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Critical Review

This section will compare and contrast the articles taken for the review in order to evaluate
the effectiveness of core strengthening exercise on sitting balance of sub-acute to chronic
stroke patients. To carry out the critical review, CASP-RCT checklist will be used and
attached in Appendix section for reference.

There are basically three broad questions in critical review, the first question deals with
validity of the study, the second question deals with the findings and third question deals with
generalisability of the findings and whether the outcome can be implemented locally or not.

From health focus point of view each of the article taken into consideration has clearly stated
their objectives, targeted audience and interventions. The meta-analytic review carried out by
Sorinola group has clearly stated the study objective as additional trunk training against
conventional rehabilitation as the research topic. However, the abstract that is meant to be
clear, concise and clarified presentation of the research topic lacks clarity. The study didn’t
mention what is meant by additional trunk exercise and how they are defined. But the other
articles such as Yoo et al (2010) Chung group (2013) has clearly stated their interventions
and targeted audience. While Yoo et al has compared conventional exercise against core
strengthening exercise, Chung group has compared core stabilisation exercise against
conventional rehabilitation exercise. Similarly, Sun et al (2016) has evaluated core stabilising
exercise against conventional exercise. The fifth study by Valdes group (2015) has clearly
stated the intervention that core stability exercise and outcomes to be evaluated trunk control,
gait, and activities of daily living, sitting and standing balance in sub-acute patients. The fifth
article has more validity and reliability as compared to other articles taken for study because
the authors have clearly identified the targeted group. In Randomised controlled trial,
presence of external validity that is identification of a target population can determine
whether the outcome can be generalised or not. The objective of the research proposal was to
evaluate the effectiveness of core strengthening exercise on sitting balance of sub-acute to
chronic stroke patients. Except the study by Yoo and Valdes group, the other group’s hasn’t
identified their patients precisely (targeted audience). However, the other studies have taken
only stroke patients without identifying the degree of severity or stroke status. Therefore the
outcomes of such results can be made local or not still remains a question mark.

In context of randomisation of the sample or sampling methods, the Meta analysis of Soriola
cannot be considered as it is a secondary research analysis. Although from level of evidence
pyramid, meta-analysis review holds the top most position, the limitation is the researcher has
less control over the results since they are already published, therefore their authenticity is
limited to journals in which they are published and other qualitative analysis of authors and
study methodology. The randomisation remained same for rest of the studies except for Sun
group (2016) where the control group was subjected to only conventional exercise for six
weeks and experimental group that was subjected to core strengthening exercise for a period
of six weeks. Therefore the results or outcomes in case of Sun et al group will have
confounding factors or bias factors as the intervention was very specifically targeted. The
other studies where they have reversed the intervention and evaluated the results are a better
method of randomisation that can improve the study outcome. The advantages of the studies
included for consideration is all the studies have detailed the inclusion and exclusion criteria
for the samples or subjects included in the study. Inclusion and exclusion criteria reduce the
population bias and bring the entire sample on same base that makes comparison easier,
reliable and valid.

The randomised controlled trial carried out by Yoo et al includes physiotherapist help for
stroke patients in carrying out the exercise as they have weak muscles. In this case, the extent
of help physiotherapist must be properly structured. Since, the weakness and strength of
stroke patients vary from one another; the help is a bias for the study. The RCT protocol
maintained by Yoo and Chung group was similar where the core strengthening exercise was
carried out for a period of 3 days per week, 30 minutes and for a period of 4 weeks. The
advantage of similar intervention is comparable outcomes. Similar strategies were used by
other studies such as the intervention administered by Sun group (2016) includes one hour of
exercise for six days and for a period of six weeks. However, the time allotted for
intervention of interest in case of Cabanas –Valdes is very less that is 15 min per day. So,
whether the time set for the study is sufficient enough to produce result or not must be
evaluated at first strategy. In case, 15 minutes per day doesn’t produce noticeable or
significant results, then the outcomes will be biased.

The study by Sun group (2016) has blinded the study by including a physician who is not
included in the study. However the two other studies that are Valdes group (2015) and Chung
group (2015) has not mentioned how they have blinded the study protocols to the
investigators. Blinding in randomised controlled trial helps in reducing the researcher bias in
the study. Therefore, the study results from Sun group (2016) will be more reliable as
compared to other studies.

The studies considered involved different index and scoring system to assess the outcome.
Yoo et al (2010) employed Trunk Control Test, Trunk Impairment scale and Berg Balance
scale. Chung et al (2013) employed time up and go test (TUG) and gait parameters (velocity,
step length, cadence, and stride length). Sun et al (2016) employed modified barthel index
and Berg balance scale and Valdes group (2015) Trunk Impairment scale and Berg Balance
scale. The comparative analysis of the RCT’s implicates the different tools used for outcome
measurement are majorly taken from evidence based literature. Berg balance scale has been
used to measure the balance and fall among stroke patients and continues to be used for
stroke patients (Huang et al., 2017). From methodology rigour, the studies have followed
established protocols and tools to assess the outcome of the studies.


The major finding of Meta analysis review is moderate effect of core strengthening exercise
on mobility and standing balance on stroke patients, however the effect remains weak for
trunk performance through trunk exercise. The study by Chung reported significant increase
in velocity, TUG and cadence in experimental group that was subjected to core strengthening
exercise. However, the results of Sun group were different where except for Berg balance
scale improvement in experimental group no significant difference was observed. Similarly,
Valdes group reported improvement in balance, gait and strength in experimental group as
compared to the control group. The treatment effect was not too large since the number of
samples exposed to treatment arm is not high. Secondly, even though different methods or
tools was used at p value less than 0.05, the results were not conclusive and researchers
advocate to carry out more empirical research into the treatment arm. However the
confidence limits for each study remain same at 95% CI implicating, the statistical coherence
in studies.

The study results cannot be implemented locally because the sample size is too less, secondly
the studies are mostly carried out in Asian population. Stroke patients are affected by
environmental and societal factors too. Therefore, how such factors are controlled during the
treatment is not known. Thus, larger sample size is required for clinical generalisability.

Huang, Y. J., Lin, G. H., Lee, S. C., Chen, Y. M., Huang, S. L., & Hsieh, C. L. (2017).
Group-and Individual-Level Responsiveness of the 3-Point Berg Balance Scale and 3-Point
Postural Assessment Scale for Stroke Patients. Archives of physical medicine and

Stuart, E. A., Bradshaw, C. P., & Leaf, P. J. (2015). Assessing the generalizability of
randomized trial results to target populations. Prevention Science, 16(3), 475-485.