|Year : 2018 | Volume
| Issue : 4 | Page : 130-133
Effect of the spacing technique to improve balance and gait in stroke survivor: An experimental study
Neelima1, Rama Kumar Sahu2
1 Department of Physiotherapy and Rehabilitation, Indian Head Injury Foundation, DCWA Medical Centre, Zamrudhpur, New Delhi, India
2 Department of Occupational Therapy, SVNIRTAR, Cuttack, Odisha, India
|Date of Submission||26-Sep-2018|
|Date of Acceptance||06-Dec-2018|
|Date of Web Publication||06-Feb-2019|
House No. 6171, Block No. 1, Street No. 4, 2nd Floor, Dev Nagar, Karol Bagh, New Delhi - 110 005
Source of Support: None, Conflict of Interest: None
Background: Spacing effect is the observation that information presented using spaced repetitions is better remembered than information presented via massed repetitions (Challis, 1993). Many studies of spacing effect reported positive effect on motor learning, but there is a limited application of spacing strategies for the people with stroke which could potentially result in a significant improvement in balance and gait training for everyday functioning. The aim of this study was to determine whether spaced learning improves motor learning as regards balance and gait in people with stroke. Objectives: The aim of this study is to study the effect of spacing technique in improving balance and gait in patients with stroke. Study Design: This study is in pretest–posttest experimental study design. Methods: Thirty patients with stroke were selected and randomly assigned to Experimental and Control groups. Experimental group consists of 15 patients with 9 males and 6 females patients who received conventional therapy along with spaced exercise protocol thrice a week for 8 weeks. Control group consists of 15 patients with 12 male and 3 female patients who received conventional therapy. Tinetti Performance-Oriented Mobility Assessment (TPOMA) was used as an outcome measure. Results: Statistical analysis showed that there was significant improvement in the Experimental group, measured with TPOMA on Mann–Whitney U-test where the result shows U = 14 which corresponds to P= 0.000 along with 95% confidence interval (0.000, 0.095). Conclusions: The study concluded that application of the spacing technique program with conventional therapy improves balance and gait more effectively than only with the conventional therapy. Thus, spacing effect or spaced interval practice along with conventional therapy should be considered during the management of stroke population to improve balance and gait.
Keywords: Balance, Gait, Motor Learning, Spacing Effect, Stroke
|How to cite this article:|
Neelima, Sahu RK. Effect of the spacing technique to improve balance and gait in stroke survivor: An experimental study. Indian J Occup Ther 2018;50:130-3
|How to cite this URL:|
Neelima, Sahu RK. Effect of the spacing technique to improve balance and gait in stroke survivor: An experimental study. Indian J Occup Ther [serial online] 2018 [cited 2019 Jul 20];50:130-3. Available from: http://www.ijotonweb.org/text.asp?2018/50/4/130/251763
| Introduction|| |
Stroke is one of the most common neurological disorders leading to chronic disability.
Stroke is the second leading cause of death for people above the age of 60 and the fifth leading cause in people aged 15–59 (Indian Stroke Association). The incidence of the disease in India to be around 130/100,000 population every year and says about 20% of heart patients are susceptible to it.
The disease has turned out to result in most common disability and dependence with more than 70% of stroke survivors remaining vocationally impaired and more than 30% requiring assistance with activities for daily living. The resulting paralysis after stroke reduces motor skills and related functional abilities.
After stroke, the recovery of balance in considered to be of crucial importance to achieve autonomy in the activity of daily living. Balance is defined as the ability to maintain the projection of body's center of mass within limit of base of support as in standing or sitting or in transit to a new base of support as in walking. Balance is also described as to maintain or move within a weight-bearing posture without falling.,
Balance can further be broken down into three aspects, i.e., steadiness, symmetry, and dynamic stability which are mainly disturbed in stroke patients.,
Motor learning is a set of internal processes associated with practice or experiences leading to relatively permanent changes in the capability for skilled behavior. The process of motor learning has been described by Fitts and Posner as occurring in relatively distinct stages, termed cognitive, associated, and autonomous.
Various learning strategies have been shown to significantly improve the learning of new information; however, there has been very little work in applying such strategies to people with stroke, which could potentially result in a significant improvement in cognitive and motor learning for everyday functioning. One such technique is called spacing effect.
Spacing effect is the observation that information presented using spaced repetitions is better remembered than information presented via massed repetitions (Challis, 1993).
Spacing effect refers to spaced practice intervals in which the practice time is equal to or less than the rest time. It is the preferred mode for many patients undergoing active rehabilitation who demonstrate limited performance capabilities and endurance. With adequate rest periods, performance can be improved without the interfering effect of fatigue or increasing safety issue.
Spaced practice is also beneficial with low motivation level, short attention span, poor concentration, and motor planning deficit. Spaced practice is also considered if the task itself is complex, large, or has high energy cost.,
Learning over time enhances memory and the survival of new neurons. A large body of literature has documented that learning trials spaced over time lead to better recall than massed learning (consecutive learning trials).
Spaced repetition of an item or task hold considerable potential to enhance subsequent performance relative to massed repetition.,
However, most of the studies examining the impact of the spacing effect have been conducted only with laboratory-based tasks. Thus, the impact of the spacing effect on everyday activities in clinical samples remains unclear. The aim of the study was to examine the effect of spacing technique on balance and gait in patients with stroke.
| Methods|| |
Pretest and Posttest experimental study design with two groups: spacing technique (Experimental group) and Control group, which were allocated randomly through lottery system after which, pretest scores were recorded initially, then 2 months of intervention (thrice a week) was given, and posttest scores were recorded.
The study was conducted as per the “Declaration of Helsinki” guidelines as institute does not have registered ethical committee and written informed consent was obtained from all the patients.
Mini–Mental Scale Examination (MMSE) and Berg Balance Scale (BBS) were used as a screening tool and Tinetti Performance-Oriented Mobility Assessment (TPOMA) was used as a measuring tool.
The patients who met the following inclusion criteria were selected for the study: Brunnstrom Stage 3 and above, single stroke, at least 6-months poststroke, age within 40–60 years, both right and left hemiplegic, both genders, MMSE score 24 and above, and BBS score as medium fall risk (21–40). The patients were excluded from the study if they exhibited, any neurological disease affecting balance other than stroke, vestibular lesion, orthopedic condition, any perceptual and cognitive deficits such as hemispatial neglect, attention, and memory deficits, Wernicke's or global aphasia, and history of repeated stroke.
After meeting the inclusion and exclusion criteria, 30 patients were assessed using assessment pro forma and informed consent was obtained from the patients and allocated randomly through lottery system into the two groups: Group 1: Experimental group and Group 2: Control group. All patients underwent an initial baseline assessment on TPOMA.
Patients received spacing effect protocol in which functional task such as sitting on table and performing reaching activity [Figure 1], sit to stand, step-ups, standing with narrow base of support in tandem position, and reaching for objects including down the floor, ball kicking, holding object with bilateral hands while walking, and stairs climbing, are performed with 5 min of spaced repetition in a 1:10 h session.
|Figure 1: Standing with Narrow Base of Support and Performing Forward Reaching Task|
Click here to view
Exercises were gradually introduced and the number of repetitions was determined by the therapist on the basis of the patient's performance.
In Experimental group, protocol was provided along with conventional occupational therapy, 3 sessions per week for 8 weeks were provided. The conventional occupational therapy included for both upper and lower limbs not based on specific approach. For example, all activities working on activities of daily living (ADL) skills, hand function along with neurodevelopment, and neurophysiologic techniques such as weight-bearing and bilateral activities, were carried out.
After completion of 8 weeks of intervention posttest was recorded.
| Results|| |
After completion of posttreatment evaluation, data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY: USA).
Descriptive characteristics of patients are mentioned [Table 1] in illustrations. Statistical tests were carried out with the level of confidence set at α ≤ 0.05. The score of pretreatment and posttreatment data of balance and gait using TPOMA was analyzed using nonparametric statistics as TPOMA provides baseline data predictive of fall which is an ordinal scale with maximum score of 28 where independent variable is spacing and depended variable is balance and gait. Mann–Whitney U-test was used to determine mean values and difference in improvement between Experimental (Spacing Technique) and Control groups, the result shows U = 14 which corresponds to P= 0.000. Wilcoxon test was used to determine significant changes in pre- and post-treatment within the experimental (Spacing Technique) and control group. The Wilcoxon signed rank test for experimental group shows Z=(-)3.429 and control group Z=(-)3.435 which corresponds to p=0.001. Probability set at α≤0.05, the result is significant along with 95%CI (0.000, 0.181) [Table 2]. Mann Whitney U test was used to determine mean values and difference in improvement between experimental (Spacing Technique) and control group, the result shows U=14 which corresponds to p=0.000. As the α≤0.05 hence, there is a significance difference between the two sets of data along with 95%CI (0.000, 0.095) [Table 3].
|Table 2: Wilcoxon Rank Test of Experimental (Spacing Technique) Group and Control Group|
Click here to view
|Table 3: Mann–Whitney U-tests Results between the groups Showing Mean Rank, Sum of Ranks, and that their Significant Difference in Posttest between Experimental and Control Group (P=0.00)|
Click here to view
[Graph 1] showing mean score changes on the TPOMA in both Control and Experimental groups and [Graph 2] shows a comparison between two groups in illustration.
| Discussion|| |
The results of this study suggest that spacing technique is effective in improving balance and gait in stroke survivor as compared to Control group. Significant improvement in balance and gait as compared to Control group which could be explained by the intervention program facilitating motor learning by spacing effect or spaced interval practice for 8 weeks that was directed toward enhancing balance and gait. Spacing technique is based on spaced-interval practice which can be preferred mode for many patients undergoing active rehabilitation who demonstrate limited performance capabilities and endurance. With adequate rest periods, performance can be improved without the interfering effect of fatigue or increasing safety issues.
The data taken for analysis were the individual improvements of patients. The mean rank of improvements in the Experimental groups is more than the Control group. Hence, the result is favorable toward the Experimental group. This shows there is significantly more improvement in the Experimental group as compared to Control group.
The result of Wilcoxon test for within the group shows significant improvement in both Experimental and Control group. Furthermore, the result of Mann–Whitney U-test for between the groups shows significant improvement. Thus, the result shows positive influence of spacing effect or spaced interval practice on improving balance and gait in stroke along with conventional therapy.
This study is supported by studies which suggest spacing practice session across days benefits the learning of motor skills and the spacing effect indicates that information is learned better when presentation trials are distributed over time rather than consecutively. This study although is related to cognitive functions, we may draw a similar process is acting behind the motor learning meditation.
Literature suggest spacing and repetition effects in human memory, that is, information is added to an existing trace and learning over time enhances memory and the survival of new neurons, this effect could have been seen if further retention have been assessed after a long-term follow-up in the motor tasks of balance and gait and further execution of learned tasks could be seen in activities of daily living. Although there is a positive influence of spacing technique could be seen in all the groups.
The study was conducted with small sample size, the study setup may be changed geographically, and specialty wise and required follow-up evaluation were not carried out to see the retention.
Further study can be done to check the effect on the upper extremity functions and ADL training, further study can also be done in cognition areas affected in stroke, other measurement tool may be used to restrict in a specific area.
| Conclusions|| |
Occupational therapist commonly uses the functional approach in the central nervous system dysfunctions such as stroke. People with stroke have deficits in motor control which largely impedes their functional performance. The spacing effect or distributed practice exercises improves recall of the task which has been performed. This makes translation of the task to various components of ADL.
The result of the present study suggests that there is a significant improvement in balance and gait in stroke survivors in both the groups. There is significantly more improvement noticed in the Experimental group; hence, it is evident that application of the spacing effect with conventional therapy improves balance and gait more effectively than only the conventional therapy. Spacing effect or spaced interval practice along with conventional therapy should be considered during management of stroke population to improve balance and gait.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Shah SB, Jayavant S. Study of balance training in ambulatory hemiplegics. Indian J Occup Ther 2006;38:9-15.
Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke 2013;15:128-134.
Taylor FC, Suresh KK. Stroke in India factsheet: Asia Network for Chronic Disease. Hyderabad: Public Health Foundation of India. 2012.
Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: A systematic review. Lancet Neurol 2009;8:355-369.
Goverover Y, Arango-Lasprilla JC, Hillary FG, Chiaravalloti N, Deluca J. Application of the spacing effect to improve learning and memory for functional tasks in traumatic brain injury: A pilot study. Am J Occup Ther 2009;63:543-548.
Shea CH, Lai Q, Black C, Park JH. Spacing practice sessions across days benefits the learning of motor skills. Hum Mov Sci 2000;19:737-760.
O'Sullivan SB, Schmitz TJ. Physical Rehabilitation. 5th
ed. New Delhi: Jaypee Brothers; 2007;p. 475:705-8.
Shumway-Cook A. Normal postural control. Motor Control: Theory and Practical Applications. 2nd
ed. United States of America: Lippincott Williams & Wilkins; 2001. p. 41-42.
Dempster FN. Spacing effects and their implications for theory and practice. Educ Psychol Rev 1989;1:309-330.
Vertesi A, Lever JA, Molloy DW, Sanderson B, Tuttle I, Pokoradi L, et al.
Standardized mini-mental state examination. Use and interpretation. Can Fam Physician 2001;47:2018-2023.
Blum L, Korner-Bitensky N. Usefulness of the berg balance scale in stroke rehabilitation: A systematic review. Phys Ther 2008;88:559-566.
Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986;34:119-126.
Arya KN, Pandian S, Abhilasha CR, Verma A. Does the motor level of the paretic extremities affect balance in poststroke subjects? A pilot RCT. Sci World J 2014;2014:1-8.
Deekshita B, Srikumari V, Madhavi K. Effect of task oriented exercises on standing balance in subjects with stroke. Int J Physiother 2014;1:242-247.
Raaijmakers JG. Spacing and repetition effects in human memory: Application of the SAM model. Cogn Sci 2003;27:431-452.
Sisti HM, Glass AL, Shors TJ. Neurogenesis and the spacing effect: Learning over time enhances memory and the survival of new neurons. Learn Mem 2007;14:368-375.
[Table 1], [Table 2], [Table 3]