Comprehensive clinical sitting balance measures for individuals following stroke: a systematic review on the methodological quality

PURPOSE

The aim of this systematic review was to examine the psychometric properties of published clinical sitting measurement scales containing dynamic tasks in individuals following stroke.

METHOD

Databases, including Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, Cochrane, PubMed and Allied and Complementary Medicine Database (AMED) were searched from inception to December 2015. The search strategy included terms relating to sitting, balance and postural control. Two reviewers independently selected and extracted data from the identified articles and assessed the methodological quality of the papers using the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

Fourteen clinical sitting measurement scales (39 papers) containing dynamic tasks met the inclusion criteria and various measurement properties were evaluated. The methodological quality of the majority of the included studies was rated as poor to fair using the COSMIN checklist, with common limitations including small sample size and inappropriate use of statistical methods.

CONCLUSIONS

This review was unable to identify measures with sufficient psychometric properties to enable recommendation as preferred tools. However, measures were identified that warrant further specific psychometric investigations to fulfil requirements for a high quality measure. Implications for Rehabilitation Fourteen clinical sitting balance scales containing dynamic tasks are available to measure sitting balance with individuals following stroke. No single scale has sufficient psychometric properties to enable recommendation as a preferred tool for measuring sitting balance with stroke survivors. Use of a balance scale or dedicated sitting balance measure containing static and dynamic sitting items should be utilised to monitor progress for individuals following stroke with more severe deficits.

Effect of Core Stability Training on Trunk Function, Standing Balance, and Mobility in Stroke Patients

BACKGROUND

Trunk function is important for standing balance, mobility, and functional outcome after stroke, but few studies have evaluated the effects of exercises aimed at improving core stability in stroke patients.

OBJECTIVE

To investigate the effectiveness of core stability training on trunk function, standing balance, and mobility in stroke patients.

METHODS

An assessor-blinded, randomized controlled trial was undertaken in a stroke rehabilitation ward, with 32 participants randomly assigned to an experimental group or a control group (n = 16 each). The experimental group received 400 minutes of core stability training in place of conventional programs within total training time, while the control group received only conventional programs. Primary outcome measures were evaluated using the Trunk Impairment Scale (TIS), which reflects trunk function. Secondary outcome measures were evaluated by pelvic tilt active range of motion in the sagittal plane, the Balance Evaluation Systems Test-brief version (Brief-BESTest), Functional Reach test, Timed Up-and-Go test (TUG), and Functional Ambulation Categories (FAC). A general linear repeated-measures model was used to analyze the results.

RESULTS

A treatment effect was found for the experimental group on the dynamic balance subscale and total score of the TIS ( P = .002 and P < .001, respectively), pelvic tilt active range of motion ( P < .001), Brief-BESTest ( P < .001), TUG ( P = .008), and FAC ( P = .022).

CONCLUSIONS

Core stability training has beneficial effects on trunk function, standing balance, and mobility in stroke patients. Our findings might provide support for introducing core stability training in stroke rehabilitation.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Effects of proprioceptive neuromuscular facilitation neck pattern exercise on the ability to control the trunk and maintain balance in chronic stroke patients

[Purpose] The aim of this study was to investigate the effects of proprioceptive neuromuscular facilitation neck pattern exercise on the ability to control the trunk and balance in chronic stroke patients. [Subjects and Methods] A total of 30 study subjects were selected and randomly divided into an experimental group of 15 subjects, who received the proprioceptive neuromuscular facilitation neck pattern exercise, and a control group of 15 subjects, who received a traditional rehabilitation treatment. [Results] Statistically significant changes in all the items of the Trunk Impairment Scale, the Trunk Impairment Scale total score, and the Berg Balance Scale were observed in both the experimental group and the control group. significant between-group differences were found in all items among the subitems of the Trunk Impairment Scale except the static sitting balance. [Conclusion] Proprioceptive neuromuscular facilitation neck pattern exercise was shown to have a positive effect on increasing the ability to control the trunk and maintain balance in chronic stroke patients.

An exploration of trunk reposition error in subjects with acute stroke: An observational design

BACKGROUND & OBJECTIVE

Trunk reposition error (TRE) is a component of trunk control, yet has not been reported in acute stroke. The purpose of this study was to quantify TRE in acute stroke and report this with related rehabilitation outcomes.

METHODS

Sixty subjects, 30 with acute stroke and 30 healthy controls, completed this study. Subjects with acute stroke were measured before and after an in-patient acute rehabilitation stay.

MEASURES

TRE using an electromagnetic tracking device, Berg Balance Scale, Postural Assessment Scale for Stroke, and Functional Independence Measures. Pre-post measures were analyzed with paired t-tests. Between-group measures were analyzed with independent w-tests.

RESULTS

There were significant between group differences (acute stroke vs. controls) for all functional outcome measures (P < 0.001) and for three-dimensional TRE (P = 0.001). There were significant improvements in all functional outcome measures following an in-patient rehabilitation stay (P < 0.001). All measures of TRE reduced but did not achieve significance.

CONCLUSION

TRE was not as severely impaired as anticipated and was variable based on plane of measure. Time in a rehabilitation setting produced significant improvements in functional outcomes but TRE improvements were not as robust. These results indicate a need for further investigation of the strength of the interrelationship between TRE and function.

Analysis of Trunk Rolling Performances by Mattress Mobility Detection System in Poststroke Patients: A Pilot Study

Purpose. The purpose of this study was to investigate the correlation of kinematic variables with quality of trunk control in poststroke patients. Methods. This cross-sectional study included stroke subjects with mild to moderate motor deficit corresponding to Brunnstrom stages 3-4. Trunk functional performance was measured using bed mobility monitor system. All tasks were repeated ten times for both directions in each subject. Outcome measurements included the movement time and displacement of center of pressure (CoP) from supine to side lying and returning. Results. The results revealed that a significant longer turning time was observed when turning from the paretic side toward the nonparetic side compared to the other direction, with an estimated mean difference of 0.427 sec (P = 0.005). We found a significant difference in the time of rolling back to supine position between two directions. The displacement of CoP in rolling back from side lying on the nonparetic side was smaller than that from the paretic side with an estimated mean difference of −0.797 cm (P = 0.023). Conclusions. The impaired trunk mobility was associated with increased movement time and decreased displacement of CoP in poststroke patients. Trunk rolling performance has potential in assessment of stroke patients.

The effect of additional core stability exercises on improving dynamic sitting balance and trunk control for subacute stroke patients: a randomized controlled trial

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.

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.

Correlations among trunk impairment, functional performance, and muscle activity during forward reaching tasks in patients with chronic stroke

[Purpose] This study aimed to investigate the relationships among trunk impairment, functional performance, and muscle activity during forward reaching tasks in patients with chronic stroke. [Subjects and Methods] Twenty-three chronic stroke patients participated in this study. Trunk impairment and functional performance were evaluated using the Trunk Impairment Scale, Berg Balance Scale, Timed Up and Go Test, and 10-Meter Walk Test. All subjects were asked to perform 3 different forward reaching tasks (affected side reaching, forward reaching, and less-affected side reaching), and measurements were taken during these 3 tasks by using surface electromyography. Correlation analyses were performed to assess the relationships among trunk impairment, functional performance, and muscle activity during the forward reaching tasks. [Results] Spearman’s correlation analysis revealed a strong, significant correlation between the Trunk Impairment Scale and functional performance, that was associated with balance and gait ability. During the 3 different forward reaching tasks, muscle activities of the less-affected lower extremity were significantly correlated with functional performance. [Conclusion] This study revealed the correlations among trunk impairment, functional performance, and muscle activity during forward reaching tasks in patients with chronic stroke and emphasized the importance of trunk rehabilitation.

Effect of Trunk Support on Upper Extremity Function in People With Chronic Stroke and People Who Are Healthy

BACKGROUND

Trunk control is thought to contribute to upper extremity (UE) function. However, this common assumption in neurorehabilitation has not been validated in clinical trials.

OBJECTIVE

The study objectives were to investigate the effect of providing external trunk support on trunk control and UE function and to examine the relationship between trunk control and UE function in people with chronic stroke and people who were healthy.

DESIGN

A cross-sectional study was conducted.

METHODS

Twenty-five people with chronic stroke and 34 people who were healthy and matched for age and sex were recruited. Trunk control was assessed with the Trunk Impairment Scale (TIS), and UE impairment and UE function were assessed with the UE subsection of the Fugl-Meyer Assessment (FMA-UE) and the Streamlined Wolf Motor Function Test (SWMFT), respectively. The TIS and SWMFT were evaluated, with and without external trunk support; the FMA-UE was evaluated without trunk support.

RESULTS

With trunk support, people with stroke showed improvement from 18 to 20 points on the TIS, a reduction in SWMFT performance times from 37.20 seconds to 35.37 seconds for the affected UE, and improvement from 3.3 points to 3.4 points on the SWMFT Functional Ability Scale for the function of the affected UE. With trunk support, the SWMFT performance time for people who were healthy was reduced from 1.61 seconds to 1.48 seconds for the dominant UE and from 1.71 seconds to 1.59 seconds for the nondominant UE. A significant moderate correlation was found between the TIS and the FMA-UE (r=.53) for people with stroke.

LIMITATIONS

The limitations included a nonmasked assessor and a standardized height of the external trunk support.

CONCLUSIONS

External trunk support improved trunk control in people with chronic stroke and had a statistically significant effect on UE function in both people with chronic stroke and people who were healthy. The findings suggest an association between trunk control and the UE when external trunk support was provided and support the hypothesis that lower trunk and lumbar stabilization provided by external support enables an improvement in the ability to use the UE for functional activities.

A review on assessment and treatment of the trunk in stroke: A need or luxury

Trunk function has been identified as an important early predictor of functional outcome after stroke and the same deteriorates on both contralateral and ipsilateral sides of the body following stroke. The primary contribution of the trunk muscles is to allow the body to remain upright, adjust weight shifts, and control movements against constant pull of gravity and is considered central key point of the body. Proximal stability of the trunk is a pre-requisite for distal limb mobility, balance, gait and functional activities and its positive correlation in hemiplegia has been demonstrated in a cross-sectional study. Both isokinetic and handheld dynamometer muscle strength testing demonstrated the weakness of bilateral trunk flexors, extensors and rotator muscles in both acute and chronic hemiplegic patients. This was confirmed by electromyography analysis which identified poor bilateral trunk muscles activity in patients with stroke. Trunk impairment scale is sensitive to evaluate the selective muscle control of upper and lower trunk, and it has been reported that lateral flexion of the trunk is easier than rotation of the trunk and the clinical observation concurs to the difficulty in lower trunk rotation of stroke patients. However, trunk exercises given early after stroke could produce enhanced balance performance post- stroke. This review attempts to report the evidence supporting the involvement of the trunk and its influence on balance and functional performance in post-stroke hemiplegia.

Development and decline of upright gait stability

Upright gait is a peculiar characteristic of humans that requires the ability to manage upper body dynamic balance while walking, despite the perturbations that are generated by movements of the lower limbs. Most of the studies on upright gait stability have compared young adults and the elderly to determine the effects of aging. In other studies, the comparison was between healthy subjects and patients to examine specific pathologies. Fewer researches have also investigated the development of upright gait stability in children. This review discusses these studies in order to provide an overview of this relevant aspect of human locomotion. A clear trend from development to decline of upright gait stability has been depicted across the entire lifespan, from toddlers at first steps to elderly. In old individuals, even if healthy, the deterioration of skeletal muscle, combined with sensorial and cognitive performance, reduces the ability to maintain an upright trunk during walking, increasing the instability and the risk of falls. Further, the pathological causes of altered development or of a sudden loss of gait stability, as well as the environmental influence are investigated. The last part of this review is focused on the control of upper body accelerations during walking, a particularly interesting topic for the recent development of low-cost wearable accelerometers.

A pilot study on the effect of functional electrical stimulation of stroke patients in a sitting position on balance and activities of daily living

[Purpose] This study investigated the effect of functional electrical stimulation (FES) of stroke patients in a sitting position on balance and activities of daily living. [Methods] FES was applied to stroke patients (six male, three female) while in a sitting and supine position. FES was applied six times for 30 minutes each for a total of six weeks. [Results] The timed up and go (TUG) values at weeks 2, 4, and 6 after FES treatment in a sitting position were noticeably decreased in a time-dependent manner, compared with controls. In the sitting, the functional reach test (FRT) values were significantly increased in a time-dependent manner. The same values in the supine position weakly showed a similar pattern to those in the sitting position. Furthermore, the functional independent measurement (FIM) values in the sitting position were markedly increased in a time-dependent manner. In the sitting position, the intensity of FES was markedly decreased in a time-dependent manner. The same values in the supine position weakly showed a similar pattern to those in the sitting position. [Conclusion] These results suggest that the conditions of stroke patients in both the sitting and supine positions after FES treatment were improved and that FES had a greater effect in the sitting position.

Does the Inclusion of Virtual Reality Games within Conventional Rehabilitation Enhance Balance Retraining after a Recent Episode of Stroke?

This randomised controlled and double-blinded pilot study evaluated if interactive virtual reality balance related games integrated within conventional rehabilitation sessions resulted in more superior retraining of dynamic balance compared to CR after stroke. 19 subjects diagnosed with a recent episode of stroke were recruited from a local rehabilitation hospital and randomly assigned to either a control or an experimental group. Subjects in the control groups underwent 60 minutes of conventional rehabilitation while those in the experimental groups underwent 40 minutes of convention rehabilitation and 20 minutes of self-directed virtual reality balanced rehabilitation. Functional Reach Test, Timed Up and Go, Modified Barthel Index, Berg Balance Scale, and Centre of Pressure of subjects in both groups were evaluated before and on completion of the rehabilitation sessions. Results indicate that the inclusion of interactive virtual reality balance related games within conventional rehabilitation can lead to improved functional mobility and balance after a recent episode of stroke without increasing treatment time that requires more health professional manpower.

[Early rehabilitation for neurologic patients]

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients' impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.

To what extent can multimorbidity be viewed as a determinant of postural control in stroke patients?

OBJECTIVE

To investigate the determinants of postural imbalance after stroke in geriatric patients admitted for low-intensity rehabilitation in skilled nursing facilities (SNFs), particularly the role of multimorbidity.

DESIGN

Cross-sectional study design.

SETTING

Fifteen SNFs.

PARTICIPANTS

All patients who were admitted for rehabilitation after stroke in one of the participating SNFs (N=378) were eligible.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Berg Balance Scale (BBS) was selected as a measure of standing balance and the Functional Ambulation Categories (FAC) as a measure of walking balance.

RESULTS

Multimorbidity was present in 34% of the patients. The patients with multimorbidity differed from the patients without multimorbidity with respect to age, proprioception, and vibration sense, but not for any of the cognitive tests, muscle strength, or sitting balance. Patients with multimorbidity had, on average, lower scores on both outcome measures. In linear regression analyses, both the BBS and FAC were best explained by multimorbidity, muscle strength, and the interaction between muscle strength and static sitting balance (overall explained variance 66% and 67%, respectively), while proprioception added only to the variance of the FAC.

CONCLUSIONS

Multimorbidity was independently related to postural imbalance after stroke in patients admitted for rehabilitation in SNFs. Muscle strength and the interaction of muscle strength with static sitting balance were important determinants of both standing and walking balance, indicating these factors as essential targets for rehabilitation.

The Trunk Impairment Scale - modified to ordinal scales in the Norwegian version

PURPOSE

To translate the Trunk Impairment Scale (TIS), a measure of trunk control in patients after stroke, into Norwegian (TIS-NV), and to explore its construct validity, internal consistency, intertester and test-retest reliability.

METHOD

TIS was translated according to international guidelines. The validity study was performed on data from 201 patients with acute stroke. Fifty patients with stroke and acquired brain injury were recruited to examine intertester and test-retest reliability. Construct validity was analyzed with exploratory and confirmatory factor analysis and item response theory, internal consistency with Cronbach's alpha test, and intertester and test-retest reliability with kappa and intraclass correlation coefficient tests.

RESULTS

The back-translated version of TIS-NV was validated by the original developer. The subscale Static sitting balance was removed. By combining items from the subscales Dynamic sitting balance and Coordination, six ordinal superitems (testlets) were constructed. The TIS-NV was renamed the modified TIS-NV (TIS-modNV). After modifications the TIS-modNV fitted well to a locally dependent unidimensional item response theory model. It demonstrated good construct validity, excellent internal consistency, and high intertester and test-retest reliability for the total score.

CONCLUSIONS

This study supports that the TIS-modNV is a valid and reliable scale for use in clinical practice and research.