Boxing and Scapular Stabilization Training in Hemiparetics

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.

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.

Eligibility Criteria:
Inclusion Criteria:

* Patients diagnosed with first time ever stroke
* Patients with hemiparesis
* Patients who are between the ages of 40-70
* Patients who has Mini Mental Test score above 23
* Patients whose functional level is less than 4 according to the Modified Rankin Scale
* Patients who has upper extremity spasticity lower than 2 on Modified Ashworth Scale
* Patients who can do 120 degrees of shoulder flexion

Exclusion Criteria:

* Having a chronic disease (for example: uncontrolled hypertension,heart disease...)
* Subluxation and fracture at the shoulder
* Risk of fracture and pain at the shoulder
* Visual and hearing impairment
* Unilateral neglect
* Botulinum toxin administration or surgical operation in the last 6 months patients