In the present experimental study, total of 51 patients were included. Subjects were taken from SPB Physiotherapy College OPD and selected by purposive sampling method. This study was conducted from December 2017-March 2018 and completed with 51 ambulatory stroke subjects. Seventeen subjects in each group were allocated. Ethical clearance (G/MPT/OO3) was taken from the institutional committee. The purpose of this study was explained and a written informed consent was obtained from all the subjects. Subjects were allocated on the basis of the inclusion and exclusion criteria and their demographic data was collected. Sample size calculated was 42, with a drop out chances of 20%.

Subjects having 45-75 year age, first episode of cerebrovascular stroke, diagnosed according to Brunnstorm’s recovery stage 3 or higher than 3, with post-stoke duration of 6 to 18 months and Mental competency (>=24) through Mini Mental Scale were included in the study. The subjects must have BBS score 41-56 and ability to walk independently for 10 meter with or without assistance. Subjects with any neurological deficit other than stroke, sensory disorders affecting balance, any known perceptual disorders including vision has been excluded from the study. Subjects have also been excluded if they had musculoskeletal disorders of lower extremity leading to instability or pain, any known cardiovascular disorders or any surgery or trauma in lower limb in the past six months.

Subjects were asked to perform set of exercises for five days a week with total duration of four weeks. Pre and post-intervention assessment was carried out by using BBS and TUG. Data was collected and analysed. Subjects were allocated in to three groups using quasi randomisation in which the first patient were allocated to Group A (Conventional physiotherapy training), second to Group B (Wobble board training without visual feedback) and third to Group C {Wobble board training with visual feedback (Sensamove Miniboard)}.

Conventional therapy included mat activities (stretching as well as strengthening), weight bearing or shifting and standing lower-extremity exercise in parallel bars and balance activities, unilateral stance activities, tandem stance, ambulation activities, training in functional activities such as bed mobility, scooting in a sitting position, standing, reaching, transfers, stair climbing and gait training. On the first day of first week, pre-test measurement of balance by using BBS and TUG scale were taken. Subjects were trained for 50 minutes each day. In each session subjects were given 20 minutes for balance training and 30 minutes for conventional therapy. These treatments were given for five days a week for total four weeks. Five repetitions were demonstrated for each exercise. Then post measurements of BBS and TUG were taken after four weeks. To prevent accidents during exercise, assistance was permitted by parallel bar.

Statistical tests were performed using SPSS version 20.00 software. Significance was set at p≤0.05 for all analyses. Paired t-test was used for intra-group comparisons. ANOVA and post-HOC tests were for inter-group comparisons between all three groups for BBS and TUG.

The study included 51 post stroke patients of which 28 (55%) were males and 23 (45%) were females. The mean age of was 59.25±8.937. Participant baseline characteristics of Brunstrom and MMSE are given in [Table/Fig-1]. The appropriate tool for comparison of the change in the level of a variable is student’s paired t-test for intra-group comparison. The level of significance is taken at 5%. For inter-group comparison ANOVA and Post HOC test was conducted. The results of the comparison of all the group participant with BBS and TUG pre-test and post-test values are presented in [Table/Fig-2,3]. The participants involved in the Wobble board training with visual feedback (Sensamove Miniboard) showed significant improvement (p<0.05) compared to conventional physiotherapy and Wobble board training with visual feedback.

The present study results show that all the interventions such as conventional physiotherapy training, wobble board training without visual feedback and wobble board training with visual feedback are effective to improve balance in ambulatory stroke patients but wobble board with visual feedback is highly significant as p <0.05 to improve balance in ambulatory stroke patients as compared to other two intervention groups. Hoseinabadi MR et al., studied the effects of physical therapy on exaggerated muscle tonicity, balance and quality of life on hemiparetic patients due to stroke, and showed that the average balance and quality of life significantly improved and tonicity of muscle also decreased [17]. Thus, physical therapy can enhance balance and quality of life of hemiparetic patients. Jeya Raman RK et al., found that the intensive strength training intervention is an effective procedure and found that balance was improved in post-stroke hemiplegics [18]. These findings are suggestive that balance and mobility can be improved by conventional physiotherapy training.

Wobble board exercise regimen can be used to strengthen weak lower extremity muscles and improve static balance of subjects. The reason for improvement in Group B can be due to effect of training on reflex control of muscle activity when exercising in close kinematic chain (wobble board). There was improved intramuscular and intermuscular coordination and more activation of agonists helps in achieving stabilisation of extremities and thus help in improving balance which improves strength. It also improves standing balance by controlling center of gravity and maintains a standing posture on unstable surface conditions. Teslim O et al., performed a study on the effect of six weeks wobble board exercises on static and dynamic balance of stroke survivors and concluded that wobble board exercise improved both static (eye closed) and dynamic balance of stroke survivor [19]. This supports our finding too, in hemiparetic patients after few weeks of stroke there occurs excessive postural oscillations and instability [20]. With time these abnormalities improve, reflecting better somatosensory integration, with gradual increase in use of proprioceptive and exteroceptive afferent information of the paretic lower limb [21]. In our study, for group C (Wobble board training with visual feedback) there was a noticeable improvement in balance when compared to Group A and Group B. Visual information can be used to compensate the inappropriate proprioception and correct the body asymmetry through the reorganisation of information. By providing constant visual feedback specially during tasks make the patients more aware and patients can autocorrect their body position and this mechanism help patients to improve balance. Authors have reported gains in more stance symmetry in subjects with hemiparesis who were trained with either visual feedback of the position of the center of pressure or weight distribution over those who received conventional training [19,22]. Gung found improvement in visual training group, compared to control group and also found improvement in the ADL and improvements at six months of follow-up in the trained group [13,20]. Nichols DS et al., and Betker AL et al., reported that balance training with visual feedback achieved higher participation and compliance, a lower incidence of falls, and a lower center of mass amplitude [23,24]. Some studies also indicate that the use of visual biofeedback/force plate training improves stance symmetry in subjects with hemiplegia following stroke [9,25]. This helps to improve balance and the fact is supported by the present study too.

ANOVA and post HOC tests demonstrated that the balance improvement of BBS and TUG is highly significant in Group C compared to Group B and Group A. This shows that the wobble board training with visual feedback is the most effective than all the interventions for improving balance in ambulatory stroke patients. Catherine walker suggests that BBS scores provide support that activity-based balance performance improved over time [26]. Study by Shrivastava A et al., showed that balance training by Force Platform Visual Feedback technique significantly improves balance by using BBS and functional outcome, even in chronic phase after stroke [27]. In present study both outcome measure BBS and TUG were improved. Major improvement was noted in Group C.

Researchers suggested that visual information can be compensated for sensory motor loss and with training, subjects can assimilate the information, thus establishing a central motor program such that the external feedback would no longer be required [28]. In majority of stroke patients motor function was impaired and they weretotally dependent on visual feedback to perform motor tasks. The tasks were new to patients but with the help of adequate feedback as well as clear instructions, greater improvement was achieved.

Long term follows-up of the patients were not done after completion of the intervention duration; hence long term benefits of intervention are unknown in this study. Same study can be performed including equal number of male and female patients comparing results of males and females.

All the three interventions used in the present study like conventional physiotherapy, wobble board without visual feedback and with visual feedback are effective for providing balance training in ambulatory stroke patients. Major improvement was noted in training with wobble board with visual feedback (Sensamove Miniboard). Here, with the help of Sensamove miniboard, patients can get visual feedback and balance improvement was maximum. So administrating training with wobble board with visual feedback (Sensamove Miniboard) is the most effective.