Report #034

#034 – Trunk exercise after stroke

Estimated reading time: 5 minutes, 38 seconds.

Adding trunk exercise to rehabilitation therapy can improve trunk function, balance ability, gait performance, and functional mobility after stroke

A Systematic Review with Meta-Analyses, 2020. (Open Access)

🤔Why

  • Trunk muscles are bilaterally affected after a stroke-onset, leading to an impairment of trunk function.
  • Since trunk structures are important to maintain the body in a stable state, and stroke patients have a decreased control, it affects their ability to maintain balance.
  • Also, studies have shown that the degree of trunk impairment determines, to what extent, patients recover their motor function months after stroke-onset.
  • These points lead to an increased interest in the effectiveness of additional trunk-focused exercise programs (ATEP), leading to the conclusion ATEP is effective for motor recovery after stroke.
  • But, factors such as the initial trunk impairment, patients age, and the volume of ATEP are yet to be analyzed.
  • Therefore, the aim of this systematic review was to analyze the influence of potential effect modifiers as the initial trunk impairment, and participants’ age, the start of the intervention after stroke-onset, and the total volume of the ATEP on trunk function, balance ability, gait performance, and functional mobility in the stroke population.

📊Results

  • 20 Studies, 587 participant in the experimental group (EG) and 587 in the control group (CG).

(Skip to conclusion ⏩)

See outcome measures here

Characteristics of the treatment programs included in the studies:

Duration: 2 to 8 weeks, in which 4 weeks was the most common (12 studies).

Session duration: 10 to 60 min, with 30 min being the most common duration.

Total volume: ranged between 240 and 1200 min, with an average of 511 min.

Time in which the intervention started after stroke-onset, ranged from 15 days to 34 months.

The effect of ATEP on:

  • Trunk function: ATEP improved trunk function, with a 13% of pre-post change with respect to the control group. (13 studies)
  • Balance: ATEP improved balance ability, which was a 17% of pre-post change with respect to the control group. (9 studies)
    • Also in balance, ATEP improved the forward non-affected-arm reach (6 studies), the lateral non-affected-arm reach (4 studies), and the lateral affected-arm reach (3 studies)
  • Gait: ATEP improved gait performance. (8 studies)
  • Functional mobility: ATEP improved the Timed Up and Go (TUG) test. (6 studies)

Potential Effect Modifiers:

  • Initial Trunk Impairment: The median score was 55.15% of the total score on the trunk function scale.
    • Studies with higher initial trunk impairment showed a greater motor recovery, in trunk function, balance, and limits of stability.
    • Studies with lower trunk impairment showed a medium effect size on outcome measures.
    • It must be noted that those participants who had a higher initial trunk impairment were older, and they also started the rehabilitation programs earlier
  • Age: The median score was 58.65 years, with nine studies below and 10 studies over the median
    • Medium effect on balance ability for studies with older participants.
    • In studies with younger participants, high effect sizes were observed on trunk function and balance ability and a medium effect on limits of stability.
    • The change on functional mobility was higher in the older participant’s group but not significant.
  • Time since Stroke-Onset until Rehabilitation: The median score was 194.67 days from stroke-onset until the rehabilitation started, with nine studies below and 10 studies over the median.
    • Studies that started ATEP early after stroke onset showed medium to high effect size on trunk function, balance ability, and gait performance
    • Studies that ATEP later also showed medium to high effect size but with lower scores.

Total Volume of Additional Trunk Exercises Program: The median score was 387.5 min, with nine studies below and nine studies over the median.

  • Studies with a short duration of ATEP showed high effect sizes on trunk function, limits of stability, and gait performance, and medium effect size on balance ability.
  • Studies with long duration of ATEP showed high effect sizes on trunk function and balance ability, and a low-to-medium effect on gait performance and limits of stability.
  • Functional mobility improved slightly more in the shorter ATEP group, but not significantly.

🕵🏾Explanations and notes on results

  • ATEP improved gait performance but it did not have a significant effect on TUG, TUG requires trunk control which ATEP improved, but other factors such as lower limbs muscle strength, sensory and cognitive deficits.
  • This study indicated that a higher initial trunk impairment is related to a greater motor recovery, which is against previous studies that indicated that the more severe the motor impairment after stroke-onset, the more severe the chronic deficits. Although the rationale behind these findings is not clear, one bias can be found in these studies, patients that had more severe impairments started treatment earlier, which according to the current study leads to better outcomes.
  • Note that longer training programs were more effective on trunk function and balance. And, shorter training programs showed better results on limits of stability, gait performance, and functional mobility. Although the controversy in these results can be caused by the low number of studies included, the results obtained seem to indicate that even short trunk training programs (<387.5 min) could be enough to induce meaningful improvements on motor recovery.

⏩Conclusion

  • Adding trunk exercise to conventional rehabilitation therapy can improve trunk function, balance ability, gait performance, and functional mobility.
  • Older patients, and those with higher initial trunk impairment, obtained, in general, greater improvements on the outcomes assessed. (Explained above)
  • Short durations of additional trunk exercise programs could be enough to cause positive effects on motor recovery.

⏮️Previously on trunk exercise and stroke

  • The addition of core stability exercises to usual care physiotherapy after stroke may lead to improved trunk control and dynamic balance. Therefore, core stability exercises should be included in rehabilitation if improvements in these domains will help clients achieve their goals. (I reported on this article here) (Reference)
  • Trunk exercise performed over a physio-ball is effective in improving trunk performance during the acute and subacute stage, but no evidence on its effect during the chronic stage. (Open Access)
  • Adding trunk restraint to task-oriented training may improve function in patients with subacute stroke. (Restricted Access)
  • The introduction of trunk-based inpatient training protocols brings short-term benefits in trunk performance and balance in stroke patients. (Open Access)

ğŸ˜ŽOther Cool Articles

  • Role of Myokines in Regulating Skeletal Muscle Mass and Function. (Open Access)
  • Arm-Hand Boost Therapy During Inpatient Stroke Rehabilitation: A Pilot Randomized Controlled Trial. (Open Access)
  • Exploring the Relationship Between Sleep Quality, Sleep-Related Biomarkers, and Motor Skill Acquisition Using Virtual Reality in People With Parkinson’s Disease: A Pilot Study. (Open Access)
  • Rehabilitation of Neuromuscular Diseases During COVID-19: Pitfalls and Opportunities. (Open Access)

Thank you for reading, I’ll see you in the next one.

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