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Does lumbar mobilization help stroke patients to improve functional outcomes?

Byline: Umama Haq, Arshad Nawaz Malik and Qurat-Ul-Ain

Abstract

Stroke survivors often face functional deficits and gait impairments. The current study aimed to observe effects of lumbar mobilization on gait of stroke patients. Quasi interventional study was conducted on 30 stroke survivors. Sample included either gender with onset of stroke (>03-months), patients with other pathologies were excluded. Gait was assessed using gait dynamic index, timed up and go test; 5-times sit to stand and 10meter walk test. Three sessions of lumbar mobilization were given to all patients and the data were analyzed on Spss-20. Participants had a mean age of 50+-10.66 years. Among stroke survivors 20(66.7%) had haemorrhagic stroke while 10(33.3%) stroke survivors had ischaemic stroke. After 03 days of intervention significant improvement was recorded in timed up and go test score (p<0.001) 5-times sit to stand (p<0.001) and 10-meter walk test (p<0.001).

Dynamic balance and walking also improved as reported by gait dynamic index (p<0.001). The Current study suggested lumbarmobilization to be effective in improving gait in stroke survivors.

Keywords: Gait, Lumbar mobilization, Stroke.

Introduction

Trunk is the vital part of body and its control is essential for optimal performance. Keeping body upright, adjusting weight shifts and selective movement of trunk muscle with center of mass controlled in with base of support during postural changes either static or dynamic is defined as trunk control.1-3 Likhiet al in their recent study found that functional independence is highly correlated with level of trunk impairment in stroke survivors.4 Stroke leaves an individual with numerous limitations including sensory-motor impairment of the trunk thus affecting functional performance.2 Stroke alters individual's trunk muscle strength and position sense 2 having significant influence on balance in patients. In addition specific movements at lower and upper trunk are compromised in chronic stroke 3 Karthikbabu et al in their review reported that trunk exercises improve functional and balance performances in hemiplegic stroke survivors.5

Evidence regarding stability of trunk influencing specific functional activities is still insufficient and requires further investigations.6 Likewise no evidence was found whether spinal mobilization is effective for improving trunk problems in stroke patients although it's quite evident that spinal mobilization is effective in managing most mobile lumbar area of the trunk.7 Stroke survivors face functional deficits and gait problems. The Current study aimed to observe effects of lumbar-mobilization on gait of stroke patients. The purpose of this study is to observe the effects of lumbar mobilization on gait in stroke patients.

Table: Friedman Test FOR TUG, 10 Meter Walk Test and 5 Times Sit To Stand.

Variables###Mean+-Std. Deviation###p-value

5 STSTS Baseline###21.19+-8.98###<0.001

5 STSTS after Ist Session###1.95+-8.32

5 STSTS after 2nd Session###18.20+-7.35

5 STSTS after 3rd Sessioon###16.95+-7.29

10 MWT Baseline###13.88+-8.39###<0.001

10 MWT after 1st Session###13.25+-8.25

10 MWT after 2nd Session###12.48+-7.68

10 MWT after 3rd Session###11.57+-7.32

TUG Baseline###23.60+-13.01### 0.05). Repeated measure ANOVA was applied for Gait dynamic index and showed significant p value p < 0.001. Friedman test was applied for remaining tools. Treatment included 3 sessions of lumbar mobilization in addition to normal task oriented training given for 03 days a week. Each session of lumbar mobilization was 2Hz Central Posteroanterior Maitland mobilization at L1L5 (120 oscillations per minute) for 3 minutes. 8,9 Data was obtained at baseline and then after three sessions. Sample had 66.7% male participants and 33.3% female stroke patients. Analysis showed that average age of participants was 50.00 +- 10.66 year. Out of total sample 12 patients (40%) had right hemiplegia and 18(60%) patients had left hemiplegia. 10 (33.3%) patients had stroke due to infarction and 20(66.7%) had haemorrhagic stroke.

Those who were medically diagnosed with MCA lesion were 18 (60%), with PCA were 8 (26.7%) and with ACA were only 4 (13.3%). Results for gait dynamic index are shown in figure. Post measurements of outcome tools including TUG, 10 Meter Walk Test and 5 Times Sit to Stand was reported using Friedman Test and shown in Table.

Discussion

This study evaluated acute effects of the application of mobilization technique and has an advantage over other modes of treatment as the result is immediate. It was observed that there was a significant improvement in mobility and balance in stroke patients. The GDI scores showed improvement after 03 sessions of lumbar mobilization. The findings of present study confirm the results of a past study conducted by Christopher M. Powers 10 and others to evaluate the lumbar spine during posterior to anterior mobilization. Their findings showed that posterior to anterior spinal mobilization caused extension at vertebrae and they further conducted this study again using MRI. The results of both of their studies showed that posterior to anterior spinal mobilization consistently caused extension at the tested segment.10 Lumbar extension is a major parameter of gait. The restricted ranges at lumbar level caused poor ambulation and balance.

The study by Steel J. and others suggested that lumbar extensor deconditioning or disability may result in gait variability.11 Results of 10MWT showed significance impact of treatment after 03 consecutive sessions. Pope and his colleagues conducted an RCT on different therapeutic treatments on back pain. They gave 3 weeks treatment protocol to every patient. One group received spinal manipulation, second received transcutaneous Muscle Stimulation and the third received massage and corset. After 3 weeks of treatment it was noted that spinal manipulation showed greatest improvement in flexion while others showed improvement in extension. This proved that spinal manipulation in movements is quite effective.12 Measurement of 5times sit to stand showed skewed data. Yet knowing this fact the result of this study showed improvement after 03 sessions of lumbar mobilization.

Previously a study conducted by Joel G. Picker to examine the neurophysiologic effects of spinal manipulation showed that there is an impact of spinal manipulation on primary afferent nerves from paraspinal tissues, the motor control system and pain processing. The results of this study proved that spinal manipulation has an impact on pain and by reducing pain the restricted movement can be improved in stroke survivors.13 Joint mobilization was used initially for the treatment of spastic children in 1980's. This method aimed to better the alignment and balance of the patients. The current study showed a significant improvement in mobility level through TUG after 03 sessions of lumbar mobilization. Tsirakis V and his colleagues 14 conducted a study to examine the effects of modified spinal mobilization with leg movement technique on sympathetic outflow to the lower limbs. They applied unilateral postero-anterior mobilization technique, at 2Hz on the left L4/5 lumbar zygophyseal joint.

The results of their study showed significant side specific peripheral at SNS changes in the lower limbs.14 Results of this study suggest that mobilization is helpful in improving gait and also improves mobility as seen by timed up and go test and 10 meter walk test.

Conclusion and Recommendations

In accordance with the above results the study suggests that lumbar mobilization is effective in improving gait in stroke patients. Lumbar mobilization should be added in routine rehab to improve the mobility level. Further studies should be conducted with larger samples and comparison group to get detailed outcomes of Spinal mobilization.

Disclaimer: None to declare.

Conflict of Interest: None to declare.

Funding disclosure: None to declare.

References

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2. Ryerson S, Byl NN, Brown DA, Wong RA, Hidler JM. Altered trunk position sense and its relation to balance functions in people poststroke. J Neurol Phys Ther 2008; 32: 14-20.

3. Verheyden G, Nieuwboer A, Feys H, Thijs V, Vaes K, De Weerdt W. Discriminant ability of the Trunk Impairment Scale: a comparison between stroke patients and healthy individuals. Disabil Rehabil 2005; 27: 1023-8.

4. Likhi M, Jidesh V, Kanagaraj R, George JK. Does trunk, arm, or leg control correlate best with overall function in stroke subjects? Top Stroke rehabil 2013; 20: 62-7.

5. Karthikbabu S, Chakrapani M, Ganeshan S, Rakshith KC, Nafeez S, Prem V. A review on assessment and treatment of the trunk in stroke: a need or luxury. Neural Regen Res 2012; 7: 1974-7.

6. Cabanas-Valdes R, Cuchi GU, Bagur-Calafat C. Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. Neuro Rehabiliion 2013; 33: 575-92.

7. Wyszy?ski S, Stiler S, Piotrkowicz J, Federowicz P. Assessment of the Effects of Mobilisation on the Ranage of Motion and the Level of Pain in Patients with Lumbar Spine Symptoms. Puls Uczelni 2016; 2: 11-6.

8. Piekarz V, Perry J. An investigation into the effects of applying a lumbar Maitland mobilisation at different frequencies on sympathetic nervous system activity levels in the lower limb. Man Ther 2016; 23: 83-9.

9. Shah SG, Kage V. Effect of seven sessions of posterior-to-anterior spinal mobilisation versus prone press-ups in non-specific low back pain-randomized clinical trial. J Clin Diagn Res 2016; 10: YC103.

10. Powers CM, Beneck GJ, Kulig K, Landel RF, Fredericson M. Effects of a single session of posterior-to-anterior spinal mobilization and press-up exercise on pain response and lumbar spine extension in people with nonspecific low back pain. Phys Ther 2008; 88: 48593.

11. Steele J, Bruce-Low S, Smith D, Jessop D, Osborne N. Lumbar kinematic variability during gait in chronic low back pain and associations with pain, disability and isolated lumbar extension strength. Clin Biomech 2014; 29: 1131-8.

12. Pain SLB. A Prospective Randomized Three-Week Trial of Spinal Manipulation, Transcutaneous Muscle Stimulation, Massage and Corset i n the Treatment of. Spine. 1994;19: 2571-7.

13. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J 2002; 2: 357-71.

14. Tsirakis V, Perry J. The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic outflow to the lower limbs. Man Ther 2015; 20: 103-8.
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Publication:Journal of Pakistan Medical Association
Article Type:Report
Date:Feb 28, 2019
Words:1837
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