Boxing and Scapular Stabilization Training in Hemiparetics
Condition: Stroke; Hemiparesis
MeSH terms: Paresis
Study type: Interventional

Summary: 
      In recent years, it has been observed that scapular stabilization exercises given in addition
      to stretching exercises in stroke patients strengthen the scapular muscles and improve
      walking and trunk alignment. In a study published in 2020, in which the investigators
      compared the effects of virtual and real boxing training on upper extremity functions,
      balance and cognitive functions in stroke patients, significant improvement was observed in
      each parameter in both groups.

      When the investigators look at the literature, the investigators see that there is no study
      comparing the effects of both scapular stabilization and boxing training on upper extremity
      functions and trunk balance in stroke patients.

      Therefore the aim of this study, compare the effects of boxing and scapular stabilization
      training on scapular mobility (primary outcome measure), upper extremity range of motion,
      shoulder proprioception, scapular balance angle, scapular muscle strength, trunk muscle
      strength, upper extremity motor functions, trunk balance and treatment satisfaction
      (secondary outcome measures) in hemiparetic individuals with stroke.
    

Detailed description: 
      Upper extremity dysfunction can be seen in approximately 30% to 66% of hemiplegic patients.
      Loss of the Betz cell, which is the most abundant in the cerebral cortex and is responsible
      for the control of the hand, leads to impaired hand functions in hemiparetic patients who
      have had a stroke. Flexor spasticity predominates in the upper extremities. In addition to
      internal rotation and adduction of the shoulder, retraction and depression of the scapula are
      observed. The subscapularis and pectoral muscles are the muscles whose tone increases the
      most in this process. In addition, the rhomboids, serratus anterior, deltoid, trapezius
      middle, and lower parts are the muscles that weaken the most. For upper extremity elevation,
      the humeral head must be located within the glenoid fossa. Deltoid and rotator cuff muscles
      work as a force couple to achieve this. The most important muscles preventing glenohumeral
      joint subluxation are the posterior deltoid, supraspinatus, and infraspinatus.

      A visible change in the movement pattern and position of the scapula relative to the thorax
      is defined as scapular dyskinesia. In the literature, there is no consensus on whether
      scapular dyskinesia occurs secondary to any pathology or influence, or whether it is the
      cause of these pathologies. In an EMG study performed during shoulder flexion in stroke
      patients, delayed muscle activation of the lower trapezius muscle was observed in stroke
      patients with shoulder pain compared to stroke patients without shoulder pain. In the
      electromyography study conducted by Betz et al. in 2014, they observed that the Serratus
      anterior muscle was inactive or late active in some of the stroke patients with shoulder
      pain, while the infraspinatus muscle was activated earlier and the activation lasted longer
      in stroke patients without shoulder pain. The researchers pointed out that these results show
      the role of the timing of activation of the infraspinatus muscle in shoulder stabilization
      and prevention of shoulder pain in stroke patients, and that infraspinatus muscle
      strengthening exercises should be added to rehabilitation to prevent shoulder impingement
      syndrome, and they drew attention to the importance of serratus anterior and lower trapezius
      muscle in scapular motor control to provide dynamic stabilization.

      Postural stability is defined as the relationship of body parts to the center of gravity. It
      has been said that the basic prerequisite for movements requiring complex controlled ability
      is postural stability. Many studies have investigated the relationship between balance
      disorder and lower extremity dysfunction in stroke, however, it is thought that upper
      extremity dysfunction also affects balance significantly.Williams et al. showed in their
      study that scapulothoracic joint stabilization, mostly generated by the trapezius and
      serratus anterior muscles, contributes significantly to trunk core stability. During
      voluntary arm movements, force moments occur in the shoulder depending on the weight and
      dynamics of the arm. These forces and moments can affect the ability to sit, stand and also
      change positions. Body stabilization during walking is provided by ± 1.5 ° movement of the
      upper body. This movement can increase the stability of the head by reducing false signals
      from the otolith and vestibular systems. In the study conducted by Awad et al. in hemiparetic
      patients with stroke, stretching exercises for the pectorals, latissimus dorsi, rhomboids,
      and teres major muscles, scapular stabilization exercises in addition to trunk control
      exercises were applied 3 times a week for 6 weeks, and it was observed that scapular muscle
      strength increased and trunk alignment improved. In another study by Jo et al. in 2019, it
      was observed that strengthening exercises given to the scapular muscles 3 times a week for 8
      weeks in addition to stretching exercises improved upper extremity and walking functions.

      In a study published in 2020, in which the investigators compared the effects of virtual and
      real boxing training on upper extremity functions, balance, and cognitive functions in stroke
      patients, significant improvement was observed in each parameter in both groups .

      When the investigators look at the literature, the investigators see that there is no study
      comparing the effects of both scapular stabilization and boxing training on upper extremity
      functions and trunk balance in stroke patients.

      Therefore the aim of this study, compare the effects of boxing and scapular stabilization
      training on scapular mobility (primary outcome measure), upper extremity range of motion,
      shoulder proprioception, scapular balance angle, scapular muscle strength, trunk muscle
      strength, upper extremity motor functions, trunk balance and treatment satisfaction
      (secondary outcome measures) in hemiparetic individuals with stroke.
    

Intervention name(s): Boxing Training; Scapular Stabilization
Intervention type(s): Other; Other
Intervention description(s): In addition to boxing training, stretching exercises and posture training will be given at BG. A physiotherapist with a boxing training certificate will perform modified boxing training that progresses according to the degree of difficulty. There will be four difficulty levels. The complexity of the exercises will increase at 2-week intervals as the patient progresses. As a result, 0-2 weeks 1st level, 2-4 weeks 2nd level, 4-6 weeks 3rd level and 6-8 weeks 4th level exercises will be done.
In the first level, patients will be asked to punch the fixed boxing mat hanging on the wall with various instructions. Then, in levels 2-4, target gloves and heavy punching bags will be used to increase the difficulty level. As the sessions progress, the resistance and frequencies between the levels will be increased by the physiotherapist. There will be 3 sessions of 30-minute boxing training per week for 8 weeks at BG.; In addition to scapular stabilization training, stretching exercises and posture training will be given in SSG. Progressive strengthening training for the scapular muscles will be used in the SSG. There will be four difficulty levels. The complexity of the exercises will increase at 2-week intervals as the patient progresses. As a result, 0-2 weeks 1st level, 2-4 weeks 2nd level, 4-6 weeks 3rd level and 6-8 weeks 4th level exercises will be done.
At the first level, scapular clock exercise, obstacle crossing exercise, wall gliding exercise with teraband, push up exercise, trunk rotation and maximum hip flexion will be performed. Then at levels 2-4, as the levels increase, the exercises at the first level will be more difficult (ball weight, surface, number of hurdles and hurdle crossing exercise position, by changing the teraband elasticity, push-up position). In SSG, 3 sessions of 30-minute scapular stabilization training will be applied per week for 8 weeks.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: boxing; upper extremity function; balance; Stroke