609414

research-article2015
CRE0010.1177/0269215515609414Clinical RehabilitationCabanas-Valds et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

The effect of additional core 2016, Vol. 30(10) 10241033

The Author(s) 2015
Reprints and permissions:
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DOI: 10.1177/0269215515609414

dynamic sitting balance and trunk cre.sagepub.com

control for subacute stroke

patients: a randomized
controlled trial

Rosa Cabanas-Valds1, Caritat Bagur-Calafat1,

Montserrat Girabent-Farrs2,
Fernanda M Caballero-Gmez3,
Montserrat Hernndez-Valio4
and Gerard Urrtia Cuch5

Abstract
Objective: To examine the effect of core stability exercises on trunk control, dynamic sitting and standing
balance, gait, and activities of daily living in subacute stroke patients.
Design: A randomized controlled trial.
Setting: Inpatient rehabilitation hospital in two centres.
Subjects: Eighty patients (mean of 23.25 (16.7) days post-stroke) were randomly assigned to an
experimental group and a control group.
Interventions: Both groups underwent conventional therapy for five days/week for five weeks and the
experimental group performed core stability exercises for 15 min/day. The patients were assessed before
and after intervention.
Main measures: The Trunk Impairment Scale (Spanish-Version) and Function in Sitting Test were used
to measure the primary outcome of dynamic sitting balance. Secondary outcome measures were standing
balance and gait as evaluated via Berg Balance Scale, Tinetti Test, Brunel Balance Assessment, Postural
Assessment Scale for Stroke (Spanish-Version), and activities of daily living using Barthel Index.

1Department of Physiotherapy, Faculty of Medicine and 5Centro

Health Sciences, Universitat Internacional de Catalunya (UIC)
Barcelona, Catalonia, Spain
2Department of Physiotherapy (Biostatistics Unit), Faculty of
Medicine and Health Sciences, Universitat Internacional de
Catalunya, Barcelona, Catalonia, Spain
3Physical Medicine and Rehabilitation, Parc Taul Sabadell
Hospital Universitari, Sabadell, Catalonia, Spain
4Department of Physiotherapy, Parc Sanitari Pere Virgili,
Barcelona, Catalonia, Spain
Cochrane Iberoamericano, Institut dInvestigaci
Biomdica Sant Pau, CIBERESP, Barcelona, Catalonia, Spain
Corresponding author:
Rosa Cabanas-Valds, Department of Physiotherapy, Faculty
of Medicine and Health Sciences, Universitat Internacional de
Catalunya (UIC) Josep Trueta street, E-08195 Sant Cugat del
Valls Barcelona, Catalonia, Spain.
Email: rosacabanas@uic.es
Cabanas-Valds et al. 1025

Results: The experimental group showed statistically significant differences for all of the total scale scores
(P<0.05), except for the sitting section of the Brunel Balance Assessment. The mean (SD) difference
between groups in Trunk Impairment Scale total score was 3.40 (4.12) points, and its subscale dynamic
sitting balance was 2.28 (3.29). The Berg Balance Scale was 14.54 (18.19) points, and the Barthel Index
was 13.17 (25.27) points. Collectively, these results were in favour of the experimental group.
Conclusions: Core stability exercises in addition to conventional therapy improves trunk control,
dynamic sitting balance, standing balance, gait and activities of daily living in subacute post-stroke patients.

Keywords
Hemiplegia, activities of daily living, core stability, stroke, trunk control

Received: 28 March 2015; accepted: 5 September 2015

Introduction
Impairments in balance can be a consequence of
changes in the sensory and integrative aspects of
motor control.1 More than 80% of subjects who
have suffered a first-time stroke have balance dis-
ability in the sub-acute phase.2
Trunk impairment, restricted balance, and
impaired postural control in patients with stroke
are correlated3 with increasing risk of falls and
impaired mobility.4 This creates disability and
dependency in their activities of daily living.
The core is central to almost all kinetic chains in
the body. Control of core strength, balance, and
motion maximizes all kinetic chains of upper and
lower extremity function,5 which is essential to pro-
viding a solid base to exert or resist force.6 A stable
and strong core may contribute to more efficient use
of the lower limbs.7 Core stability is defined as the
ability of the lumbopelvic-hip complex to prevent
buckling of the vertebral column and return it to
equilibrium following perturbation.8
A systematic review9 has shown that imple-
menting core stability exercises may be a viable
strategy for improving trunk performance and
dynamic sitting balance, standing balance, and gait
in post-stroke patients. However, common meth-
odological limitations in the design and the report-
ing of these studies included in the review justified
the need for further well-designed studies.
Given the importance of core stability with bal-
ance, this study aimed to investigate the effect of
including additional core stability exercises to con-
ventional therapy on improving trunk performance
and dynamic sitting balance. Additionally, this
study aimed to determine whether core stability
exercises might also positively affect standing bal-
ance, gait and activities of daily living in sub-acute
post-stroke patients.
Methods
Trial design
A blinded-assessor randomized controlled trial
with two parallel groups were performed in two
centres. Patients were recruited from the Parc
Sanitari Pere Virgili (Barcelona, Spain) and Parc
Taul Sabadell Hospital Universitari (Sabadell,
Spain) between October 2012 and March 2014.
All patients (age 18 years or older) who had
experienced their first stroke, whether ischaemic or
haemorrhagic (not requiring surgery), within the
last three months were eligible for inclusion. The
stroke diagnosis was based on the World Health
Organization guidelines and was confirmed by clin-
ical examination and magnetic resonance imaging.
Exclusion criteria included significant disability
prior to stroke as evidenced by a score of >3 on the
modified Rankin scale,10 a Barthel Index11 score 75,
and a Spanish Version of Trunk Impairment Scale
2.012,13 score 10. Other exclusion criteria included
orthopaedic or neurological impairments that could
influence sitting balance, inability to understand
instructions as assessed by a Mini Mental State
Examination score 24, apraxia, and hemineglect.
1026 Clinical Rehabilitation 30(10)
Information on patients age, days post-stroke,
stroke severity as assessed by National Institutes of
Health Stroke Scale, and the side and location of
the lesion was collected from medical records.
Participants were asked to sign an informed con-
sent before participating.
The ethical committee from Parc Taul Sabadell
Hospital Universitari gave approval. The study was
carried out as per the standards set by the
Declaration of Helsinki.
The number of patients required for this study
was calculated taking into consideration the score
variable dynamic sitting balance subscale on the
Spanish Version of Trunk Impairment Scale 2.0. A
standard deviation of 2.3 was assumed in both
groups based on our results in the validation study
for this scale performed prior to the trial.
We also assumed a type I error of 5% and a two-
tailed t-test with 80% power. We estimated that 37
patients would need to be included in each study
arm in order to detect a 1.5-point improvement,
yielding a total of 74 patients. To offset any possi-
ble dropouts estimated at <10%, the final sample
size was set at 80 patients.
Study participants were randomly allocated to
either an experimental group or control group by
means of a random computer-generated list spe-
cific to each centre. The randomization was man-
aged by an external person uninvolved in the
treatment or follow-up of patients. The method of
allocation was concealed in sequentially num-
bered, sealed, opaque envelopes.
The principal investigator sequentially enrolled
patients and communicated the decision to the
physiotherapists (a total of eight), who then
assigned patients to an intervention (control or
experimental group) according to the content of the
envelopes. The principal investigator did not par-
ticipate in the intervention but performed all of the
clinical evaluations in a blinded manner.
Interventions
All patients followed the conventional therapy pro-
gramme for stroke patients provided by their
respective rehabilitation centre for a 5-week period,
consisting of 1 hour of treatment a day, 5 times a
week for 5 weeks (25 sessions). The conventional
treatment programme was patient-specific and
consists mainly of physiotherapy, such as tone
facilitation, stretching, passive mobilization, and
range-of-motion exercises for the hemiparetic side,
walking between parallel bars, and occupational
therapy and nursing care. Additionally, activities of
the trunk integrated in postural control and task-
directed movement were performed.
In addition, patients in the experimental group
performed core stability exercises for 15 minutes
daily, totalling 6.15 hours. All physiotherapists
were neurology experts and received one day of
education on training in specific exercises by the
principal investigator. The physiotherapists per-
formed the therapy with their hands on the patient
to ensure proper quality of movement and did not
participate in the patients evaluation.
Adequate rest periods were allowed between
exercises. The core stability exercises were selec-
tive, repetitive movements and involved tasks
without resistance to improve strength, endurance,
and coordination of the core.
The specific programme used in this study was
inspired by an analysis of the interventions used in
the trials included in the systematic review.9 The
programme was divided into three steps based on
the level of difficulty (see Supplementary Figures
1-2). Training was determined by the patients abil-
ity to undertake easy exercises and progress to
more challenging exercises. They did not move on
to higher levels until they had mastered the exer-
cise they were engaged in.
When the individuals were unable to sit unsup-
ported, they performed core stability exercises in
step 1. Step 1: the exercises were performed in a
supine position on a plinth or bed (see
Supplementary Figure 1). When the patient was
able to sit for one minute on the edge of the plinth
or bed without any back or arm support with hips
and knees bent at 90 and feet flat on the support
surface, they moved on to step 2. Step 2: the exer-
cises were performed in a sitting position on a sta-
ble surface (see Supplementary Figure 2). When
the patient was able to sit on an unstable surface
thirty seconds, she/he moved on to step 3. Step 3:
the exercises were performed in sitting position on
a physioball (see Supplementary Figure 2).
Cabanas-Valds et al. 1027
Outcome measures
The primary outcome was dynamic sitting balance
and trunk control measured by the Spanish Version
of Trunk Impairment Scale 2.0. This scale consists
of two sub-scales: dynamic sitting balance (which
evaluates the subjects ability to actively shorten
each side of the trunk) and coordination (which
assesses the subjects ability to independently rotate
the shoulder girdle and pelvic girdle). These sub-
scale scores range from 0-10 and 0-6, respectively.
The Function in Sitting Test is a 14-item perfor-
mance-based clinical examination of sitting balance.
It is designed to evaluate sensory, motor, proactive,
reactive, and steady-state balance factors.
Secondary outcome measures were standing
balance, gait, and activities of daily living as meas-
ured by the following scales: the Brunel Balance
Assessment is a 12-point ordinal scale consisting
of a hierarchical series of functional performance
tests that range from supported sitting and standing
balance to advanced stepping tasks (gait); the Berg
Balance Scale is a 14-item objective measuring
tool designed to assess static balance; the Spanish
Version of the Postural Assessment Scale for
Stroke14 is a 12-point ordinal scale used to evaluate
postural control; the Tinetti Test consists of 2 sub-
scales for gait (12-point) and balance (16-point);
the Barthel Index is a 10-point scale that evaluates
functional performance. All the scales have been
validated for stroke patients, and higher scores are
indicative of better performances.
Statistical methods
The patients were assessed before and after the
intervention. The patients characteristics were
described using frequencies for the categorical data
variables and for the continuous data mean and
standard deviation for both the control and experi-
mental groups and the pre- and post-treatment
measurements. The Pearsons Chi-square test was
used for categorical variables, and the Mann-
Whitney U test (no normal distribution) and
Students t-test (normal distribution) were
employed for continuous variables.
The Shapiro-Wilk test was used to determine
whether the control and experimental groups were
homogeneous at baseline for each of the recorded
variables. A new variable called change score
was created, which is the difference between post
and pre-treatment value. This new variable was
subsequently compared between the two groups
using the Mann-Whitney U test and Students
t-test.
All statistical analyses were performed using
the Statistical Package for the Social Sciences v.21
with a significance level of P<0.05.
Results
The patients were randomized into two groups: an
experimental group (n = 40) and a control group
(n = 40) (see Figure 1). Table 1 shows the charac-
teristics of both groups at baseline. No differences
were found between the two groups for the col-
lected demographic variables or stroke-related
parameters. Comparisons between the groups at
baseline also showed no difference for any physi-
cal outcome measures (P>0.05), except for the
stepping section of the Brunel Balance Assessment
(gait) (P=0.020). The patients in this study were
shown to have mainly mild-to-moderate disability
after stroke as assessed by the National Institutes of
Health Stroke Scale.
Table 2 presents the comparison of treatment
effects between groups for all primary and second-
ary outcome measures, where the P-value reflects
the between-group differences of the change
scores. Patients in the experimental group signifi-
cantly improved compared to the control group in
all outcome measures except for the sitting section
of the Brunel Balance Assessment.
The mean (SD) change total score of the
Spanish Version of Trunk Impairment Scale 2.0 for
the experimental group was 5.88 (3.48) points,
and the total score for the control group was 2.48
(2.20) points (P<0.001). For the dynamic sitting
balance sub-scale of the Spanish Version of Trunk
Impairment Scale 2.0, the score for the experimen-
tal group was 4.10 (2.90) points, and for the con-
trol group, the score was 1.80 (1.73) points,
indicating a 23% improvement in dynamic sitting
for the experimental group (P<0.001).
For the Berg Balance Scale, the change score
mean (SD) in the experimental group was 23.02
1028 Clinical Rehabilitation 30(10)

Figure 1. Flow chart of patients allocated to the core stability exercise study.

(15.95) points, and for the control group, it was Discussion

8.48 (8.74) points (P<0.001). For the Tinetti gait
sub-scale, the change score was 24% higher in the
experimental group compared to the control group
(P<0.002). Furthermore, the change score for the
Barthel Index scale for the experimental group was
36.60 (18.01) points, and for control group, the
score was 23.33 (16.87) points (P<0.002).
The study results showed that 6.15 hours of addi-
tional core stability exercises increased dynamic
sitting balance and trunk performance in sub-acute
stroke patients. The results also suggest a carry-
over effect of core stability exercises on standing
balance, gait and activities of daily living.
Cabanas-Valds et al. 1029

Table 1. Characteristics of the experimental and control group at baseline.

Variable Pre-treatment P-value*

Control Experimental
Group (n=40) Group (n=40)
Age, mean years (SD) 75.69 (9.40) 74.92 (10.70) 0.758a
Gender (women/men) 21/18 19/21 0.823b
Time post-stroke, days (SD) 21.37 (16.00) 25.12 (17.30) 0.225a
Paretic side (left/right) 18/21 17/23 0.653b
Type of stroke (ischemic/hemorrhagic) 31/8 33/7 0.576b
Thrombolysis (n) 6 (2.34) 7 (2.8) 0.762a
Scales Scoring
Range
NIHSS stroke severity (previous) 042 8.54 (5.06) 9.42 (5.37) 0.531b
Modified Rankin (previous disability) 06 0.5 (1.06) 0.5 (1.01) 0.861b
Primary outcome measure
S-TIS 2.0 dynamic sitting balance 010 2.70 (2.31) 2.65 (2.36) 0.889b
S-TIS 2.0 coordination 06 1.10 (0.94) 0.85 (0.70) 0.329b
S-TIS 2.0 total 016 3.8 (3.09) 3.50 (2.92) 0.732b
FIST 056 21.95 (16.50) 20.75 (16.52) 0.575b
Secondary outcome measure
BBA sitting 03 2.18 (0.91) 2.02 (1.18) 0.769b
BBA standing 03 0.61 (1.04) 0.40 (0.90) 0.280b
BBA stepping 06 0.26 (0.78) 0.00 (0.00) 0.020*
BBA total 012 3.02 (2.19) 2.30 (1.65) 0.224b
BBS 056 8.54 (11.14) 5.42 (5.60) 0.564b
Tinetti balance 016 3.36 (2.90) 2.52 (2.03) 0.524b
Tinetti gait 012 0.56 (1.77) 0.20 (0.88) 0.359b
Tinetti total 028 3.85 (4.11) 3.22 (3.90) 0.782b
S-PASS 036 15.59 (6.36) 14.72 (6.78) 0.694b
Barthel Index 0100 30.90 (15.08) 32.00 (15.27) 0.748c

Values are presented as mean (SD) or absolute frequency, aPearson Chi-square, bMann-Whitney U test, cStudents t-test, *p<0.05.
NIHSS: National Institutes of Health Stroke Scale, S-TIS (2.0): Spanish Version of Trunk Impairment Scale 2.0, FIST: Function in
Sitting Test, BBA: Brunel Balance Assessment, BBS: Berg Balance Scale, S-PASS: Spanish Version of Postural Assessment Scale for
Stroke.

A strength of this study is that it is the first trial
of core stability exercises across two centres with
80 stroke patients of an average age of 75 years.
Additionally, all outcomes were evaluated by the
same therapist in a blinded manner.
Another key characteristic of our study was the
description and standardization of the progression
of exercises at three levels of increasing difficulty.
Such methods not only allowed for reproducibility
but also enabled the admission of patients who
could not tolerate the sitting position in our study,
unlike many previous studies in which eligible
patients had to remain sitting. Rose etal.15 advo-
cated the design of systematic and gradual training
programmes to improve balance and walking for
post-stroke patients.
The specific core stability exercise intervention
used in our study was designed to improve the
endurance of the core muscles that stabilize the
trunk and pelvis. This method is based on previous
experimental treatment of randomized controlled
trials9 and takes the physiological basis of exercise
into consideration. The core stability exercises ena-
bled improvement of reaction times, which is an
1030 Clinical Rehabilitation 30(10)

Table 2. Comparison of change score of outcome measures between control and experimental group.

Outcome Control group (n=39) Experimental group (n=40) D=Mean D/total p-value
measures difference of subscale
the change score (%)
score

Post- Change Post- Change

treatment scorec treatment scorec
S-TIS 2.0 4.51 (2.95) 1.82 (1.73) 6.75 (3.00) 4.10 (2.80) 2.28 (3.29) 22.80 0.001a
dynamic
sitting balance
S-TIS 2.0 1.77 (1.01) 0.66 (0.86) 2.63 (1.31) 1.77 (1.20) 1.11 (1.48) 18.50 0.001b
coordination
S-TIS 2.0 total 6.30 (3.70) 2.48 (2.20) 9.38 (3.90) 5.88 (3.48) 3.40 (4.12) 21.25 0.001a
FIST 35.23 (16.71) 13.28 (11.80) 43.70 (13.75) 22.92 (14.31) 9.64 (18.55) 17.21 0.002a
BBA sitting 2.70 (0.73) 0.51 (0.75) 2.90 (0.49) 0.87 (1.15) 0.36 (1,37) 12.00 0.251b
BBA standing 1.64 (1.32) 1.02 (1.08) 2.17 (1.21) 1.77 (1.44) 0.75 (1.80) 25.00 0.004b
BBA stepping 1.33 (1.70) 1.07 (1.42) 2.37 (2.30) 2.37 (2.30) 1.30 (2.70) 21.67 0.017b
BBA total 5.41 (3.20) 2.38 (2.04) 7.55 (3.55) 5.25 (3.11) 2.87 (3.72) 23.92 0.001b
BBS 17.03 (15.11) 8.48 (8.74) 28.45 (17.75) 23.02 (15.95) 14.54 (18.19) 25.96 0.001a
Tinetti 5.92 (3.81) 2.56 (2.51) 9.75 (4.15) 7.22 (3.73) 4.66 (4.50) 29.13 0.001b
balance
Tinetti gait 3.18 (3.71) 2.62 (3.52) 5.77 (4.54) 5.57 (4.43) 2.95 (5.66) 24.58 0.002b
Tinetti total 9.00 (7.23) 5.15 (5.48) 15.52 (8.33) 12.30 (8.65) 7.15 (10.24) 25.54 0.001b
S-PASS 21.43 (7.53) 5.84 (5.00) 25.82 (6.70) 11.10 (6.35) 5.26 (8.08) 14.61 0.001b
Barthel Index 54.23 (23.32) 23.33 (16.87) 68.50 (22.37) 36.50 (18.81) 13.17 (25.27) 13.17 0.002a

Values are presented as mean (standard deviation).

aAnalysed by Students t-test, bAnalysed by Mann Whitney Test U, cChange score: Difference post-pre of outcome (p-value<0.05).

S-TIS 2.0: Spanish version of Trunk Impairment Scales 2.0, FIST: Function in Sitting Test, BBA: Brunel Balance Assessment,
BBS: Berg Balance Scale, S-PASS: Spanish version of Postural Assessment Scale for Stroke Patients.

important factor in optimal balance. This result is
consistent with recent work showing that core mus-
cle endurance is associated with balance perfor-
mance in elderly subjects.16
Additionally, the average age of the study popu-
lation was 75.3 (10.03) years, which is close to
the average age of stroke patients in high-income
countries.17 This age group is in inconsistent with
several studies that included younger patients.18-21
Another factor to be taken into account is that
improvement occurred within days of the stroke,22
and the mean number days post-stroke to perform
core stability exercises in this study was earlier
than in previous investigations.18-20
Furthermore, the magnitude of improvements
observed in our study, as measured by the Span-
ish Version of Trunk Impairment Scale 2.0, was
somewhat higher than that observed in previous
studies.18,23 This difference could be because our
study added some exercises performed on an unsta-
ble surface (i.e., the physioball). This observation
is corroborated by other studies20,21,24 that also
included a similar series of exercises.
Training the core musculature on an unstable
surface improves balance, stability, and proprio-
ceptive capabilities.25 Additionally, spine stability
depends not only on muscular strength but also
proper sensory input that alerts the central nervous
system about interactions between the body and the
environment, providing constant feedback and
allowing refinement of movement.26
The improvement in standing balance in the
experimental group as assessed by the Berg
Balance Scale was almost three times more than
Cabanas-Valds et al. 1031
control group. This result may be because the
patients in the experimental group achieved good
sitting balance earlier than the control group due to
the core stability exercise regimen, thus allowing
them to begin the more difficult standing tasks ear-
lier. Kaji etal.27 showed that the use of core stabil-
ity exercises in healthy subjects transiently
decreased the area of the centre-of-pressure trajec-
tory and its mediolateral and total excursions dur-
ing quiet standing with the eyes closed.
The results of this study also highlight the exist-
ence of a positive relationship between core stabil-
ity exercises and gait. Additionally, these findings
are corroborated by Gjelsvik etal.,28 Saeys etal.,20
and Chung etal.,29 all illustrating a relationship
between improved trunk control and walking. We
speculate that this positive association is due to the
central nervous system stabilizing the spine through
the contraction of the trunk and pelvic musculature
in response to the reactive forces of the lower
limbs30 and the greater stability of the pelvis during
the walking support phase.
During the performance of motor skills, antici-
patory postural adjustments play an important role
in maintaining balance during task performance
and in the central control of posture.6 These adjust-
ments in the trunk are executed before or along
with a focal movement of the limbs.31
To the best of our knowledge, this is the first
study to demonstrate the beneficial effect of addi-
tional core stability exercises on activities of daily
living as measured by the Barthel Index. In the
experimental group, the score was 68 (22.37)
after treatment compared to control group was 54
(23.32). A Barthel Index score 60 points means
that the patient has made a transition from com-
plete dependence to assisted independence, accord-
ing to Granacher etal.32 Core stability is important
for the successful performance of activities of daily
life in elderly, healthy subjects.
There are some limitations to our study. First,
the control group did not receive additional ther-
apy. The experimental group performed 6.15 hours
more therapy than the control group. It is plausible
that the improvements could be due to longer exer-
cise, but we do not believe that this is the only
reason for the improvement observed with core
stability exercises. Previous studies18,33 have added
10 hours of core stability exercises in their inter-
vention group, and the results were of a similar
magnitude to ours, leading us to conclude that
these exercises alone are a relevant factor to explain
the benefits observed in our study. A second limita-
tion was that there was a lack of long-term follow-
up of the patients to determine whether the
improvement observed in the short term was main-
tained over time.
Future research needs to examine core stability
exercises to learn how to teach patients how to per-
form these exercises without a therapist being
present.
In conclusion, core stability exercise training
along with conventional therapy improves trunk
control, dynamic sitting balance, standing balance,
gait, and activities of daily living in sub-acute post-
stroke patients.
Clinical messages
An additional 6.15 hours of exercise
therapy focused on increasing core sta-
bility led to a significant improvement in
mobility and activities of daily living.
Core stability exercises are suitable for
post-stroke patients unable to maintain a
sitting position.
Acknowledgements
The authors would like to thank: Professor Doctor Xavi
Girons, Mrs. Ana Germn, Mr. JC Oliva Morera, Mr.
Xavi Bel, Mrs. Silvia Covarrubias, Mrs. Anabel Gelices,
Mrs. Marta Puiggene, Mrs. Laura de Juana, Mrs.
Esperanza Almansa, Mr. Gary Siuming Lau, and Mrs.
Elena de Pontcharra.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publication
of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
1032 Clinical Rehabilitation 30(10)
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 Next event

Annual Meeting 2016 21-23 November 2016

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Theme: Rehabilitation following major trauma

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Closing date for receipt of abstracts 30 September 2016

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