Are unstable support surfaces superior to stable support surfaces during trunk rehabilitation after stroke? A systematic review

Immediate effects of standing unstable board intervention on the non-paralyzed leg on sitting balance in severe hemiplegia: a randomized controlled trial

BACKGROUND

Unstable board intervention for patients with stroke improves sitting balance and trunk function. However, because patients with severe stroke are at high risk of falling, it is mostly adapted in mild cases.

OBJECTIVE

We aimed to examine the effect of standing unstable board intervention for the non-paralyzed lower limbs on sitting balance in patients with hemiplegia.

METHODS

The participants were 42 patients with stroke who were randomly assigned to a control or intervention group. In the intervention group, the non-paralyzed leg was placed on an unstable board, and the patient wore a knee-ankle-foot orthosis on the paralyzed side and practiced standing and weight-bearing exercises on the unstable board for 3 days. The outcomes were the angle of righting reaction of the neck, trunk, and both lower legs and the movement distance of the center of pressure of the righting reaction from lateral tilted sitting.

RESULTS

In the intervention group, the righting reaction angle of the trunk to the paralyzed and non-paralyzed sides and the movement distance of the center of pressure were increased significantly after the unstable board intervention.

CONCLUSION

The standing unstable board intervention for the non-paralyzed lower limb increased sensory input to the non-paralyzed side of the trunk weight-bearing on the lower limb of the paralyzed side. The increase in the righting reaction angle and the movement distance of the center of pressure contributed to improved sitting balance.

Correlation between trunk function improvement and recovery of activities of daily living after stroke in older adult patients

OBJECTIVES

To examine the impact of improved trunk function on activities of daily living in stroke patients using the Functional Independence Measure (FIM).

METHODS

This retrospective observational study was conducted on patients aged ≥ 65 years who had cerebral infarction. Patients were divided into a group with improved trunk function and a group without trunk function improvement based on the difference between the calculated Functional Assessment for Control of Trunk (FACT) gain at discharge and admission.

RESULTS

Of the 218 patients (mean age, 79.5 ± 7.9 years; 56.9% were men) included, 110 patients had improved FACT scores. Multiple linear regression analysis revealed that the group with improved FACT scores had higher FIM gain (coefficient = 7.562, 95% confidence interval = 3.870-11.253, P < 0.001). Multivariate logistic regression showed that the factors associated with FACT score improvement were the Mini Nutritional Assessment Short-Form score at admission, National Institutes of Health Stroke Scale score at admission, FACT score at admission, length of hospital stay, and period of rehabilitation.

DISCUSSIONS

Improvement in trunk function suggests a positive correlation with the recovery of activities of daily living in patients with cerebral infarction. This relationship should be further validated through prospective observational studies.

The Effect on Muscle Activity of Reaching Beyond Arm's Length on a Mobile Seat: A Pilot Study for Trunk Control Training for People After Stroke

Objective

This pilot study compared muscle activity during lateral reaching tasks between mobile and stable sitting using a novel therapy chair in people after stroke and healthy controls.

Design

Observational pilot study.

Setting

This study was conducted in a rehabilitation center for people after stroke and at the university's movement laboratory for healthy participants.

Participants

A total of eleven people after stroke and fifteen healthy people (N=26) took part.

Interventions

Lateral reaching exercises to the ipsilateral and contralateral sides were performed on a mobile and a stable seat.

Main Outcome Measure

Muscular activity of the multifidus, erector spinae and external oblique was measured bilaterally. A within-subject linear mixed model was applied to analyze the effects of seat condition, task, muscle side, and group.

Results

A seat condition effect was found for the multifidus and external oblique that was dependent on the muscle side and task. During ipsilateral reaching, the activity of the multifidi decreased for people after stroke on the mobile seat, while increasing for healthy participants. The erector spinae showed no condition effect. Decreased activity of the external oblique was found for both groups on the mobile seat.

Conclusions

Mobile sitting influences muscular activity. However, these preliminary results should be further investigated in order to generate recommendations for rehabilitation.

Hip and trunk kinematics during reaching on a mobile and stable seat

Reaching movements are often used to assess selective trunk control in people with neurological conditions. Also, it is known that reaching performance after stroke is increased through training on a mobile seat compared to conventional physical therapy. However, the effect of a mobile seat on joint kinematics has not yet been investigated. This study aimed to quantify differences in the range of motion of the hip and trunk during reaching exercises on a mobile and stable sitting surface. Fifteen healthy participants performed reaching beyond arm's length on a mobile and a stable seat in four different directions: ipsilateral, anterior, contralateral, and contralateral diagonal. Biomechanical data were collected, including kinematics of the hip and trunk, and surface electromyography of the trunk muscles. The mobile sitting surface led to a higher range of motion in the trunk and the hip in the frontal and sagittal plane, but not in the rotational plane. Differences between reaching directions were found in all joint directions, except that of trunk flexion. Hence, movement patterns of the hip and trunk differ during reaching on different sitting surfaces and in different directions. A larger range of motion in the frontal or sagittal plane while training on the mobile seat provides added neuromuscular stimuli to the trunk muscles (= a higher demand on trunk muscles), which could result in more efficient training and therefore, increased trunk control after stroke. However, this has to be investigated in a future study with people after stroke.

Effect of Balance Training in Sitting Position Using Visual Feedback on Balance and Gait Ability in Chronic Stroke Patients

Chronic stroke often results in balance and gait impairments, significantly impacting patients' quality of life. The purpose of this study was to investigate whether the combined effect of unstable surface balance training and visual feedback, based on proprioceptive neuromuscular stimulation in patients with chronic stroke, is effective in restoring balance and gait ability. A total of 39 chronic stroke patients were randomly assigned to a visual feedback combined with unstable surface balance training group (VUSBG), an unstable surface balance training group (USBG), or a conventional physical therapy group (CG). This study was conducted with the Trunk Impairment Scale, the Bug Balance Scale, the Timed Get Up and Go Test, and Gait Analysis. VUSBG and USBG improved function and gait (stride length and hip/knee flexion angle), but there was no significant difference in the CG group. Specific results showed that the stride length in the VUSBG improved by 25% (p < 0.05), and the hip/knee flexion angle improved by 18% (p < 0.05). The post-hoc analysis revealed that VUSBG had a greater impact on the hip/knee flexion angle relative to the other two groups, as well as gait velocity and stride length relative to CG. Visual feedback complex exercise based on the principle of proprioceptive neuromuscular facilitation could be an intervention strategy to improve gait speed, trunk stability, and mobility in chronic stroke patients.

Effect of torso training on unstable surface on lower limb motor function in patients with incomplete spinal cord injury

OBJECTIVES

To investigate the effect of torso training on unstable surface on lower limb motor function in patients with incomplete spinal cord injury.

METHODS

A total of 80 patients with incomplete spinal cord injury caused by thoracolumbar fracture admitted in Ningbo Yinzhou No.2 Hospital from April 2020 to December 2021 were randomly divided into control group and study group, with 40 cases in each group. In addition to routine training, the control group received torso training on stable surface and the study group received torso training on unstable surface. The gait, lower limb muscle strength, balance function, lower limb function, mobility and nerve function of the two groups were compared.

RESULTS

After treatment, the stride length, stride frequency and comfortable walking speed improved in the two groups (all P<0.05), and the improvements in study group were more significant (all P<0.05). The muscle strength of quadriceps femoris, gluteus maximus, hamstring, anterior tibialis and gastrocnemius were improved in the two groups (all P<0.05), and the improvements in study group were more significant (all P<0.05); the total trajectories of static eye opening and static eye closing gravity center movement in the two groups were significantly shorter (all P<0.05), and the improvements in the study group were more significant (all P<0.05). The dynamic stability limit range and the American Spinal Injury Association (ASIA) lower extremity motor score, Berg balance scale, modified Barthel index scale in the two groups were significantly higher (all P<0.05), and these scores in study group were significantly higher than those in the control group (all P<0.05). Both groups showed a significant improvement in ASIA grade (all P<0.05), and the improvement in the study group was significantly better (P<0.05).

CONCLUSIONS

Torso training on unstable surface can effectively improve the gait and lower limb muscle strength of patients with incomplete spinal cord injury and improve the lower limb motor function.

Trunk training following stroke

BACKGROUND

Previous systematic reviews and randomised controlled trials have investigated the effect of post-stroke trunk training. Findings suggest that trunk training improves trunk function and activity or the execution of a task or action by an individual. But it is unclear what effect trunk training has on daily life activities, quality of life, and other outcomes.

OBJECTIVES

To assess the effectiveness of trunk training after stroke on activities of daily living (ADL), trunk function, arm-hand function or activity, standing balance, leg function, walking ability, and quality of life when comparing with both dose-matched as non-dose-matched control groups.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, and five other databases to 25 October 2021. We searched trial registries to identify additional relevant published, unpublished, and ongoing trials. We hand searched the bibliographies of included studies.

SELECTION CRITERIA

We selected randomised controlled trials comparing trunk training versus non-dose-matched or dose-matched control therapy including adults (18 years or older) with either ischaemic or haemorrhagic stroke. Outcome measures of trials included ADL, trunk function, arm-hand function or activity, standing balance, leg function, walking ability, and quality of life.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two main analyses were carried out. The first analysis included trials where the therapy duration of control intervention was non-dose-matched with the therapy duration of the experimental group and the second analysis where there was comparison with a dose-matched control intervention (equal therapy duration in both the control as in the experimental group).  MAIN RESULTS: We included 68 trials with a total of 2585 participants. In the analysis of the non-dose-matched groups (pooling of all trials with different training duration in the experimental as in the control intervention), we could see that trunk training had a positive effect on ADL (standardised mean difference (SMD) 0.96; 95% confidence interval (CI) 0.69 to 1.24; P < 0.001; 5 trials; 283 participants; very low-certainty evidence), trunk function (SMD 1.49, 95% CI 1.26 to 1.71; P < 0.001; 14 trials, 466 participants; very low-certainty evidence), arm-hand function (SMD 0.67, 95% CI 0.19 to 1.15; P = 0.006; 2 trials, 74 participants; low-certainty evidence), arm-hand activity (SMD 0.84, 95% CI 0.009 to 1.59; P = 0.03; 1 trial, 30 participants; very low-certainty evidence), standing balance (SMD 0.57, 95% CI 0.35 to 0.79; P < 0.001; 11 trials, 410 participants; very low-certainty evidence), leg function (SMD 1.10, 95% CI 0.57 to 1.63; P < 0.001; 1 trial, 64 participants; very low-certainty evidence), walking ability (SMD 0.73, 95% CI 0.52 to 0.94; P < 0.001; 11 trials, 383 participants; low-certainty evidence) and quality of life (SMD 0.50, 95% CI 0.11 to 0.89; P = 0.01; 2 trials, 108 participants; low-certainty evidence). Non-dose-matched trunk training led to no difference for the outcome serious adverse events (odds ratio: 7.94, 95% CI 0.16 to 400.89; 6 trials, 201 participants; very low-certainty evidence). In the analysis of the dose-matched groups (pooling of all trials with equal training duration in the experimental as in the control intervention), we saw that trunk training had a positive effect on trunk function (SMD 1.03, 95% CI 0.91 to 1.16; P < 0.001; 36 trials, 1217 participants; very low-certainty evidence), standing balance (SMD 1.00, 95% CI 0.86 to 1.15; P < 0.001; 22 trials, 917 participants; very low-certainty evidence), leg function (SMD 1.57, 95% CI 1.28 to 1.87; P < 0.001; 4 trials, 254 participants; very low-certainty evidence), walking ability (SMD 0.69, 95% CI 0.51 to 0.87; P < 0.001; 19 trials, 535 participants; low-certainty evidence) and quality of life (SMD 0.70, 95% CI 0.29 to 1.11; P < 0.001; 2 trials, 111 participants; low-certainty evidence), but not for ADL (SMD 0.10; 95% confidence interval (CI) -0.17 to 0.37; P = 0.48; 9 trials; 229 participants; very low-certainty evidence), arm-hand function (SMD 0.76, 95% CI -0.18 to 1.70; P = 0.11; 1 trial, 19 participants; low-certainty evidence), arm-hand activity (SMD 0.17, 95% CI -0.21 to 0.56; P = 0.38; 3 trials, 112 participants; very low-certainty evidence). Trunk training also led to no difference for the outcome serious adverse events (odds ratio (OR): 7.39, 95% CI 0.15 to 372.38; 10 trials, 381 participants; very low-certainty evidence). Time post stroke led to a significant subgroup difference for standing balance (P < 0.001) in non-dose-matched therapy. In non-dose-matched therapy, different trunk therapy approaches had a significant effect on ADL (< 0.001), trunk function (P < 0.001) and standing balance (< 0.001). When participants received dose-matched therapy, analysis of subgroup differences showed that the trunk therapy approach had a significant effect on ADL (P = 0.001), trunk function (P < 0.001), arm-hand activity (P < 0.001), standing balance (P = 0.002), and leg function (P = 0.002). Also for dose-matched therapy, subgroup analysis for time post stroke resulted in a significant difference for the outcomes standing balance (P < 0.001), walking ability (P = 0.003) and leg function (P < 0.001), time post stroke significantly modified the effect of intervention.  Core-stability trunk (15 trials), selective-trunk (14 trials) and unstable-trunk (16 trials) training approaches were mostly applied in the included trials.

AUTHORS' CONCLUSIONS

There is evidence to suggest that trunk training as part of rehabilitation improves ADL, trunk function, standing balance, walking ability, upper and lower limb function, and quality of life in people after stroke. Core-stability, selective-, and unstable-trunk training were the trunk training approaches mostly applied in the included trials. When considering only trials with a low risk of bias, results were mostly confirmed, with very low to moderate certainty, depending on the outcome.

Effectiveness of Mechanical Horse-Riding Simulator-Based Interventions in Patients with Cerebral Palsy-A Systematic Review and Meta-Analysis

BACKGROUND

Mechanical horse-riding simulator (HRS) exercises are a type of therapy based on the use of robotic or mechanical devices that produces movement similar to a real horse with the aim of simulating hippotherapy. This review analyses the effectiveness of HRS therapies in patients with cerebral palsy (CP).

METHODS

A systematic review and a meta-analysis were carried out by searching studies in PubMed Medline, SCOPUS, Web of Science, CINAHL, PEDro and SciELO up until October 2022. We selected clinical trials that assessed the effectiveness of HRS therapy, compared to other interventions, in patients with CP. The main variables were gross motor function (its global score and dimensions, such as sitting ability), functional balance, spasticity, hip range of motion (ROM), posturographic balance and satisfaction. The risk of bias was assessed using the Cochrane Risk of Bias Tool. The pooled effect was calculated using Cohen's Standardized Mean Difference (SMD) for a 95% confidence interval (95% CI).

RESULTS

Twelve studies were included in the systematic review, and 10 were included in the meta-analysis, providing data from 343 patients with spastic diplegic CP. Our findings revealed that HRS plus physiotherapy is more effective than physiotherapy in improving the total gross motor function (SMD 0.98; 95% CI 0.35-1.62), sitting ability of the gross motor function (SMD 0.84; 95% CI 0.32-1.36) and functional balance (SMD 0.6; 95% CI 0.1-1.08), and HRS therapy is better than sham to improve pelvic abduction ROM (SMD 0.79; 95% CI 0.21-1.37).

CONCLUSIONS

Horse-riding simulator-based therapy is an effective therapy to improve gross motor function, functional balance and abduction pelvic ROM in children with CP, in comparison to physiotherapy or sham.

Validity and reliability of center of pressure measures to quantify trunk control ability in individuals after stroke in subacute phase during unstable sitting test

Objective

The objective of this study was to assess, for individuals with hemiparesis after a stroke in subacute phase, the validity and reliability of center of pressure (CoP) parameters measured during sitting balance on an unstable support.

Materials and methods

Thirty-two individuals after stroke were included in this observational study for validity and reliability (mean age: 64.34 ± 9.30y, 23 men, mean post-stroke duration: 55.64 ± 27days). Intra-Class Correlation (ICC) and Bland Altman plot assessed intra-rater reliability and inter-rater reliability of CoP parameters during unstable sitting balance test (anteroposterior or mediolateral imbalance). Validity was established by correlating CoP parameters with the Modified Functional Reach Test, trunk strength, Balance Assessment in Sitting and Standing and Timed Up and Go tests.

Results

The findings highlighted significant correlations between CoP parameters and trunk strength for anteroposterior seated destabilization. Good to excellent intra and inter-rater reliability (0.87 ≤ ICC ≤ 0.95) was observed for all CoP length parameters and CoP mean velocity in both mediolateral and anteroposterior imbalance conditions. CoP parameters for mediolateral unstable sitting condition were more reliable than for anteroposterior instability.

Conclusion

Trunk control assessment during unstable sitting position on a seesaw is a reliable test for assessing trunk control ability in individuals after a stroke. CoP length and mean velocity are found to be the best parameters.

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Center of pressure values during anteroposterior perturbation is related to trunk strength.

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Center of pressure length parameters have excellent intra-rater and inter-rater reliability in individuals after a stroke in subacute phase.

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The reliability is better when the sitting instability is in mediolateral direction.

Efficacy of Robot-Assisted Gait Training Combined with Robotic Balance Training in Subacute Stroke Patients: A Randomized Clinical Trial

Recently, the use of robotic technology in gait and balance rehabilitation of stroke patients has been introduced, with positive results. The purpose of this study was to evaluate the effectiveness of robotic gait and trunk rehabilitation compared to robotic gait training alone on balance, activities, and participation measures in patients with subacute stroke. The study was a randomized, controlled, single blind, parallel group clinical trial. Thirty-six patients with first ischemic or hemorrhagic stroke event were enrolled, and they were randomized in two groups: Gait Group (GG), where they received only robotic treatment for gait rehabilitation through an end-effector system, and Gait/Trunk Group (GTG) where they performed end-effector gait rehabilitation and balance with a robotic platform, 3 times/week for 12 sessions/month. At the end of the study, there was an improvement in balance ability in both groups. Instead, the lower limb muscle strength and muscle tone significantly improved only in the GTG group, where we found a significant reduction in the trunk oscillations and displacement during dynamic exercises more than the GG group. The robotic platform which was added to the gait robotic treatment offers more intense and controlled training of the trunk that positively influences the tone and strength of lower limb muscles.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Stroke Patients Showed Improvements in Balance in Response to Visual Restriction Exercise

OBJECTIVE

Several strategies have been designed to improve balance after stroke. Although recent studies have suggested that the balance training in stroke should include exercises that are performed in different sensory conflict conditions, little attention has been paid to manipulation of visual input. This study aimed to compare effects of balance training on an unstable surface with balance training under visual deprivation conditions in persons with stroke.

METHOD

Forty-five stroke patients were randomized into three groups: the visual deprivation- stable based training (VD-SBT); unstable based training (UBT); and control (C) groups. Subjects of the VD-SBT group performed balance training on a stable surface with closed eyes. The UBT group performed balance training on an unstable surface with open eyes. Patients were assessed before and after interventions for Timed Up and Go (TUG), Four Square Step (FSS) and Five Times Sit to Stand (FTSS) tests.

RESULT

There was a significant difference in pre- post intervention time of TUG, FSS and FTSS tests in all three groups. In a comparison of three groups, the UBT and VD-SBT groups had a significant improvement in time of all tests but significant improvement in time of all tests was observed in the VD-SBT group in comparison with the UBT group. In the field of balance training, the manipulation of visual input was more effective than the manipulation of standing surface to reweighting the sensory information.

CONCLUSION

We recommended balance rehabilitation programs after stroke performed under conditions to stimulate the use of underused sensory input.

Core Stability Exercises Yield Multiple Benefits for Patients with Chronic Stroke - Randomized Controlled Trial

OBJECTIVE

This study examines the effect of core stability exercises on trunk control, core muscle strength, standing weight-bearing symmetry and balance confidence of people with chronic stroke.

DESIGN

This was an assessor-blinded randomized controlled trial involving 84 ambulatory patients with middle cerebral artery stroke, randomly assigned to three training groups. Two experimental groups practiced core stability exercises either on stable or unstable support surfaces. In contrast, the control group received standard physiotherapy. All the participants an hour-long training session a day, thrice a week over a six-week duration, and followed-up after 12 months. Trunk Impairment Scale, core muscle strength, weight-bearing asymmetry in standing and Activities-specific Balance Confidence scale were the outcome measures.

RESULTS

Compared to the control group, the two experimental groups demonstrated a significant improvement on all the outcome measures from baseline to post-training and from baseline to 12-month follow-up (P < 0.001). The two experimental groups demonstrated no significant difference between them on all the measures (P > 0.05).

CONCLUSION

Core stability exercises on stable and unstable support surfaces are equally beneficial in improving trunk control, core muscle strength, standing weight-bearing symmetry and balance confidence of ambulatory patients with chronic stroke than the standard physiotherapy.

Effects of Trunk Exercise on Unstable Surfaces in Persons with Stroke: A Randomized Controlled Trial

Background: Improving balance-related ability is an important goal in stroke rehabilitation. Evidence is needed to demonstrate how this goal could be better achieved. Aim: Determine if trunk exercises on unstable surfaces would improve trunk control and balance for persons in the subacute stage of stroke. Design: An assessor-blind randomized controlled trial. Setting: Inpatients in the department of rehabilitation in a general hospital. Population: Patients who suffered a first-time stroke with onset from one to six months. Methods: Inpatients with stroke were assigned to upper limb exercises (control group, n = 17) or trunk exercises on unstable surfaces (experimental group, n = 18) to receive training twice a week for six weeks, in addition to their daily conventional stroke rehabilitation. Sensorimotor function tests, including hand grip, plantar sensitivity, stroke rehabilitation assessment of movement and Fugl-Meyer lower extremity motor scale, and clinical outcome assessments, including Trunk Impairment Scale and 6 m walk test, were conducted before and after six weeks of training. The center of the pressure area while maintaining static posture and peak displacement while leaning forward, as well as the average speed of raising the unaffected arm, were measured in sitting without foot support, sitting with foot support and standing to reflect trunk control, sitting balance and standing balance, respectively. Results: The between-group differences in the sensorimotor functions were nonsignificant before and after training. Compared with the control group, the experimental group had significantly greater forward leaning and faster arm raising in sitting without foot support, higher Trunk Impairment Scale total score, and shorter 6 m walking time after training, but not before training. Conclusion: Trunk exercises on unstable surfaces could further improve trunk control, the ability to raise the unaffected arm rapidly in sitting, and walking for persons in the subacute stage of stroke. This intervention may be considered to be included in stroke rehabilitation.

Effects of trunk exercise with physioball to improve trunk balance among subjects with stroke: a systematic review and meta-analysis

Poststroke subjects present with difficulties of reduced functional mobility and balance. Trunk impairment is common among stroke subjects which hinder the performance of upper and lower limb. In poststroke rehabilitation limbs are provided much attention than the trunk. Trunk function has been identified as an important early predictor of functional outcome after stroke. Physioball is commonly used among healthy subjects in performing trunk exercises. This systematic review with meta-analysis is conducted to investigate the effect of trunk exercises performed using physioball in improving trunk performance after stroke. Six authors identified relevant articles from the following databases: PubMed, Google Scholar, CINAHL (Cumulative Index and Nursing and Allied Health Literature), PEDro (Physiotherapy Evidence Database). Articles evaluating the effect of physioball exercise for improving trunk stability among stroke subjects were included. Databases were screened from 2009 and up to 2019. Qualitative synthesis of evidence was prepared and meta-analysis was implemented to draw pooled effects of physioball exercise on improving trunk performance and balance among stroke subjects. Eight papers were included, totaling 273 participants. All the articles included in this review demonstrated moderate to good quality. Meta-analysis performed with seven papers demonstrated statistical significance of physioball in improving trunk performance during acute and subacute stages of stroke. Brunnel Balance Assessment outcomes demonstrated statistically significant improvement of balance among overall stroke survivors. Trunk exercise performed over a physioball is effective during the acute and subacute stage. This meta-analysis could not find its significant effect in improving trunk performance in the chronic stages.

Dynamic Stability and Trunk Control Improvements Following Robotic Balance and Core Stability Training in Chronic Stroke Survivors: A Pilot Study

Stroke survivors show greater postural oscillations and altered muscular activation compared to healthy controls. This results in difficulties in walking and standing, and in an increased risk of falls. A proper control of the trunk is related to a stable walk and to a lower falling risk; to this extent, rehabilitative protocols are currently working on core stability. The main objective of this work was to evaluate the effectiveness of trunk and balance training performed with a new robotic device designed for evaluation and training of balance and core stability, in improving the recovery of chronic stroke patients compared with a traditional physical therapy program. Thirty chronic stroke patients, randomly divided in two groups, either underwent a traditional rehabilitative protocol, or a robot-based program. Each patient was assessed before and after the rehabilitation and at 3-months follow-up with clinical and robot-based evaluation exercises focused on static and dynamic balance and trunk control. Results from clinical scores showed an improvement in both groups in balance and trunk control. Robot-based indices analysis indicated that the experimental group showed greater improvements in proprioceptive control, reactive balance and postural control in unstable conditions, compared to the control group, showing an improved trunk control with reduced compensatory strategies at the end of the training. Moreover, the experimental group had an increased retention of the benefits obtained with training at 3 months follow up. These results support the idea that such robotic device is a promising tool for stroke rehabilitation.

Relationship between trunk control, core muscle strength and balance confidence in community-dwelling patients with chronic stroke

BACKGROUND AND OBJECTIVE

Impaired trunk control and core muscle weakness affect balance capacity after stroke, but confirmatory literature is lacking. The objective was to examine the relationship between trunk control, core muscle strength and self-confidence on balance efficacy in community-dwelling chronic stroke survivors and to identify trunk performance measures for determining balance confidence.

METHODS

Patients with a median post-stroke duration of 12 (IQR 7-18) months and independent walking ability participated in this cross-sectional study. Trunk control, core muscle strength and balance confidence were measured using trunk impairment scale 2.0 (TIS 2.0), handheld dynamometer and activity-specific balance confidence scale, respectively. Correlation among TIS 2.0, core muscle strength and balance confidence were tested by Pearson's correlation coefficient. Stepwise multivariate linear regression analysis was conducted to examine the most important trunk performance variables determining balance confidence.

RESULTS

Of 177 study participants, the median (IQR) score for TIS 2.0 was 10 (7-12) out of 16 and for balance confidence 41 (27-61) out of 100. Trunk control was highly correlated to overall core muscles strength (r = 0.61-0.70, p <.001) and balance confidence (r = 0.66, p <.001). The major trunk determinants of balance confidence were TIS 2.0 total score (partial R² = 0.433) and dynamic sitting balance, i.e. trunk lateral flexion (partial R² = 0.376) in chronic stroke.

CONCLUSION

A significant and strong positive association exists among trunk control, core muscles strength and balance confidence in community-dwelling patients with chronic stroke, warranting further investigation of the effect of targeted trunk rehabilitation strategies on functional balance.

Inter-Day Reliability and Changes of Surface Electromyography on Two Postural Muscles Throughout 12 Weeks of Hippotherapy on Patients with Cerebral Palsy: A Pilot Study

Cerebral palsy (CP) is an umbrella term covering a group of permanent developmental disorders of movement and posture characterized by highly variable clinical features. The aim of this study was to assess the short-term and mid-term effects of neurorehabilitation via hippotherapy on the contractile properties of two key postural muscles during functional sitting in such patients. Thirty-minute hippotherapy sessions were conducted biweekly for 12 weeks in 18 patients (18.1 ± 5.7 years old). Surface electromyography (EMG) was implemented bilaterally in rectus abdominis and adductor magnus. We quantitatively analyzed the amplitude of EMG signals in the time domain and its spectral characteristics in the frequency domain. EMGs were recorded at the beginning and end of each session on day one and at week six and week twelve. Statistical analysis revealed a substantial inter-day reliability of the EMG signals for both muscles, validating the methodological approach. To a lesser extent, while beyond the scope of the current study, quantitative changes suggested a more selective recruitment/contractile properties’ shift of the examined muscles. Exploring postural control during functional activities would contribute to understanding the relationship between structural impairment, activity performance and patient capabilities, allowing the design of neurorehabilitation programs aimed at improving postural and functional skills according to each individual’s needs. The present study provides basic quantitative data supporting the body of scientific evidence making hippotherapy an approach of choice for CP neurorehabilitation.

Short- and Mid-Term Improvement of Postural Balance after a Neurorehabilitation Program via Hippotherapy in Patients with Sensorimotor Impairment after Cerebral Palsy: A Preliminary Kinetic Approach

There is still a lack of studies focused on trunk neurorehabilitation. Accordingly, it is unclear which therapeutic modalities are the most effective in improving static/dynamic balance after brain damage. We designed a pilot study on hippotherapy to assess its short- and mid-term effect on dynamic postural balance in patients with moderate-to-severe sensorimotor impairment secondary to cerebral palsy. Five patients aged 15.4 ± 6.1 years old were recruited. All of them had moderate-to-severe alterations of the muscle tone with associated postural balance impairment. Standing and walking were also impaired. Ten minutes horse riding simulator followed by twenty minutes hippotherapy session were conducted during five session days separated by one week each. We analyzed the displacement of the Center of Pressure (COP) on the sitting surface of the simulator’s saddle by means of a customized pressure pad. We measured the general behavior of the COP displacement as well as the postural adjustments when pace changed from walk to trot to walk during the sessions and among sessions. Statistical analysis revealed an improved postural control both by the end of the session and from session 1 to session 5. These results suggest that hippotherapy might support regularization of postural control in a long-term neurorehabilitation context.

Effect of proprioceptive stimulation induced by footplate during center of pressure movement tracking training on the balance abilities of patients with chronic hemiplegic stroke: a randomized, controlled, pilot study

Background: Balance requires highly complex interactions involving muscle strength, joint flexibility, visual, vestibular, and proprioceptive senses.Objective: The purpose of this pilot study was to compare the effects of COP (center of pressure) movement tracking training conducted using the Biodex Balance System SD® in static and dynamic modes on balance ability in stroke patients.Methods: Twenty-six stroke patients were randomly assigned to a control group (COP movement tracking training in static mode ; stable; n = 13 or an experimental group (COP movement tracking training in dynamic mode; unstable; n = 13). Both groups underwent neurodevelopmental therapy followed by an additional 15 min of COP movement training three times a week for 6 consecutive weeks. The timed-up and go test, COP pathway velocity, COP pathway length, and limit of stability were measured before and after intervention.Results: The experimental group showed greater reductions in COP pathway length and COP pathway velocity than the control group (5%, F (1, 24) = 6.125, p = .021, η² = .203; 5.4%, F (1, 24) = 6.661, p = .016, η² = .217, respectively). No significant intergroup difference was observed for the timed-up and go test or limit of stability results.Conclusion: COP movement tracking training in dynamic mode was found to be a more effective intervention for improving the static balancing abilities of stroke patients than training in static mode.

Rehabilitation interventions for improving balance following stroke: An overview of systematic reviews

Background

The aim of this study was to synthesize evidence from systematic reviews, to summarise the effects of rehabilitation interventions for improving balance in stroke survivors.

Methods

We conducted an overview of systematic reviews (SRs). We included Cochrane Systematic Reviews and non-Cochrane Systematic Reviews of randomized-controlled clinical trials and not-randomized clinical trials, in all types of stroke, comparing the effects of interventions, control interventions and no interventions on balance-related outcomes. We conducted a comprehensive search of electronic databases, from inception to December 2017. Data extracted included: number and type of participants, type of intervention, control intervention, method of assessing risk of bias of primary studies, balance outcome measures and results of statistical meta-analyses. Methodological quality of included reviews was assessed using AMSTAR 2. A narrative description of the characteristics of the SRs was provided and results of meta-analyses summarised with reference to their methodological quality.

Results

51 SRs (248 primary studies and 10,638 participants) met the inclusion criteria and were included in the overview. All participants were adults with stroke. A wide variety of different balance and postural control outcomes were included. 61% of SRs focussed on the effectiveness of physical therapy, 20% virtual reality, 6% electromechanical devices, 4% Tai-Chi, whole body vibration and circuit training intervention, and 2% cognitive rehabilitation. The methodology of 54% of SRs were judged to be of a “low or critically low” quality, 23% “moderate” quality and 22% “high” quality.

Conclusions

There are 51 SRs of evidence relating to the effectiveness of interventions to improve balance in people with stroke, but the majority of these are of poor methodological quality, limiting our ability to draw clear implications. Only 22% of these SRs were judged to be of high quality, highlighting the need to address important methodological issues within rehabilitation research.

The effectiveness of trunk training on trunk control, sitting and standing balance and mobility post-stroke: a systematic review and meta-analysis

Objective:

To investigate the effectiveness of trunk training on trunk control, sitting and standing balance and mobility.

Data sources:

PubMed/MEDLINE, Web of Science, Physiotherapy Evidence Database (PEDro), Cochrane Library, Rehab+ and ScienceDirect were searched until January 2019.

Review methods:

Randomized controlled trials were included if they investigated the effect of trunk exercises on balance and gait after stroke. Four reviewers independently screened and performed data extraction and risk of bias assessment with the PEDro scale. Disagreements were resolved by a fifth independent reviewer. A meta-analysis was performed to quantitatively describe the results.

Results:

After screening of 1881 studies, 22 studies and 394 participants met the inclusion criteria. Trunk training was executed as core stability, reaching, weight-shift or proprioceptive neuromuscular facilitation exercises. The amount of therapy varied from a total of 3–36 hours between studies. The median PEDro score was 6 out of 10 which corresponds with a low risk of bias. Meta-analysis was performed with a random-effects model due to differences in study population, interventions received and follow-up length. The overall treatment effect was large for trunk control standardized mean differences (SMD) 1.08 (95% confidence interval (CI): 0.96–1.31), standing balance SMD 0.84 (95% CI: 0.04–0.98) and mobility SMD 0.88 (95% CI: 0.67–1.09).

Conclusions:

In patients suffering from stroke, there is a strong amount of evidence showing that trunk training is able to improve trunk control, sitting and standing balance and mobility.