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Table of Contents
Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 14-18

Effect of libra balance board exercises versus pilates on dynamic balance, gait, and quality of life in stroke subjects: A randomized clinical trial

Department of Neuro Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission17-May-2019
Date of Decision28-Jun-2019
Date of Acceptance13-Mar-2020
Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Neeraja Vijay Deshmuk
KAHER Institute of Physiotherapy, Nehrunagar, Belagavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_34_19

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Background and Objectives: Stroke survivors are more prone for sensorimotor impairments such as dynamic balance and gait disabilities resulting in physical disabilities, striking a major socioeconomic burden on the family and society, if the goals of the rehabilitation are inappropriate. The present study aimed to compare the effect of Libra balance board exercises and Pilates exercises on dynamic balance, gait, and quality of life in subacute and chronic stroke patients.
Materials and Methods: The present study was a randomized clinical trial that included 34 individuals, 17 in each group with subacute and chronic stroke in the age group of 40–65 years. All the patients having Brunnstrom voluntary control grades 3–5. Intervention included Libra balance board exercises and Pilates exercises for 30 min, five sessions per week over a period of 4 weeks. Patients were assessed at the baseline using Berg Balance Scale, Dynamic Gait Index, Activity-specific Balance Confidence Scale, and Stroke-specific Quality of Life Scale and reassessed after 4 weeks.
Results: There was statistical significance in all the outcome measures in both the groups with P < 0.0001. However, Berg balance score showed statistical significance (P ≤ 0.001) in Group A with P < 0.05 when compared between the two groups.
Conclusion: The study concluded that both Libra balance board exercises and Pilates exercises were beneficial in the enhancement of dynamic balance, gait, and quality of life in patients with subacute and chronic stroke

Keywords: Dynamic balance, Gait, Libra balance board exercises, Pilates, Quality of life, Stroke

How to cite this article:
Deshmuk NV, Chitra J. Effect of libra balance board exercises versus pilates on dynamic balance, gait, and quality of life in stroke subjects: A randomized clinical trial. Indian J Phys Ther Res 2020;2:14-8

How to cite this URL:
Deshmuk NV, Chitra J. Effect of libra balance board exercises versus pilates on dynamic balance, gait, and quality of life in stroke subjects: A randomized clinical trial. Indian J Phys Ther Res [serial online] 2020 [cited 2023 Jun 2];2:14-8. Available from: https://www.ijptr.org/text.asp?2020/2/1/14/288861

  Introduction Top

Stroke is a cerebrovascular episode wherein the bloodstream to the brain is substantially altered and it leads to a sudden loss of neurological functioning. The prevalence of stroke is globally increasing with a predic[table 70] million new cases anticipated by 2030.[1] There is a significant loss of function depending on the degree of brain injury, location and extent of brain injury, and the amount of collateral blood flow. Atherosclerosis, ischemia, and hemorrhage are the major contributory factors to stroke or cerebrovascular disease.[2],[3]

Red flags of stroke involve precipitous numbness or weakness of the arm, leg, and face, particularly on one side of the body, difficulty in speech and language, communication, or understanding, visual disturbances and severe headache, dizziness, nausea, and vomiting.[4] The other most frequently reported symptoms are altered sensations on the paretic side, impaired coordination, postural control and impaired static as well as dynamic balance, perceptual, and cognitive deficits and gait disorders.[5]

Balance deficits such as impaired steadiness, symmetry and postural control throughout quiet standing, late and less synchronized responses to internal and external balance perturbations, and augmented weight-bearing on the nonaffected extremity are key factors for falls post stroke. Therefore, patients develop more dependency on caregivers, and thus, quality of life declines. The prevalence of balance defects among stroke survivors is 36.8% in 2018 in Nigeria. In acute and subacute stroke, the occurrence of gait disorders is 63.6%.[6],[7]

In traditional balance exercises, specific movements are recurred and patients find these exercises purposeless and tedious subsequently lessens motivation and acquiescence with exercise protocol. Recently, multidisciplinary rehabilitation approaches for improving balance has been implemented. Various studies carried out in chronic stroke survivors with Pilates exercises on static as well as dynamic balance found that Pilates exercises are efficient in the recovery of walking ability.[8] Exercises using Libra balance board are also beneficial for dynamic balance, gait, and quality of life in the geriatric population.[9]

As there is a dearth in literature on the comparative effect of Pilates exercises program and Libra balance board training on dynamic balance, gait, and quality of life, the current study intends to determine and compare the effectiveness of Libra balance board exercises and Pilates exercises on the same in individuals with subacute and chronic stroke.

  Materials and Methods Top

Study design

The study was a randomized clinical trial conducted in a tertiary care hospital, Belagavi, Karnataka, from April 1, 2018, to March 31, 2019. The ethical clearance was obtained from the Institutional Ethical Committee. From all the participants, informed consent was obtained in writing before participating in this study.


All individuals clinically diagnosed with subacute and chronic stroke were recruited for the study. Both genders between the age group of 40 and 65 years diagnosed with stroke more than 3-month onset with Brunnstrom voluntary control grades 3–5, able to stand without support, and able to follow verbal commands were included in the study. Patients with visual and vestibular impairments, any cardiovascular or orthopedic conditions, cognitive impairments, and using walking aid or foot orthotics were excluded from the study.

Sample size calculated was 34, based on the previous literature considering effect size. All the patients were randomly allocated using the envelope method into two groups.

Measurement of treatment outcomes

All the outcome measures were recorded by a therapist prior to the intervention (baseline measures) and post intervention (i.e., after 4 weeks).

Berg Balance Scale (BBS) was used to evaluate the accurate ability of patient's capacity to balance securely while performing series of predetermined tasks and has intra-rater, inter-rater, and test–retest reliability of 0.98. It is a 14-item scale with each item consisting of a 5-point ordinal scale ranging from 0 to 4, with 0 indicating the lowest level of function and 4 the highest level of function and takes approximately 20 min to complete.[10]

Activity-specific Balance Confidence (ABC) Scale test was used to measure the functional balance. Test–retest reliability of this test was 0.86. This test required 5–10 min to administer. Scoring was done on the ordinal scale of 16 items.[11]

Dynamic Gait Index (DGI) assesses gait, balance, and fall risk. It determines the walking abilities during more challenging tasks. Inter-rated and intra-rated reliability is 0.96. It consists of eight functional walking tests, performed by the patient and marked out of three according to the lowest category. It takes approximately 15 min to complete. Twenty-four is the total individual score possible. Scores of ≤19 have been related to the increasing incidence of falls.[12]

Stroke-specific Quality of Life (SSQOL) Scale is a subjective measure proposed to evaluate health-related quality of life, particularly in stroke patients. The test–retest reliability is 0.92.[13]


Libra balance board exercises were given for 30 min, five sessions per week over a period of 4 weeks. The starting position of each patient was in standing. Each patient placed his/her feet on the electronic Libra balance board and he/she had to direct the ball by shifting his/her body weight in the anterior–posterior or medial–lateral directions and try to hit the object on the screen. During the session the patient received visual feedback regarding the amount of their body sway while performing the task.

In Pilates group, mat exercises or exercises in standing were given by the therapist for 30 min. Strengthening of the musculature of the pelvic girdle, lower limb, and trunk stabilization muscles were included and performed along with the rhythm of inspiration and expiration, and there was a rest period of 2 min before the initiation of the further exercise. Each patient was asked to concentrate on the pattern of breathing and perform each exercise repeatedly for ten times.

Description of Pilates exercises:[14]

  • Hundred – performed in supine lying: head lift followed by bilateral leg lift
  • Bridge – performed in crook lying by lifting the pelvis off the mat
  • Alternate toe taps – performed in lying with both hips and knees in 90° flexion followed by the tapping of toes on the mat
  • Side to side – lower body and pelvic twisting from one side to other side in crook lying upholding the upper body in neutral
  • Side kick – abduction in side lying
  • Quadruped – together lifting contralateral upper and lower extremity in the quadruped position
  • Spine twist – spinal side-to-side rotations with both the hands at 90° of forward flexion in kneel standing
  • Side leg lift – hip abduction and adduction in standing
  • Tandem stance – toe touching the heel of the other foot in standing
  • Ball wall squat – semi squatting by keeping Swiss ball at the lower back area.

  Results Top

SPSS version 23 (armonk, Newyork, USA) was used for the statistical analysis. Within-group comparison of the pre–post intervention scores of outcome measures such as BBS, DGI, ABC Scale, and SSQOL was done by Wilcoxon signed-rank test and between-group comparisons was done by Mann–Whitney U-test. [Table 1] demonstrates the demographic profile and baseline characteristics of the participants. On comparing age, gender, body height, weight, and body mass index, the participants in each group were homogeneous. There was a statistically significant improvement in the BBS, DGI, ABC, and SSQOL scores among the two groups when compared for pre- and post-intervention, indicating an improvement with Libra balance board exercises as well as Pilates exercises with significant P (P < 0.0001) [Table 2]. The comparison of BBS, DGI, ABC, and SSQOL scores between the groups was done [Table 3], in which for BBS, P value was statistically significant (P = 0.024), but P values for DGI, ABC, and SSQOL were 0.053, 0.085, and 0.106, respectively, which was not statistically significant.
Table 1: Demographic characteristics of participants in the groups

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Table 2: Comparison of Berg Balance Scale, Dynamic Gait Index, Activity-specific Balance Confidence Scale, and stroke-specific quality of life scores within the groups using Wilcoxon signed-rank test

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Table 3: Comparison of Berg Balance Scale, Dynamic Gait Index, Activity-specific Balance Confidence Scale, and stroke-specific quality of life score between the groups

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  Discussion Top

The present study reports that significant improvement was observed in dynamic balance, gait, and quality of life in terms of BBS, DGI, ABC, and SSQOL scores with Libra Balance Board exercises as well as Pilates exercises in patients with subacute and chronic stroke.

The improvement observed in BBS score is significantly more in patients treated with Libra balance board exercises. The possible reason for this significant improvement in dynamic balance may be due to the probable learning mechanism that entities with subacute and chronic stroke can regain abilities in the adjustment of dynamic balance and walking patterns in reaction to self-initiated perturbation using anticipatory (feed forward) postural adjustment. In multidirectional perturbations, the recruitment of synergistic muscle is directed toward the perturbation and produces a specific biomechanical function to re-establish the center of mass. The muscle recruitment provides a motor repertoire for trunk muscles during balance training. The training induced on the balance board made the patients to rely strongly on their proprioceptive system. Literature suggests that changes in the brain structure induce motor learning by exergaming which helps in sensory re-education, retraining of voluntary motor control of balance, and to improve the patient's independence and motivation to exercise with visual feedback[15] and also augmented training with appropriate feedback improves motor learning and videogame-based exercises improve balance and gait in older adults.[16]

In addition, improvement in balance and gait in patients in Pilates group could have been due to the trunk, pelvic, and lower-extremity musculature strengthening associated with upheld equilibrium. The improved integration of movement fluidity, control, precision, and proprioception improves kinesthetic awareness, allowing the patients to efficiently control bodily movements as well as posture.[10] Literature states the effectiveness of Pilates exercises in improving postural stability in neurologically intact as well as in stroke patients.[17]

Libra Balance Board exercises were game based and the patients included in this group were highly engrossed in the games, hence adhering to the program. Thus, a significant improvement was seen in the quality of life of these individuals. Lee et al. conducted a study to evaluate the effect of virtual-reality games in improving balance, gait, depression, and interpersonal relationships in stroke patients and found beneficial effects.[18] The impact of Pilates in stroke patients on the serotonin hormone improves physical performance, mood, sleep quality, and personal judgments and also reduces the degree of depression, which could have had a positive effect on the quality of life.[10] These findings support the results of the present study, where Pilates demonstrated a statistical significant change in the scores of SSQOL. The limitation of the study is a short duration of the study and no blinding of evaluators or participants.

  Conclusion Top

The present study concludes that Libra Balance Board exercises and Pilates are useful in the improving the dynamic balance, gait, and quality of life in patients with subacute and chronic stroke. Furthermore, it was observed in between-group comparison, Libra Balance Board exercises were more superior to Pilates in terms of balance improvement. Future studies can be taken up to assess the long-term effect of Libra balance board exercises in subacute and chronic stroke patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


We are grateful to the head of the institution for granting us permission to conduct the study and use the research-related infrastructure. Our heartfelt thanks to the Miss. Neha Deshmukh for statistical analysis and helping us in writing the manuscript. We are thankful to all the individuals for participating in the study, without whom the study would not have been possible.

Financial support and sponsorship


Conflicts of interest

There are no conflict of interest.

  References Top

Kuklina EV, Tong X, George MG, Bansil P. Epidemiology and prevention of stroke: A worldwide perspective. Expert Rev Neurother 2012;12:199-208.  Back to cited text no. 1
Cash EJ. Textbook of Neurology for Physiotherapist. 4th ed. London: Wolfe Publications; 1992.  Back to cited text no. 2
O'Sullivan SB, Schmitz TJ, Fulk G. Physical rehabilitation. 5th edition FA Davis 2019;706-7.  Back to cited text no. 3
Nicol MB, Thrift AG. Knowledge of risk factors and warning signs of stroke. Vasc Health Risk Manag 2005;1:137-47.  Back to cited text no. 4
Lisabeth LD, Brown DL, Hughes R, Majersik JJ, Morgenstern LB. Acute stroke symptoms: Comparing women and men. Stroke 2009;40:2031-6.  Back to cited text no. 5
Tyson SF, Hanley M, Chillala J, Selley A, Tallis RC. Balance disability after stroke. Phys Ther 2006;86:30-8.  Back to cited text no. 6
Kwakkel G, Veerbeek JM, van Wegen EE, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol 2015;14:224-34.  Back to cited text no. 7
Lim HS, Kim YL, Lee SM. The effects of Pilates exercise training on static and dynamic balance in chronic stroke patients: A randomized controlled trial. J Phys Ther Sci 2016;28:1819-24.  Back to cited text no. 8
Mhaske GC, Kumar S. Effect of wobble board exercise with mirror feedback on balance and gait training in geriatric population: An experimental study, MedPulse – International Medical Journal 2016;3:961-6.  Back to cited text no. 9
Blum L, Korner-Bitensky N. Usefulness of the Berg Balance Scale in stroke rehabilitation: A systematic review. Phys Ther 2008;88:559-66.  Back to cited text no. 10
Jonsdottir J, Cattaneo D. Reliability and validity of the Dynamic Gait Index in persons with chronic stroke. Arch Phys Med Rehabil 2007;88:1410-5.  Back to cited text no. 11
Stasny BM, Newton RA, Viggiano LoCascio L, Bedio N, Lauke C, Conroy M, et al. The ABC scale and fall risk: A systematic review. Phys Occup Ther Geriatr 2011;29:233-42.  Back to cited text no. 12
Silva SM, Corrêa FI, Faria CD, Corrêa JC. Psychometric properties of the stroke specific quality of life scale for the assessment of participation in stroke survivors using the rasch model: A preliminary study. J Phys Ther Sci 2015;27:389-92.  Back to cited text no. 13
Surbala L, Khuman PR, Gopal Nambi S, Kalpesh S. Pilates in functional balance and quality of life in sub-acute stroke subjects – A randomized controlled study. Int J Health Rehab Sci. 2013;2:204-11.  Back to cited text no. 14
Ribas CG, Alves da Silva L, Corrêa MR, Teive HG, Valderramas S. Effectiveness of exergaming in improving functional balance, fatigue and quality of life in Parkinson's disease: A pilot randomized controlled trial. Parkinsonism Relat Disord 2017;38:13-8.  Back to cited text no. 15
Papegaaij S, Morang F, Steenbrink F. Virtual and augmented reality based balance and gait training. White Pap 2017;1-8.  Back to cited text no. 16
Bird ML, Hill KD, Fell JW. A randomized controlled study investigating static and dynamic balance in older adults after training with Pilates. Arch Phys Med Rehabil 2012;93:43-9.  Back to cited text no. 17
Lee MJ, Gyeongsan S, Koo HM, Busan S, Lee SM. Effects of virtual reality therapy on balance function and ADL in hemiplegic patients. J Adv Res Dyn Control Syst 2017;21:51-5.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]


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