J Int Acad Phys Ther Res 2016; 7(1): 915-918 www.iaptr.

org
ISSN 2092-8475 http://dx.doi.org/10.20540/JIAPTR.2016.7.1.915

The Effects of Ankle Exercise on Balance in Stroke Patients

The purpose of this study was to assess the effects of Ankle exercise on Ja Pung Kooa, Nyeon Jun Kima
balance ability of stroke patients. Participants' balance ability were meas-
ured prior to the training and they conducted ankle exercise. As for ankle pohang, college, pohang, Korea
a

exercises, ankle stretching training and ankle muscle strengthening training

Received : 20 November 2015
were performed for 10 minutes respectively. They did warm up exercise for
Revised : 15 December 2015
5 minutes and then ankle exercise for 20 minutes. And then they did cool-
Accepted : 30 January 2016
down exercise for 5 minutes. Their balance ability was measured after 9
weeks. According to the results of analyzing the change of balance ability Address for correspondence
that timed up and go and Berg balance scale score significantly improved Ja Pung Koo, PT, Ph.D
but in the control group it did not significantly decrease. In comparison Department of Physical Therapy,
between the groups, Berg balance scale score significantly improved in the Pohang College, 60, Sinduk-ro,
ankle exercise group compared to the control group. Ankle exercise per- Heunghae-eup, Pohang, Korea
formed by stroke patients are considered to be effective in improving bal- TEL: +82 54-245-1295
ance ability. E-mail: [email protected]

Key words: Ankle Exercise, Balance, BBS, TUG, Stroke

INTRODUCTION bility, the role of the hip joint and ankle joint is
important. When the range of postural change is
Stroke is a disease which occurs when the blood large, the hip joint is activated, while the ankle
flow to the brain is cut off due to hemorrhage or joint operates when the range of postural change
inchemia in the blood vessels(1,2). is small(7,8). Minor movements occur in a static
Stroke patients experience various symptoms standing position, and it is known that the ground
such as sensory disorder, mobility defects, and reaction force generated with the contraction of
cognitive disorder which negatively affect func- gastrocnemius muscle, soleus muscle, and tibialis
tions for carrying out activities of daily living(3). anterior muscle in the ankle joint is utilized to
In particular, patients with hemiplegia caused by adjust balance(9).
stroke have difficulty standing up, moving, walk- Spasticity in the ankle joint of stroke patients
ing and climbing up stairs due to loss of proprio- causes muscle stiffness of ankle plantar flexor,
ceptive and static senses from the weakened cen- and restricts voluntary movement. In particular,
tral nervous system, asymmetric posture, impair- spasticity of the ankle plantar flexor undermines
ment of balance, and restricted mobility(4). balance ability(10-12). Therefore, to help stroke
Stroke patients suffer contracture in the ankle patients maintain balance, a sufficient range of
joint, and such contracture in the ankle joint and motion, muscle power, and the proprioceptive
weakened muscular strength hamper functional sense are needed.
improvement(5). Functional disorder of the ankle Hence, the current study seeks to examine the
joint negatively affects balance ability and walk- effect of muscle strengthening training and
ing, increasing risks of fall(6). stretching training for the ankle joint on improv-
For balance adjustment to ensure physical sta- ing balance ability of stroke patients.

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 The Effects of Ankle Exercise on Balance in Stroke Patients

METHODS Measurement scale

Subjects Timed Up & Go (TUG) test

TUG test may measure basic motility and bal-
The present study was conducted from March 10, ance and the subject sat on an elbow chair and
2015 to April 20, 2015 at D hospital located in walked 3 meters, came back, and then sat on the
Yong-in city with 16 stroke patients who were chair again. This test is much applied to patients
able to participate in exercise programs and with stroke, Parkinson’ s disease, and arthritis as
agreed to the present study. General characteris- well as elderly people(14).
tics of the subjects are as follows(Table 1).
Berg’balance scale(BBS) test
The BBS test is widely used to assess balance
Table 1. General characteristics of the subjects ability of patients with hemiplegia caused by
a
AEG(n=8) b
CG(n=8) stroke. The higher the score is, the better their
dynamic balance ability is(15). Previous studies
Sex(mal/female) 3/5 3/5 conducted with stroke patients reported that the
Age(yr) 69.87±2.69 69.87±2.69 test-retest reliability of the BBS was measured at
Hight(m) 1.57±.05 1.57±.05 ICC=.98(16).
Weight(kg) 57.75±3.45 57.75±3.45
Data Analysis
Paretic side(Right/Left) 6/2 5/3
MMSE-K(total score) 23.62±1.18 23.62±1.18 In the present study, the statistical program
SPSS 18.0 was used for data analysis. General
Values are mean±standard deviation, aAEG:ankleexer-
characteristics of the study subjects were pro-
cisegroup, bCG:controlgroup
duced as frequency analysis, means and standard
deviations. Wilcoxon signed-ranks tests were
Experimental Procedure conducted to examine changes in the stroke
patients' balance between before and after the
Participants' balance ability was measured prior exercises and Mann-Whitney tests were conduct-
to the exercise and they conducted ankle exercise ed to examine differences in changes between the
using elastic bands. They did warm-up exercise groups. To test statistical significance, the signifi-
for 5 minutes and then ankle exercise using elastic cance level was set to 𝑎= .05.
bands for 20 minutes. And then they did cool-
down exercise for 5 minutes. Their balance ability
was measured after 9 weeks. RESULTS
As for ankle exercises, ankle stretching training
and ankle muscle strengthening training were Changes in the result of TUG test after the Exercise
performed for 10 minutes respectively. Ankle
stretching exercises were conducted for 10 min- In the ankle exercise, TUG significantly
utes using the incline board with dorsiflexion of decreased but in the control group it did not sig-
the ankle joint maintained at 20 〬. As for ankle nificantly decrease. In comparison between the
muscle strengthening training, isometric resist- groups, TUG did not significantly in the ankle
ance training was performed on the ankle dorsi- exercise group compared to the control group
flexor muscle for 10 minutes. (p<.05) (Table 2).

Table 2. Comparison of TUG test result according to exercise type (unit : sec)

Pre test Post test D-value D-value

group Z p
(mean±S.D.) (mean±S.D.) (mean±S.D.) Z p
AEG 25.12±1.88 22.00±1.06 -3.12±2.16 -2.539 .011*
-1.659 .097
CG 26.37±1.18 25.50±1.60 -.87±1.24 -1.725 .084

*p<.05, **p<.01

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 N.J. Kim, J.P. Koo

Changes in the BBS result between prior to the exercise and after the exer-
cise. In comparison between the two groups, BBS
BBS point significantly increased in the ankle point significantly improved in the ankle exercise
exercise group after the exercise and BBS point group relative to the control group(p<.05)(Table 3).
did not significantly differ in the control group

Table 3. Changes in the BBS result (unit : point)

Pre test Post test D-value D-value

group Z p
(mean±S.D.) (mean±S.D.) (mean±S.D.) Z p
AEG 35.62±1.68 38.25±2.81 2.62±2.72 -2.046 .041*
-2.163 .031*
CG 35.00±1.69 34.37±2.77 -.62±3.50 -.705 .481

*p<.05

DISCUSSION that arm swing strength combined with ankle

stretching exercises resulted in significant
The present study aims to identify the effect of improvement in balance ability of stroke
the strengthening and stretching exercises for the patients(22).
ankle joint on the balance ability of stroke Results of the present studies correspond with
patients. the results of earlier studies which reported that
Spasticity in the legs of stroke patients places balance ability of stroke patients can be improved
the weight on the unaffected leg, making it diffi- ankle strengthening exercises and ankle stretch-
cult to manage balance(17,18). Moreover, stroke ing exercise.
patients experience stiffness in the ankle plantar The present study has limitations in that the
flexor due to spasticity, which reduces the range findings are difficult to generalize for all stroke
of motion of the ankle joint and leads to dimin- patients as the experiments were conducted with
ished muscle power of ankle dorsiflexor causing 16 stroke patients. Moreover, the result of the
difficulties with ankle dorsiflexion(5)(10-12)(19). present study is not sufficient to prove the effica-
Thus, the present study had stroke patients per- cy of ankle exercise in improving balance ability
form ankle strengthening and stretching exercises of stroke patients to carry out activities of daily
for 9 weeks, and examined changes in balance living as the study assessed the effectiveness
ability. As a result, the group that conducted both experimentally only.
ankle strengthening and stretching exercises
showed significant improvement in TUG and BBS.
Kim et al. reported that 6 weeks of propriocep-
tive exercises and ankle joint muscle strengthen- CONCLUSION
ing exercises showed significant improvement in
balance ability, and functional electrical stimula- Ankle exercise was applied for 9 weeks in order
tion and stretching exercises also resulted in sig- to look at the effects of on elderly people's bal-
nificant progress in balance ability(20). ance. TUG test and FRT was carried out in order
You et al. maintained that ankle strengthening to examine the effects of resistance exercise using
exercises combined with motor imagery training elastic bands on balance. TUG test and FRT
produced improvement in balance ability of stroke results were significantly different between prior
patients. Significant improvement in balance abil- to and after the training in the resistance exercise
ity was observed even with ankle strengthening group and the results also significantly differed
exercises alone(21). Son et al. reported that 3 between the resistance exercise group and the
months of ankle strengthening exercises were non-exercise group.
effective to improve balance ability(5). Ma reported

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 The Effects of Ankle Exercise on Balance in Stroke Patients

REFERENCES 12. Harlaar J, Becher JG, Snijders CJ. Passive stiff-

ness characteristics of ankle plantar flexor in
1. Susan BO, Thomas JS. Physical Rehabilitation: hemiplegia. Clinical Biomechnics 2000;15(4): 261-
Assessment and Treatment. 4th Ed. Philadelphia; 270.
2001:520. 13. Donald AN. Kinesiology of the Musculoskeletal
2. Prange GB, Jannink MJA, Groothuis-Oudshoorn System: Foundations for Physical Rehabilitation.
CGM, Hermens HJ, IJzerman, MJ. Systematic Mosby Publication 2002:528-529.
review of the effect of robot-aided therapy on 14. Morris S, Morris ME, Iansek R. Reliability of
recovery of the hemiparetic arm after stroke. measurements obtained with the times up and go
Journal of rehabilitation research and develop- test in people with Parkinson disease. Phys Ther
ment 2006;43(2):171-184. 2001;83(2):810-818.
3. Walker C, Brouwer BJ, Culham EG. Use of visual 15. Berg, K. Wood-Dauphinee S, Williams JI. The
feedback in retraining balance following acutes Balance Scale : reliability assessment with elderly
stroke. Phys Ther 2000;80(9):886-895. residents and patients with an acute stroke.
4. Carr JH, Shepherd RB. Neurological Scandinavian journal of rehabilitation medicine
Rehabilitation Optimizing Motor Performance. 1989;27(1):27-36.
Butterworth- Heinemann, Oxford 1998 16. Liston RA, Brouwer BJ. Reliability and validity of
5. Son JC. The effects of ankle strength exercise on measures obtained from stroke patients using
the ability of balance control in patients with the balance master. Archives of physical medi-
stroke. Unpubilshed master’ s dissertation Yongin cine and rehabilitation 1996;77(5):425-430.
Unversity 2005. 17. Mayer NH. Clinicophysiologic concepts of spas-
6. Lamontagne A. Malouin F, Richards CL, Dumas ticity and motor dysfunction in adults with an
F. Mechanisms of disturbed motor control in upper motor neuron lesion. Muscle and Nerve
ankle weakness during gait after stroke. Gait 1997;6:1-13.
Posture 2002;15(3):244-255. 18. Sackley CM, Baguley BI. Visual feedback after
7. Lee HS, Choi HS, Kwon OY. A Literature Review stroke with the Balance P erformance Monitor :
on Balance Control Factors. Physical Therapy two single case studies. Clin Regabil 1993;7(3):
Korea 1996;3(3):82-91. 189-195.
8. Runge CF, Shupert CL, Horak FB, Zajac FE. 19. Evjenth O, Hamberg J. Muscle stretching in
Ankle and hip postural strategies defined by joint manual therapy: A clinicalmanual. Sweden, Afta
torques. Gait and Posture 1999;10:161-170. rehab 1994.
9. Lewis NL, Brismee JM, James CR, Sizer PS, 20. Kim K, Lee S, Kim D, Kim KS. The effects of
Sawyer SF. The effect of stretching on muscle ankle joint muscle strengthening and proprio-
responses and postural sway responses during ceptive exercise programs accompanied by func-
computerized dynamic posturography in women tional electrical stimulation on stroke patients’
and men. Arch Phys Med Rehabil 2009; balance. J Phys Ther Sci 2015;27(9):2971-2975.
90(3):454-62. 21. Kim SS, Lee HJ, You YY. Effects of ankle
10. Thilmann AF, Fellows SJ, Garms E. The mecha- strengthening exercises combined with motor
nism of spastic muscle hypertonus. Brain 1991; imagery training on the timed up and go test
114(1):233-244. score and weight bearing ratio in stroke patients.
11. Given JD, Dewald JP, Rymer WZ. Joint depend- J Phys Ther Sci 2015;27(7):2303-2305.
ent passive stiffness in paretic and contralateral 22. Ma JS. The effects of arm swing strength and
limbs of spastic patients with hemiparetic stroke. ankle stretching exercise on gait velocity and
Journal of Neurology, Neurosurgery & Psychi- balance in stroke patients. Unpubilshed master’ s
atry 1995;59(3):271-279. dissertation Korea national university 2014.

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