6
Brief Resume of the Intended Work:
6.1 Need for the study:
Stroke is the most common cause of neurological disability in the adult population. It is responsible for
about a quarter of all deaths in the developed countries and account for much disability in the elderly.
The WHO, defines Stroke as rapidly developing clinical sign of a focal disturbance of cerebral
function of presumed vascular origin and of more than 24 hours duration, included within this
definition are most cases of cerebral infarction, cerebral hemorrhage and subarachnoid hemorrhage but
deliberately excluded are those cases in which recovery occurs within 24 hrs.1
In India, during the last decade the age adjusted prevalence rate of stroke was between 250350/100,000. Hypertension was the most important risk factor.2
Stroke is classified by etiological categories (thrombosis, embolus, or hemorrhage), specific vascular
territory (anterior cerebral artery syndrome, middle cerebral artery syndrome, and so forth) and
management categories (transient ischemic attack, minor stroke, major stroke, deteriorating stroke,
young stroke). Ischemic stroke is the most common type of stroke affecting about 80 percent of
individuals with stroke and Middle Cerebral Artery(MCA) is the most common site of occlusion in
stroke.3
Common impairments after stroke are impaired motor function, sensory, perceptual deficits, impaired
balance, cognitive limitations, aphasia and depression. The recovery of independence following stroke
is a complex process requiring the reacquisition of many skills. Since controlling the body’s position in
space is essential part of functional skills, restoration of balance is a critical part of the recovery of
ability after stroke.3
Sensory systems involved in maintenance of balance are visual, vestibular and somatosensory. The
somatosensory system provides the CNS with position and motion information about the body with
1
reference to supporting surfaces also somatosensory inputs throughout the body report information
about the relationship of body segment to one another and hence maintaining balance.4
Balance control is a complex sensorimotor function requiring the integration in the vestibular nuclei of
vestibular, visual, and somesthetic information to generate a context-specific motor response.
Maintaining balance requires the normal functioning of many parts of the brain such as a normal inner
ear, normal innervations and a control centre at the cerebellum.5
The specific causes of balance disorders in hemiparetic patients after stroke can be manifold. Balance
can be affected in various ways which include joint motion limitation, weakness, altered muscular
tone, sensory deficits, anomalous postural reactions and cognitive problems.6 A further important cause
of balance impairment in patients with stroke hemiparesis, in the absence of elementary sensory
deficits at clinical evaluation, is a deficit of the central integration of sensory inputs (somatosensory,
visual and vestibular).In normal adult subjects, the visual, vestibular and somatosensory systems are all
involved in balance control and make up the system of coordinates on which the body’s postural
control is based.6
Since stroke subjects often present with somatosensory deficits, the adaptation of regular exercises
with the use of surface and vision manipulation to challenge balance could improve the process of
somatosensory integration and have a positive effect on postural stability.7
Postural control depends on somatosensory information from the feet in contact with the surface. An
unstable surface increases the external swing which more effectively encourages postural orientation
by forcing faster modifications of the sensory system and motor system. Furthermore, it assists in the
postural strategy of self-postural control. It also sensitize the muscle spindle through gamma motor
neurons thereby improving motor output, which influences the stability of joints.8
It has been seen that when
balance exercises were performed under various sensory input
manipulations, balance and walking speed were significantly increased which indicated that
2
rehabilitation of sensorimotor integration deficits can improve balance in patients with stroke
hemiparesis.6 Also, task-oriented exercise program, assisted by sensory manipulation for 8 weeks, has
been found to be more effective at improving the standing balance of stroke subjects than a
conventional task-oriented program.7 It was found that when sitting balance training was given under
varied sensory input for 2 weeks, it was found to be more effective for improving balance and quality
of life than sitting balance training without varied sensory input in stroke patients.4
Studies have shown that 6 weeks of wobble board exercise improved both static (eye closed) and
dynamic balance of stroke survivors.5 Another study comparing balancing exercises on unstable
surface and stable surface concluded that exercises on an unstable surface was more effective than on a
stable surface at improving balance of stroke patients. The Berg Balance Scale score of both groups
were increased after 6 weeks indicating improved balance ability.8 A study done in spinal cord injury
patients found that 4 weeks of balance training on unstable surface improved sitting balance as
indicated by improved MFRT score and swaying area.9
Most of the work done regarding balance training in stroke patients has focused on task-oriented
activities with varied sensory input.4,5,7,10,11 Some studies have also compared the effect of stable and
unstable surfaces on balance in stroke patients and found that balance training on unstable surfaces is
more effective.5,8 Training on unstable surfaces has also proved to be effective in improving balance in
other neurological conditions like spinal cord injury.9 Since balance training with varied sensory input
and balance training on unstable surfaces is found to be equally effective in stroke patients, there is no
research as yet suggesting which balance training program among the two are more effective in stroke
patients with balance impairments. Hence, a study to compare the two balance training programs needs
to be done.
Hypothesis :
Null hypothesis: There will be no significant difference between training under varied sensory input
3
and training on an unstable surface on balance in stroke subjects.
Alternate hypothesis: There will be significant difference between training under varied sensory input
and training on an unstable surface on balance in stroke subjects..
6.2 Review of Literature:
Literature Review on Stroke Subjects:
Sarah F Tyson et al (2006) conducted a study to investigate the frequency of balance disability; to
characterize different levels of disability; and to identify demographics, stroke pathology factors, and
impairments associated with balance disability.75 subjects with a first-time anterior circulation stroke
were included and Prospective hospital-based cross-sectional surveys were carried out. The subjects’
stroke pathology, demographics, balance disability, function, and neurologic impairments were
recorded in a single testing session 2 to 4 weeks after stroke and they concluded that subjects with the
most severe balance disability had the most severe strokes, impairments, and disabilities. Subject
demographics, stroke pathology, and visuo-spatial neglect were not associated with balance
disability.12
I Chun Chen et al (2002) conducted a study to evaluate the delayed effects of balance training
program on hemiplegic stroke patients.41 subjects were randomly assigned into two groups; the
control group and trained group. Visual feedback balance training with the SMART Balance Master
was used in the trained group whereas, control group received conventional physical therapy. The
training protocol was 20 minutes per day, 5 days per week for 2 weeks and the outcome measures were
FIM score and SMART balance master. They concluded that balance training was beneficial for
patients after hemiplegic stroke.11
Mudie MH et al (2002) conducted a study to determine the most effective of three treatment
approaches (task-specific reach, Bobath, or Balance Performance Monitor [BPM] feedback training) to
retrain seated weight distribution long-term after stroke and whether improvements could be
4
generalized to weight distribution in standing. 40 asymmetrical stroke subjects were randomly
allocated to each of three treatment groups and a no specific training control group. One week of
measurement only was followed by two weeks of daily training sessions and measurements were
performed using the BPM daily before treatment sessions, two weeks after cessation of treatment and
12 weeks post study. They concluded that it might be possible to restore postural symmetry in sitting
in the early stages of rehabilitation with therapy that focuses on creating an awareness of body
position.13
Catherine M. Dean et al (1997) conducted a randomized placebo-controlled study to evaluate the
effect of a 2-week task-related training program aimed at increasing distance reached and the
contribution of the affected lower leg to support and balance. Twenty subjects at least 1 year after
stroke were randomized into an experimental and control group. The experimental group participated
in a standardized training program involving practice of reaching beyond arm’s length and the control
group received same training involving completion of cognitive-manipulative tasks within arm’s
length. Performance of reaching in sitting was measured before and after training using two seated
reaching tests. The study concluded that it provided strong evidence about the efficacy of task-related
motor training in improving the ability to balance during seated reaching activities after stroke.14
Literature Review on Balance:
Wim Saeys et al (2012) conducted a study to assess the effect of additional truncal exercises on
truncal function, standing balance, and mobility. An assessor-blinded randomized controlled trial was
carried out on 33 participants were randomly assigned to an experimental group (n = 18) or a control
group (n = 15). In addition to conventional therapy, the experimental group received 16 hours of
truncal exercises and the control group received 16 hours of same treatment. Truncal function was
evaluated by the Trunk Impairment Scale (TIS) and standing balance and mobility by the Tinetti Test.
The Romberg with eyes open and eyes closed, Four Test Balance Scale (FTBS), Berg Balance Scale
(BBS), Rivermead Motor Assessment Battery (RMAB), Functional Ambulation Categories, and
5
Dynamic Gait Index (DGI) were performed to elucidate the findings of the primary outcome measures.
They concluded that in addition to conventional therapy, truncal exercises have a beneficial effect on
truncal function, standing balance, and mobility in people after stroke.15
Mee Young Kim et al (2012) conducted a study to evaluate the effect of functional electrical
stimulation (FES) according to the treatment position (standing and supine) on stroke patients. 9 subacute stroke subjects were divided into two groups according to the position for treatment by FES
(standing group and supine group).The duration of FES in both groups was 30 minutes, 6 times a week
for 8 weeks and the subjects were evaluated every 2 weeks for 8 weeks using the timed-up-and-go test
(TUG) and berg balance test(BBT).The study concluded that the standing position is more beneficial
to the recovery of balance ability after stroke than the supine position.16
Katherine I. Ites et al (2011) conducted a systemic review taking databases from CINAHL,
EMBASE, Medline and Cochrane from inception till June 2009 to assess the effectiveness of
interventions used by physical therapists to minimize balance dysfunction in people with Diabetic
Peripheral Neuropathy and concluded that lower extremity strengthening exercises should be given a
fair recommendation for clinical use in treating balance dysfunction in patients with Diabetic
Peripheral Neuropathy.17
Jung Hee Kim et al (2010) conducted a study to examine the effect of balance training on an unstable
surface on spinal cord injury patients.12 patients were divided into experimental and control group.
The experimental group was treated with conventional physical therapy and exercises on an unstable
surface for 4 weeks (30 minutes a day, 5 times a week) whereas; control group received only
conventional physical therapy. Modified Functional Reach Test (MFRT), sway area and sway velocity
using BPM were measured before and after the training. They concluded that exercise on an unstable
surface improves the sitting balance of patients with spinal cord injury and this treatment can be
recommended as an effective treatment for patients with spinal cord injury.9
Literature Review on Balance Training with Varied Sensory Input:
6
Maurya M et al (2010) conducted a study to know the effect of balance training in sitting position
under varied sensory input for improving balance and quality of life in stroke patients.30 stroke
subjects were selected and randomized into an experimental and control group. The experimental
group participated in sitting balance training under varied sensory input for 2 weeks and control group
were given sitting balance training without varied sensory input. Performance of training were
measured before and after sitting balance training using berg balance scale, stroke specific quality of
life questionnaire and sitting and sit to stand component of motor assessment scale. They concluded
that Sitting balance training under varied sensory input is more effective for improving balance and
quality of life than sitting balance training without varied sensory input in stroke patients.4
Nicola Smania et al (2008) conducted a study on 7 chronic hemiparetic patients to evaluate whether
balance exercises performed under various sensory input manipulations can improve postural stability
and/or walking ability. Seven chronic hemiparetic subjects were recruited. Patient performance was
assessed before, immediately after and one week after treatment (consisting of 20 one-hour daily
sessions of several balance exercises) by means of the Sensory Organization Balance Test and the Ten
Metre Walking Test. They concluded that rehabilitation of sensorimotor integration deficits can
improve balance in patients with stroke hemiparesis.6
Kelly P Westlake et al (2007) conducted a randomized controlled trial to investigate the effect of
sensory-specific balance training on proprioceptive reintegration. 36 older participants were randomly
assigned to a balance exercise group or a falls prevention education group. The primary outcome
measure was the center of pressure (COP) velocity change score. This score represented the difference
between COP velocity over 45 seconds of quiet standing and each of six 5-second intervals following
proprioceptive perturbation through vibration with or without a secondary cognitive task. Clinical
outcome measures included the Fullerton Advanced Balance (FAB) Scale and the Activities-specific
Balance Confidence (ABC) Scale. Assessments were conducted at baseline, post-intervention, and at
an 8-week follow-up. concluded that the study supported short-term enhanced postural responses to
7
proprioceptive reintegration following a sensory-specific balance exercise program.18
Bayouk Jean François et al (2006) conducted a study to compare the effects of a task-oriented
exercise program with and without altered sensory input on postural stability in subjects with stroke.
16 hemiparetic subjects, at least 6 months post-stroke, were randomly assigned to the experimental or
control group, and participated in an 8-week task-oriented exercise program focusing on balance and
mobility exercises. Exercises were performed under normal conditions by the control group, and under
conditions of vision and surface manipulation by the experimental group. Pre- and post-test
assessments involved the measurement of the center of pressure (COP) displacement during doublelegged stance and sit-to-stand under four sensory conditions: (1) eyes open, normal surface; (2) eyes
open, soft surface; (3) eyes closed, normal surface; and (4) eyes closed, soft surface, as well as the 10m walking test. They concluded that a task-oriented exercise program, assisted by sensory
manipulation, is more effective at improving the standing balance of stroke subjects than a
conventional task-oriented program.7
Hu MH et al (1994) conducted a study on 25 health older adults to know effects of standing balance
training on the ability to maintain stability in both static two-leg and one-leg stance. 24 subjects were
randomly assigned to a training or control group. Training subjects received a 10-hour balance training
program for 4 weeks which selectively manipulated sensory inputs from the visual, vestibular, and
somatosensory systems and the outcome measure was root-mean-square values of antero-posterior
platform torque. They concluded that balance training designed to improve intersensory interaction
could effectively improve balance performance in healthy older adults.10
Literature Review on Balance Training on Unstable Surfaces:
Ogaya Shinya et al (2011) conducted a study to assess the effects of wobble board balance training on
physical function on institutionalized elderly people. 23 subjects were divided into an experimental
and a control group. The exercise program for the training group comprised balance training standing
on a wobble board for 10 minutes for 9 weeks, twice a week. After 9 weeks, standing time on a wobble
8
board, standing time on a balance mat, and maximum displacement distance of anterior-posterior
center of pressure were measured. They concluded that wobble board training is effective for elderly
people to improve their standing balance, by which they frequently control their center of gravity and
maintain a standing posture on unstable surface conditions.19
Ji Yeun Lee et al (2011) conducted a study to investigate the effects of balancing exercises on
unstable surfaces on the balance ability of stroke patients in comparison with balancing exercises on
stable surfaces. 30 stroke patients were divided into two groups; a stable surface exercise group and an
unstable surface exercise group. The balancing exercises were conducted 6 times a week for 6 weeks
and the balance was measured using the Berg balance scale (BBS) and parameters of sway of the
centre of pressure (COP).The study concluded that balancing exercise on an unstable surface was more
effective than on a stable surface at improving the balance of stroke patients.8
Ayodele Teslim Onigbinde et al (2009) conducted a study to determine the effect of a wobble board
exercise program on static and dynamic balance on hemiplegic subjects. 17 stroke survivors were
randomly selected into two groups. The subjects in the experimental group were trained on wobble
board for 6 weeks while the control group received only the baseline treatment programs. The
modified version of the timed balance test was used to assess balance while the four square step test
was used to assess dynamic balance and they concluded that wobble board exercise improved both
static (eye closed) and dynamic balance of stroke survivor used in this study.5
Literature Review on Berg Balance Scale:
Lisa Blum et al (2008) conducted a systematic review of 21 studies regarding the psychometric
properties of the Berg Balance Scale (BBS) specific to stroke and to identify strengths and weaknesses
in its usefulness for stroke rehabilitation. Twenty-one studies examining the psychometric properties
of the BBS with a stroke population were reviewed and they concluded that the BBS is a
psychometrically sound measure of balance impairment for use in post-stroke assessment.20
9
Hui Fen Mao et al (2002) conducted a study on to compare the psychometric properties of 3 clinical
balance measures, the Berg Balance Scale (BBS), the Balance subscale of the Fugl-Meyer test (FM-B),
and the Postural Assessment Scale for Stroke Patients (PASS), in stroke patients with a broad range of
neurological and functional impairment from the acute stage up to 180 days after onset. One hundred
twenty-three stroke patients were followed up prospectively with the 3 balance measures 14, 30, 90,
and 180 days after stroke onset and the study concluded that all 3 measures tested showed very
acceptable levels of reliability, validity, and responsiveness for both clinicians and researchers.2
6.3 Objectives of the Study:
1. To determine the effectiveness of training under varied sensory input on balance in stroke
subjects.
2. To determine the effectiveness of training on an unstable surface on balance in stroke subjects.
3. To compare training under varied sensory input and training on an unstable surface on balance
in stroke subjects.
7
Material and methods:
7.1 Source of Data:

ESI Hospital, Rajajinagar, Bangalore.

Padmashree Clinic, Near Nagarbhavi Circle, Bangalore

Ravi Kirloskar Memorial Hospital, Peenya , Bangalore
7.2 Methods of Collection of Data:

Population
:
Stroke subjects

Sample design
:
Convenient sampling

Sample size
:
30
10

Study design
:
Pre to post experimental and comparative study

Duration
:
6 months
Inclusion Criteria:

40-60 years of age

3-6 months post stroke8

Motor Assessment Scale sitting score of 3 4

Both males and females

No visual deficits

No sensory deficits

Ability to reach with intact arm distance equivalent to 140% of arm’s length4
Exclusion Criteria:

Any cognitive deficits4,6

Any problem which would interfere with the ability to do sitting tasks.4

Any other neurological deficits as multiple sclerosis, Parkinson’s disease etc.

Any musculoskeletal disorder like osteoarthritis, ligament injury etc.

Patient undergoing any other balance training protocol.

Non-cooperative patients
Intervention to be conducted on the patients:
Informed consent will be taken from the subjects. The subjects will be included based on the inclusion
and exclusion criteria. Then the patients will be divided into two groups considering the variables like
age, sex, side affected, area of lesion and duration of stroke.
Group A will receive balance training under varied sensory input with conventional physiotherapy
program. In this group all selected subjects will undergo sitting balance training protocol under varied
sensory input for two weeks.
11
For training in sitting, a stool without backrest will be selected for each subject and the height of stool
will be standardized for each subject. It will be adjusted to 100% of lower leg length which will be
measured from lateral knee joint line to the floor with subject standing barefoot. Also the measurement
of arm length will be done, which will be measured from tip of acromium process to the tip of middle
finger in inches.
Then the stool will be placed at a distance of 140% of arm length and line will be marked with the help
of adhesive tape on wall at 140% of arm length at shoulder level and the subject will sit on stool.
Varied sensory input will be provided to the subject in form of air filled pillows below the buttock as
well as feet. The amount of air filled will be kept constant during the entire training period.
In training protocol all subjects will be asked to touch the marked line on wall in three directions;
forward, 45 degrees towards unaffected side and 45 degrees across the body towards affected side
using unaffected hand subjects will be asked to perform all these reaching activities.
Each session will last for 20 to 30 minutes, which consists of five sessions per week for two weeks
and each session will consist of 20 repetitions, 5 times in each session in each direction.
The experimental group also will receive conventional physiotherapy for stroke which includes
strengthening and stretching exercises for upper and lower limb. It will be in the form of 1-3 sets of
10-15 repetitions in each session.4
Group B will receive balance training on an unstable surface (rocker board) with conventional
physiotherapy program.
First the subjects will sit on a stable surface with their legs straight on the floor. For distance
measurements, each subject will be seated on a square piece of paper placed on a stable surface with
the legs straight.
12
The distance after reaching forward, to the left and to the right will be separately measured. A bar will
be placed at 2 cm beyond the subjects’ initial maximum reach point in each test. Then, a rocker board
will be placed on a stable surface.
A square piece of paper will be placed on the rocker board, and each subject will have to sit in the
center of the board with their legs straight ensuring that the board did not tilt. While sitting on the
rocker board, each subject will reach forward, to the left and to the right, while trying to reach the bar.
Only when the subject could actually touch the bar will they be marked “task completed’. For forward
reach, both hands will be extended. For the left and right side reach, reaching from one side to the
other will be counted as a lap.
Finally, each subject will be seated on the rocker board with their legs straight. They will be then
asked to hold a ball with both hands and raise it up over the head. The starting position will be to hold
the ball with elbows flexed 90º. Only when the ball will be raised above the eye level with the head up
straight will it be counted as ‘task completed’.
Each task will be performed in sets of 5, consisting of 10 repetitions, each with a one minute break
between each set. Training will be performed 5 times a week, for 2 weeks.9
The experimental group also will receive conventional physiotherapy for stroke which includes
strengthening and stretching exercises for upper and lower limb. It will be in the form of 1-3 sets of
10-15 repetitions in each session.4
Before starting the intervention the subjects will be assessed with Berg Balance Scale (Premeasurement).
After 2 weeks of completion of intervention, subjects will be assessed with Berg Balance Scale (Postmeasurement) and the data will be analyzed.
Outcome measure :
13
Berg Balance Scale
Statistical Analysis:

Data analysis will be performed by SPSS (version 17) for windows. Alpha value will be set as
0.05.

Descriptive statistics will be used to find out mean, standard deviation and range for
demographic and outcome variable.

Wilcoxon’s test will be used to compare the improvement within the two groups.

Mann-Whitney ‘U’ test will be used to compare the improvement between the two groups.
7.3 Does the study require any investigation or interventions to be conducted on patients or
other humans or animals? If so, please describe briefly.
Yes, the study requires intervention to be conducted on stroke subjects of both genders with the age
group of 40 to 60 years having sub-acute stroke to compare the effectiveness of balance training
with varied sensory input and balance training on an unstable surface.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
As this study includes human subjects, ethical clearance for the study has been obtained from the
institutional ethical committee, Padmashree Institute of Physiotherapy & concerned hospitals in
Bangalore, as per the ethical guidelines for biomedical research on human subjects, 2000.ICMR, New
Delhi.
8
List of References:
1. Patricia AD. Cash textbook of neurology for Physiotherapist. 4th ed: Jaypee brothers medical
publishers; 1993
2. Banerjee TK, Das SK. Epidemiology of stroke in India. Neurology Asia. 2006;11:1-4
14
3. Sullivan SB, Schmitz TJ. Physical Rehabilitation. 5th ed: Jaypee brothers medical publishers;
2006.
4. Ibrahimi N, Tufel S, Singh H, Maurya M. Effect of sitting balance training under varied
sensory input on balance and quality of life in stroke patients. Indian Journal of Physiotherapy
and Occupational therapy. 2010;4(2):44-49
5. Ayodele TO, Awotidebe T, Awosika H. Effect of 6 weeks wobbles board exercises on static
and dynamic balance of stroke survivors. Technology and Health Care. 2009; 17:387–392.
6. Smania N, Picelli A, Gandolf M, Fiaschi A, Tinazzi M. Rehabilitation of sensorimotor
integration deficits in balance impairment of patients with stroke hemiparesis: a before/after
pilot study. Neurol Sci. 2008; 29:313–319
7. François BJ, Boucher JP, Leroux A. Balance training following stroke: effects of task-oriented
exercises with and without altered sensory input. International Journal of Rehabilitation
Research. 2006; 29(1):51-59
8. Lee JY, Park JS, Lee DH, Roh HL. The effect of exercising on unstable surfaces on the balance
ability of stroke patients. J. Phys Ther Sci. 2011; 789-792
9. Kim JH, Chung YJ, Shin HK, Effects of Balance training on patients with spinal cord injury,
2010, J Phys Ther Sci. 2010; 22:311-316
10. Hu MH, Woollacott MH. Multisensory training of standing balance in older adults: Postural
stability and one-leg stance balance. J Gerontol. 1994; 49(2):M52-61
11. Chen IC, Cheng PT, Chen CL, Chen SC, Chung CY, Yeh TH. Effects of Balance Training on
Hemiplegic Stroke Patients. Chang Gung Med J. 2002; 25:583-90
15
12. Tyson SF, Hanley M, Chillala J, Selley A, Tallis RC. Balance Disability After Stroke. Phys
Ther. 2006; 86:30-38.
13. Mudie MH, Winzeler-Mercay U, Radwan S, Lee L. Training symmetry of weight distribution
after stroke: a randomized controlled pilot study comparing task-related reach, Bobath and
feedback training approaches. Clin Rehabil. 2002; 16(6):582-92
14. Dean CM, Shepherd RB. Task-Related Training Improves Performance of Seated Reaching
Tasks After Stroke. American stroke association. 1997; 28:722-728
15. Saeys W, Truijen LV, Lafosse C, Wuyts FP, Heyning PV. Randomized Controlled Trial of
Truncal Exercises Early After Stroke to Improve Balance and Mobility. Neurorehabil Neural
Repair. 2012; 26(3):231-238
16. Kim MY, Kim JH, Lee JU, Yoon NM, Junghwan BK. The effects of functional electrical
stimulation on balance of stroke patients in the standing posture. J Phys Ther Sci. 2012; 24:7781
17. Ites KI, Anderson EJ, Cahill ML, Kearney JA, Post EC, Gilchrist LS. Balance Interventions for
Diabetic Peripheral Neuropathy: A Systematic Review. J Geriatr Phys Ther. 2011; 34:109-116
18. Westlake KP, Culham EG. Sensory-Specific Balance Training in Older Adults: Effect on
Proprioceptive Reintegration and Cognitive Demands. Phys Ther. 2007; 87:1274-1283
19. Shinya O, Tome I, Naoki S, Noriaki I. Effects of Balance Training Using Wobble Boards in the
Elderly. Journal of Strength and Conditioning Research. 2011; 25(9): 2616-2622
20. Blum L, Bitensky NK. Usefulness of the Berg Balance Scale in Stroke Rehabilitation: A
Systematic Review. Phys Ther. 2008; 88:559-566.
16
21. Mao HF, Hsueh IP, Tang PF, Sheu CF, Hsieh CF. Analysis and Comparison of the
Psychometric Properties of Three Balance Measures for Stroke Patients. American stroke
association. 2002; 33:1022-1027
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