generated random number. Blocks were num-
and the trunk muscles has not yet been fully bered, and then a random-number generator
explained by clinical studies. In other words, if the program was used to select numbers that established
question of which trunk muscle or biomechanical the sequence in which blocks were allocated to study
problem is the basis of the affected function could or the control group. There were 12 patients in the
be clearly answered, trunk muscle interventions study group and 10 in the control group.
would provide more functional benefits.
The purpose of the present study was to investigate
the effects of the individually designed Bobath-based Interventions
trunk training on trunk control, functional skills, First, the demographic and clinical data for both
walking, and balance in stroke patients. In this groups were recorded. Individual training programs
study, the main aim was to eliminate individual were then created for the patients in the study
trunk impairments affecting various functions per- group. For this purpose, the functional limitations
formed by patients. of each individual patient were identified, and mul-
tiple hypotheses regarding the potential trunk-associ-
Method ated causes underlying each limitation were
This study, in which we evaluated the efficacy of the developed. By analyzing the various deficiencies, the
Bobath-based trunk training in stroke patients, was most important factor responsible for each impair-
performed at the Physiotherapy and Rehabilitation ment was detected. Verification tests for each hypoth-
Department of Hacettepe University between June esis were performed on the trunk muscles that were
2013 and October 2014. Ethical approval was given mainly responsible for the functional limitations,
and a specific intervention plan for the particular Instructor; International Bobath Instructors Training
impairment was identified and implemented. After Association (April 15–22, 2006 and June 22–28,
this, the hypothesis was verified by observing any 2006), School of Physiotherapy and Rehabilitation,
recent functional recovery or, where this could not Hacettepe University, Ankara, Turkey). The treat-
be confirmed, a new hypothesis was developed. ment program was developed taking the functional
These interventions (exercises) were applied to the limitations of the patients into account, and consisted
patients as a treatment program successfully in of seven trunk exercises according to the Bobath
terms of functional performance (details of the devel- concept.
opment of hypotheses are given in Schema 1). These were:
Experienced physiotherapists took part in the identi- 1. stretching of the latissimus dorsi muscle
fication of functional limitations and in stroke reha- 2. functional use and strengthening of the latissimus
dorsi
bilitation during the development and validation of
3. functional strengthening of abdominal and oblique
the hypotheses (SAY, MK: Course information: abdominal muscles
Assessment and treatment of adult hemiplegia – 4. placing exercises in order to facilitate trunk
The Bobath concept. Trainer: Elia Panturin, Senior extension
5. rotations and counter-rotations (right and left) of b. Able to perform only part of the movement
the hips with the trunk extended but in a manner that is comparable to the
6. training of lumbar spine stabilizers unaffected side (in our study, two points)
7. functional reach of shoulder, anterior, right, and left
sides. c. Able to complete the movement but only
In applying the exercises, the physiotherapists acted with a marked deviation from the normal pat-
in accordance with the fundamental principles of tern (in our study, three points).
the Bobath method, such as ensuring the active par- 2 Able to complete the movement in a manner
ticipation of the patient; obtaining high-quality func- that is comparable to the unaffected side (in our
tional movements; abundant repetitions; following a study, four points).
passive movement with an active movement; and In addition, we used the scoring system developed by
holding difficult movements in the inner-range Wang et al.14 in which voluntary movements of the
position. limbs are scored on a 3-point scale (0, unable to per-
Strengthening (trunk flexion–extension) and form the test movement; 1, only partially able to per-
stretching exercises (stretching and elongation), mat form the test movement; and 2, able to complete the
activities (bridging), functional activities (weight test movement). Basic mobility items are scored on a
transfer to from anterior to posterior and left to 4-point scale similar to that used for limb move-
right), and range of motion exercises (trunk flexion, ments, except that a category has been added to
allow for independence with the help of a mobility
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Risk of falling (timed up-and-go, TUG) subscale did not (Pw0.05) (Table 2). Total
Subjects are required to stand up from a chair with STREAM points and the lower extremity subscale
armrests, walk 3 m, turn around, return to the showed significant improvements in both groups
chair, and sit down. The time taken to complete (Pv0.05); however, mobility and the upper extremity
this task is measured in seconds with a stopwatch.19 subscales improved only in the study group (Pv0.05)
(Table 2).
Statistical analyses The STREAM results of the patients who partici-
Statistical analyses of the data were performed with pated in the study are presented in a different table
SPSS 15.00. The quantitative and qualitative data in order to show changes in quality. In this table,
were expressed as mean+ standard deviation the STREAM scale items concerning trunk perform-
(x+ SD) and percentages, respectively. Wilcoxon’s ance in particular (numbers 4, 5, 6, 8, 9, 15, 21, 22,
signed ranks tests were used for group analyses, 23, 26, and 29), were intended to show more accu-
and the Mann–Whitney U test was used to compare rately and in detail changes in the quality of the
different groups. The level of significance was set at movement before and after the treatment. For
Pv0.05. example, whereas item 4 scores (rolling onto side)
showed no change with treatment in seven patients
Results from the study group, an improvement in the quality
of the movement was observed in three patients after
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Age (mean+ SD) (min–max) 55.91+ 7.92 (38–72) 54+ 13.64 (27–73) 0.68
Duration (month) (min–max) 58.66+ 55.68 (9–180) 67.20+ 43.17 (11–144) 0.69
Gender Eight females, four males Five females, five males
Hemi-side Three right, nine left Two right, eight left
Type of stroke Six ischemic, six hemorrhagic Five ischemic, five hemorrhagic
Berg Balance Test 45.33+ 2.23 46.10+ 2.47 0.45
Timed up-and-go 17.59+ 7.29 17.51+ 7.59 0.98
Functional reach 19.98+ 4.41 20.51+ 5.99 0.81
10 m walking test 18.33+ 11.00 14.49+ 5.83 0.33
Trunk Impairment Scale 13.42+ 4.29 14.80+ 5.31 0.50
Static sitting balance 4.67+ 1.50 5.70+ 1.83 0.16
Dynamic sitting balance 6.00+ 2.45 6.50+ 2.80 0.66
Coordination 2.75+ 2.22 2.60+ 2.22 0.87
Stroke rehabilitation assessment of movement 45.08+ 12.60 46.10+ 13.03 0.85
(STREAM)
Upper extremity (0–20) 11.50+ 5.87 11.10+ 6.31 0.87
Lower extremity (0–20) 13.42+ 3.63 14.0+ 3.19 0.60
Mobility (0–30) 20.17+ 5.77 20.80+ 5.53 0.79
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The most important feature of our study is that the rather than their quality. However, in our study, 11
trunk training was individually planned and func- items of the STREAM scale, thought to be related
tionally oriented. Multiple hypotheses regarding to the trunk, offer a detailed examination opportu-
functional limitations and trunk impairment were nity to reflect the quality of changes. According to
developed for each patient, tested, and refined, and the STREAM scale results, in six of the 10 patients
eventually a treatment plan focusing on the individ- for the item ‘‘abducts affected hip with knee
ual patient’s needs was developed, taking into extended’’ (one patient in the control group), five
account the principles of the Bobath concept. Exer- patients in the ‘‘flexes hip in sitting’’ item (two
cises were determined according to the functional patients in control group), four patients in ‘‘places
expectations of the patient and modified in accord- hand on sacrum’’ item (one patient in control
ance with their functional level. Each exercise was group), three patients in ‘‘rises to standing from sit-
combined with functional activity, the goal of ting’’ and ‘‘maintain standing for 20 seconds’’ items
which was to achieve both normal and fine move- became moving ‘‘compatible with healthy side
ments. From this perspective, the results of our level,’’ in other words moved more qualified.
study provide more accurate data on the effectiveness Improvements in the results of the STREAM scale
of the Bobath concept in stroke patients. For these correlate with those of the Berg Balance Scale, which
reasons, so far as we are aware, ours is the first orig- also evaluate quality, because the first two items of
inal study on this subject. the Berg Balance Scale are the same as those assessed
Another factor that makes our results worthwhile by STREAM, i.e. standing up from sitting and stand-
is the evaluation of the quality of movement and ing without support. When the results of these two
function after the treatment. The results of the measures were considered together in the study
STREAM scale, which is widely used to assess group, the improvements were proved statistically
motor function in stroke patients, are provided to (Berg Balance Scale), and the individual results as
indicate changes in the quality of activities. Accord- to how much each movement improved were detailed
ing to the Bobath concept, the quality of movement (STREAM).
and function in stroke patients is one of the most There are two studies in the literature on the effects
important goals of treatment, and evaluation of trunk exercises on reaching activity.21,22 The
approaches should include this parameter. In pre- results of the present study indicated significant
vious studies, inadequacies in the reflection of improvements in functional reaching after treatment
changes in the quality of movement are outstanding. only in the study group. In this regard, our results
Although most studies have stressed that quality is are compatible with those of Thielman and
an important goal of treatment, assessments have Dean21,22.
been made by tests such as the Fugl–Meyer, River- The effects of trunk training on sitting balance and
maid, and Frenchay Activity Index, evaluating trunk performance were evaluated by TIS in five pre-
whether movements are done or not, or how often, vious studies,2,7,8,10,23 and significant developments in
56
Table 2 Pre- and post-treatment values of the Berg Balance Test, timed up-and-go, functional reach, 10 m walking, Trunk Impairment Scale, and stroke rehabilitation assessment of
Kılınc et al.
movement (STREAM) scales for the study and control group patients
95% CI 95% CI
Berg balance (0–56) 45.40+ 2.46 45.80+ 2.53 {0.77 {0.03 0.037* 46.44+ 2.35 46.67+ 2.60 {0.56 0.12 0.169
Timed up-and-go (seconds) 18.80+ 7.41 16.12+ 5.32 0.41 4.95 0.026* 18.38+ 7.49 16.18+ 6.15 0.82 3.59 0.006*
2016
Static sitting balance 4.70+ 1.49 5.30+ 1.64 {1.29 0.09 0.081 6.00+ 1.66 6.00+ 1.66 1
Effects of Bobath-based trunk exercises
Dynamic sitting balance 6.30+ 2.00 7.40+ 2.22 {1.73 {0.47 0.003* 7.11+ 2.15 7.78+ 2.17 {1.33 0.00 0.05*
Coordination 2.50+ 2.17 2.90+ 2.23 {1.00 0.20 0.168 2.77+ 2.28 2.77+ 2.28 1
VOL .
STREAM (0{–70) 43.90+ 11.89 53.70+ 11.20 {14.74 {4.86 0.002* 46.00+ 13.82 48.44+ 14.49 {3.73 {1.16 0.002*
23
Upper extremity (0–20) 10.90+ 5.74 13.90+ 6.37 {4.91 {1.09 0.006* 11.67+ 6.42 12.00+ 6.50 {1.19 0.53 0.397
Lower extremity (0–20) 13.40+ 3.41 16.70+ 3.53 {5.02 {1.58 0.002* 14.00+ 3.32 15.56+ 4.07 {2.23 {0.88 0.001*
Mobility (0–30) 19.60+ 5.91 23.10+ 4.61 {6.33 {0.67 0.021* 20.33+ 5.66 20.89+ 5.67 {1.23 0.12 0.95
NO .
1
Evaluated by Wilcoxon’s signed ranks test; *pv0.05.
Table 3 Patient improvement according to the stroke rehabilitation assessment of movement (STREAM) scores
Mean+ SD
TIS results were shown by all like our results. The implemented on the base of the Bobath concept. In
results of another study24 demonstrated that addition, performing the trunk exercises not just for
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deficiencies of trunk function in stroke patients had the trunk but also for the upper and lower extremi-
adverse effects on standing and walking. These ties, balance, and gait performance to reach a
results were interpreted as indicating that improve- higher quality of function, makes this study different
ments in walking cannot be obtained with walking from others. In this regard, it can be suggested that
exercises only, and so trunk exercises must also be individually developed exercise programs according
attached to the treatment program. However, in to the Bobath concept improve trunk performance,
Dean et al.’s study,21 performed in 2007, the effects balance, and walking activities in stroke patients.
of trunk training on walking were assessed by a 10-
m walking test, but no change was found in walking Acknowledgements
performance with the 2-week training program com- The authors would like to thank their patients for
pared with the control group. In our study, at the end volunteering for the study.
of the 12-week training program, the 10-m walking
activity test showed significant changes in walking Disclaimer Statements
performance in the study group. In Dean’s study,
Contributors
the lack of significant improvement in walking per-
MK and SAY planned the study and generated the
formance was associated with the baseline differences
multiple hypotheses, and also prepared the phy-
in walking speeds of the two groups. Furthermore,
siotherapy program for the two groups of patients.
our study was much longer than that of Dean, and
FA coordinated the treatment of both groups, EA
we think this may have influenced our results posi-
performed the randomization, and CD and ÖO per-
tively in favor of the study group.
formed the patient assessments.
The most important limitations of the present study
are the absence of a power analysis and the small
Funding
number of patients involved. The lack of significant
The authors, their immediate family, and any
differences between the groups is believed to be due to
research foundation with which they are affiliated
the number of patients included in the study. Moreover,
have received no financial payments or other benefits
all participating patients were evaluated and treated
from any commercial entity related to the subject of
within the study period of 15 months. Therefore, our
this article.
results are presented as a pilot study and we have applied
to the ethical committee for permission to extend its Conflicts of interest
duration and increase the number of patients. There is no conflict of interest in this study.