Trunk rotation exercises versus sit-to-stand training with step-foot position on balance and gait in patients with chronic stroke

Divya K Babel; Sudheera Kunduru

doi:10.4103/ijptr.ijptr_50_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 3 | Issue : 2 | Page : 83-87

Trunk rotation exercises versus sit-to-stand training with step-foot position on balance and gait in patients with chronic stroke

Divya K Babel¹, Sudheera Kunduru²
¹ Neuro-Physiotherapist, PRS Neurosciences and Mechatronics Research Institute Private Limited, Bengaluru, Karnataka, India
² Department of Neurology Physiotherapy, Padmashree Institute of Physiotherapy, Bengaluru, Karnataka, India

Date of Submission	17-Sep-2021
Date of Decision	08-Nov-2021
Date of Acceptance	16-Dec-2021
Date of Web Publication	12-Jan-2022

Correspondence Address:
Dr. Sudheera Kunduru
Padmashree Institute of Physiotherapy, Sulikere Post, Kommaghatta, Kengeri, Bengaluru- 560.060, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_50_21

Abstract

Context: Muscle weakness, decreased range of motion, abnormal muscle tone, incoordination, and multisensory disintegration in stroke patients can lead to balance disturbances, reduced mobility, and higher risk for falls. There is paucity in literature whether trunk rotation exercises or sit-to-stand training protocol would be more beneficial for stroke-related disability.
Aims: The aim of this study is to determine the comparative effect of trunk rotation exercises and sit-to-stand training with step-foot position on balance and gait in patients with chronic stroke.
Settings and Design: Experimental study was carried out at tertiary care center.
Subjects and Methods: Thirty stroke patients were recruited and randomly included in one of the two study groups. Group A was given trunk rotation exercises and Group B received sit-to-stand training with step-foot position for 30 min, 3 times a week, for 4 weeks. Both the groups received conventional physiotherapy for another 30 min. Balance and gait were assessed before and postintervention using the Berg Balance Scale (BBS) and Dynamic Gait Index (DGI), respectively.
Statistical Analysis Used: The Mann–Whitney U-test was applied for the comparison of group data.
Results: When BBS and DGI were compared at pre-and postintervention time, results were statistically significant for both groups (P < 0.001). However, when between groups posttest scores were compared for BBS and DGI, results were statistically not significant (P > 0.05).
Conclusion: Both trunk rotation exercises and sit-to-stand training with step-foot position were equally effective in improving balance and gait in chronic poststroke subjects.

Keywords: Balance, Gait, Sit-to-stand training, Step-foot position, Stroke, Trunk rotation exercises

How to cite this article:
Babel DK, Kunduru S. Trunk rotation exercises versus sit-to-stand training with step-foot position on balance and gait in patients with chronic stroke. Indian J Phys Ther Res 2021;3:83-7

How to cite this URL:
Babel DK, Kunduru S. Trunk rotation exercises versus sit-to-stand training with step-foot position on balance and gait in patients with chronic stroke. Indian J Phys Ther Res [serial online] 2021 [cited 2022 Jan 25];3:83-7. Available from: https://www.ijptr.org/text.asp?2021/3/2/83/335667

Introduction

The survivors post stroke are at a greater risk for falls. Falls can have serious consequences on physical and psychosocial health. Fear of falling leads to reduced physical activity, social withdrawal, and loss of individuality. Balance and gait deficits are observed to be important risk factors for falls. Balance discrepancies include reduced postural steadiness during standing and reduced coordinated reactions to externally or self-created balance perturbations. Gait issues include reduced momentum at heel/toe off, reduced hip-knee flexion during swing, and decreased steadiness/stability during the stance. Interventions aiming to address these issues can prevent the occurrence of falls efficiently. Exercise programs planned to correct these balance and gait problems reducing the rate of falls in the stroke population.^[1] Poststroke, most individuals recover to some extent. However, more than 50% of them have residual deficits such as decreased walking speed and walking ability, balance impairment, and reduced confidence and mobility.

Balance is the result of complex interaction of sensory and motor systems. Functional performance depends on the sensorimotor impairment of trunk. Trunk muscles help in maintaining the center of gravity and base of support for standing, shifting weight, and static and dynamic postures. The ability to distribute body weight symmetrically in requirement with the task is an essential part of postural adjustments of trunk that always precedes any active movements. Several authors emphasized the importance of assessing trunk function to predict functional recovery as trunk balance needs a stabilized pelvis and spinal column.^[2]

After a stroke, trunk control is an important indicator of functional recovery. Trunk performance, functional skills, balance, and gait are strongly correlated in subjects with stroke. Trunk muscle weakness and altered tone increase the postural sway, dynamic instability, and difficulty in weight transfer affects an individual's performance negatively. By improving trunk control and weight transfers, it is possible to correct the body's upright posture. Literature suggests that working on muscle strength and trunk range of motion, stability, static, and dynamic trunk control are important aspects of poststroke rehabilitation.^[3]

Sit-to-stand movement is a regular and daily activity that consists of a person rising from a chair and the ability to do it is diminished after a stroke. Asymmetric weight-bearing in the lower extremities leads to imbalance in hemiplegic subjects. Asymmetrical posture is seen during movements such as walking, sitting, and standing that can lead to increased weight-bearing on the stronger limb over the weaker limb. Imbalance in the weight-bearing pattern results in difficulty controlling balance in the standing. The practice of sit-to-stand movements using various strategies to facilitate weight-bearing on the paretic limb improves functional activity, preventing falls, and also helps in reversing learned nonuse of the affected limb.^[4]

Standing up is important for functional independence. Identification of movement determinants that influence the performance of a task is important while choosing strategies for facilitation.^[5] Recovery of the ability to stand up and take a load on the paretic limb is needed for gait retraining.^[6] Previous literature suggests the importance of sit-to-stand training on balance and lower limb function after a stroke.^[7]

Most of the literature focuses on the upper and lower extremity rehabilitation after stroke without focusing much on the trunk. Although trunk rotation exercises and sit-to-stand training have shown to have a positive effect on gait and balance in subjects with stroke, there is a lack of literature on which training protocol would be more beneficial. Keeping in mind, the time taken and the exercise intensity to perform these two exercise protocols on a subject, it would be beneficial to find out which treatment protocol gives best results. Hence, there exists a need to find out which training is more effective in improving balance and gait in chronic poststroke subjects.

Subjects and Methods

Thirty subjects between the age group of 45 and 55 years, diagnosed with chronic stroke for more than 6 months,^[8] Brunnstrom stage of motor recovery 4–5, and the Berg Balance Scale (BBS) score of 21–45 were included in the study. Subjects with <15° of ankle dorsiflexion, severe visual or auditory deficits, major depression, dementia or any other cognitive impairments, unilateral spatial neglect, uncooperative subjects, and any unstable medical conditions were excluded from the study [Figure 1]. Subjects were recruited from a Tertiary Care Center, Bengaluru. Ethical clearance was obtained from the Institutional Ethical Committee. Informed written consent was taken from the participants of the study. Subjects were randomly assigned to one of the two groups. Demographic variables such as age, gender, type of stroke, side of affection, and spasticity grading were documented.

Figure 1: CONSORT flow diagram

Click here to view

Group A was given trunk rotation exercises and subjects in Group B received sit-to-stand training with step-foot position for 30 min. Both the groups received conventional therapy for another 30 min. Exercise sessions were planned thrice a week, for 4 weeks. Before the treatment, all the subjects were assessed for balance and gait using the BBS and Dynamic Gait Index (DGI). Postintervention, the two parameters were assessed again using the same outcome measures. Both the outcome measures used have been studied for their reliability and validity for their usage in subjects with chronic stroke.^{[9],[10],[11],[12]}

Trunk rotation program for the subjects in Group A

The subjects were asked to sit on the functional reeducation plinth with hip-knee flexion of 90° and feet are kept flat on the floor. Exercises given were as follows:

Flexion-extension of the lower trunk
Lateral flexion of the upper trunk – Movement is initiated from the shoulder girdle to bring the elbow toward plinth
Flexion of the lower trunk laterally – Movement is initiated from the pelvic girdle, and the pelvis is lifted off the plinth toward the rib cage
Trunk rotation
Forward reaching. Forward diagonal reach at shoulder height was added as progression
Lateral reach at their shoulder height.

The frequency of performing the exercises was in accordance with the subject's physical performance abilities. Rest was given to all the subjects whenever required during the treatment session. During training, subjects were supported to limit compensatory movements and progressed by reducing visual and auditory feedback.^[13],[14]

Sit-to-stand training with step-foot position for subjects in Group B

The normal foot was constrained by keeping it on a step, and the affected foot was kept at the ground level. While doing these exercises, both the feet were positioned with 10° ankle dorsiflexion (step height was kept at 25% of knee height). Following exercises were given:

While sitting, subjects were asked to transfer the cup from the normal side to the paretic side
Practice sit-to-stand while looking in the mirror that is kept in front of them while trying to align the body
Practice sit-to-stand while picking up objects that are in front of the affected foot with the unaffected side hand
The sit-to-stand position was practiced while putting the weight on the affected side with the help of the treating therapist
Practicing sit-to-stand without looking in the mirror.^[15]

After each session, both the groups received conventional physiotherapy such as stretching, strengthening, bridging, and weight-bearing exercises for another 30 min.^[16] All the subjects were encouraged to practice conventional exercises at home daily on the other 4 days.

Results

Statistical analysis was carried out using Microsoft Excel and SPSS version 22 for windows, Armonk NY: IBM Corp, USA. The categorical and continuous data were analyzed between groups using the Chi-square test, mean, standard deviation, and Wilcoxon test/Mann–Whitney U-test/t-test. P < 0.05 was considered statistically significant.

The distribution of the subjects with chronic stroke according to their age, gender, duration of stroke, Brunnstrom stage of motor recovery, side affected, and type of stroke is mentioned in [Table 1]. The pre- and postintervention comparison with the two study groups demonstrated statistically significant improvement in both BBS and DGI scores [Table 2]. However, the data of comparison between the groups for posttest scores showed no statistically significant changes for BBS (z = 0.1037, P > 0.05) and DGI (z = 1.5969, P > 0.05) scores indicating that both interventions showed to be equally effective [Table 3].

Table 1: Demographic and distribution characteristics of the variables

Click here to view

Table 2: Within-group comparison for Berg Balance Scale and Dynamic Gait Index for the two study groups

Click here to view

Table 3: Between group comparison of pre-and posttest intervention data of subjects with chronic stroke

Click here to view

Discussion

The objective of this study was to compare the effect of trunk rotation exercises versus sit-to-stand training with step-foot position on balance and gait in subjects with chronic stroke. Trunk muscle performance helps in predicting the functional outcome in stroke rehabilitation. Abnormal or delayed postural responses are seen in the lower limb muscles in standing after stroke. Anticipatory activation of the trunk muscles is lost during voluntary movements leading to postural instability. Increased sway during static standing, reduced the area of stability in standing, delayed and disturbed equilibrium reactions, decreased weight-bearing on the affected limb, and high fall risk are observed poststroke.^[17] In the present study, subjects in Group A who received trunk rotation exercises significantly improved on BBS and DGI. Exercises aiming at improving truncal function have shown to increase dynamic sitting balance and trunk coordination Saeys et al. stated that trunk function improves postural control while standing and in mobility that indicates the importance of trunk exercises in stroke rehabilitation.^[18] Training individuals in sitting can be a great help to those who cannot stand independently, and it can prepare the individuals for standing. Improvement that is achieved in sitting can be carried over to standing. Ramachandran et al. used trunk rotation training as a tool to improve weight transmission and concluded that subjects who trained with trunk rotation improved in weight transmission in their paretic extremity as it is possible that movements of the upper limb have elicited contraction in the affected lower extremity. The lower limb helps in increasing the base of support and breaking the momentum of the moving trunk.^[16] Rai et al. stated that improvement in trunk control could be because of exercises that comprised specific trunk movements helping in strengthening and improving postural awareness and anticipatory postural adjustments leading to good trunk control.^[17]

Subjects in Group B also improved significantly from pretest to posttest scores on BBS and DGI. This is in accordance with a study done by Machado CC et al. where the authors mentioned that a difference in vertical reaction forces and knee joint moment between the sides could be reduced by asymmetric foot positioning where the affected foot is placed behind the normal side.^[5] Evidence suggests that muscle strength and the ability to distribute weight on the paretic side are important factors that aid standing up. The weight distribution on the paretic foot can help tactile and proprioceptive stimulation improving sensory information.^[4] It has also been observed that asymmetric behavior causing learned nonuse in the affected lower limb is a result of greater use of the normal lower limb during sit-to-stand transfer. Hence, the manipulation of foot position could be a better strategy that decreases asymmetric loading during rising to standing.^[19] Similarly, in a study the authors concluded that task-oriented sit-to-stand practice improved sit-to-stand performance in these subjects. It can help in improving functional movements, prevent falls, and learned the nonuse of the paretic limb.^[4]

When the pretest scores of BBS and DGI were compared between both the groups, it was seen that both the groups were homogenous. When the posttest scores of BBS and DGI were compared between the groups, the results indicated that there was no statistical difference. Asymmetric foot position helps in reducing lateral deviation of the center of pressure and body oscillation, thereby improving balance gait performance as suggested.^[5],[14]

Posturographic analysis suggests that the stroke subjects prevent moving their center of pressure toward the weaker side in sitting and standing. In this study, while Group A focused on dynamic activities of trunk in siting, Group B focused on dynamic standing activities focusing on foot. Hence, an improvement that was similar could have been attributed to the fact that an improvement in standing balance follows dynamic sitting training in hemiplegia, which contributes to better balance and gait.^[4]

If sit-to-stand training can decrease the displacement of the center of pressure, then there is a probability that trunk exercises also reduce displacement of the same due to which the balance, and thereby gait could have improved in both the groups. The other possible reason could be that in reaching across the body at 45° angle, the body of center of gravity would have got displaced, thereby activating the lower limbs along with the trunk. Hence, in both the groups, the involvement of the lower limb can be profoundly found in varying degrees contributing to the same result.^[16],[19] Hence, it can be understood that the trunk rotation exercises can impact the load placed on the foot so that the asymmetries of trunk position also reduced. That could be the reason why both sit-to-stand training and trunk rotation exercises were equally effective in improving gait and balance in chronic stroke subjects.

Due to time restrictions, long-term follow-up of the achieved results was not possible. Further studies can be recommended to use unstable surfaces such as a physio ball or foam in comparison to sit-to-stand training. Only subjects who were able to walk independently were included in the study. Future studies can consider the effect of these protocols in subjects who need assistance. It is recommended further studies can determine the effect of trunk rotation exercises combined with sit-to-stand training with step-foot position in poststroke subjects as both these are important components of stroke rehabilitation.

Conclusion

Both trunk rotation exercises and sit-to-stand training with step-foot position were equally effective in improving balance and gait in chronic poststroke subjects and can be included in the rehabilitation of the poststroke subject with paresis to reduce the risk of falls and improve gait quality.

Financial support and sponsorship

Self-funded.

Conflicts of interest

There are no conflicts of interest.

References

1.	Weerdesteyn V, de Niet M, van Duijnhoven HJ, Geurts AC. Falls in individuals with stroke. J Rehabil Res Dev 2008;45:1195-213.
2.	Cabanas-Valdés R, Cuchi GU, Bagur-Calafat C. Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: A systematic review. NeuroRehabilitation 2013;33:575-92.
3.	Kılınç M, Avcu F, Onursal O, Ayvat E, Savcun Demirci C, Aksu Yildirim S. The effects of Bobath-based trunk exercises on trunk control, functional capacity, balance, and gait: A pilot randomized controlled trial. Top Stroke Rehabil 2016;23:50-8.
4.	Park JH, Kim YM, Lee NK. The effects of repetitive sit-to-stand training with a paretic-side asymmetrical foot position on the balance of chronic stroke subjects. J Korean Phys Ther 2015;27:169-73.
5.	Machado CC, Soares MP, Santos GV, Pinto EB. Influence of foot position in the performance of sit to stand in post stroke hemiparetic patients. Rev Pesqui em Fisioterapia 2015;5:300-5.
6.	Ferrarello F, Deluca G, Pizzi A, Baldini C, Iori F, Marchionni N, et al. Passive standing as an adjunct rehabilitation intervention after stroke: A randomized controlled trial. Arch Physiother 2015;5:2.
7.	Liu M, Chen J, Fan W, Mu J, Zhang J, Wang L, et al. Effects of modified sit-to-stand training on balance control in hemiplegic stroke patients: A randomized controlled trial. Clin Rehabil 2016;30:627-36.
8.	Jung HY. Rehabilitation in subacute and chronic stage after stroke. In: Stroke Revisited: Diagnosis and Treatment of Ischemic Stroke. Singapore: Springer; 2017. p. 351-60.
9.	Blum L, Korner-Bitensky N. Usefulness of the berg balance scale in stroke rehabilitation: A systematic review. Phys Ther 2008;88:559-66.
10.	La Porta F, Caselli S, Susassi S, Cavallini P, Tennant A, Franceschini M. Is the Berg Balance Scale an internally valid and reliable measure of balance across different etiologies in neurorehabilitation? A revisited Rasch analysis study. Arch Phys Med Rehabil 2012;93:1209-16.
11.	Jonsdottir J, Cattaneo D. Reliability and validity of the dynamic gait index in persons with chronic stroke. Arch Phys Med Rehabil 2007;88:1410-5.
12.	Lin JH, Hsu MJ, Hsu HW, Wu HC, Hsieh CL. Psychometric comparisons of 3 functional ambulation measures for patients with stroke. Stroke 2010;41:2021-5.
13.	Karthikbabu S, John MS, Manikandan N, Bhamini KR, Chakrapani M, Akshatha N. Role of trunk rehabilitation on trunk control, balance and gait in patients with chronic stroke: A pre-post design. Neurosci Med 2011;2:61-67.
14.	An SH, Park DS. The effects of trunk exercise on mobility, balance and trunk control of stroke patients. J Korean Soc Phys Med 2017;12:25-33.
15.	Kim K, Kim YM, Kang DY. Repetitive sit-to-stand training with the step-foot position on the non-paretic side, and its effects on the balance and foot pressure of chronic stroke subjects. J Phys Ther Sci 2015;27:2621-4.
16.	Ramachandran A,7 Vasanthi RK. Trunk rotation training as a tool in improving weight transmission through the paretic lower limb in hemiplegiay. Arch Physiother Glob Res 2016;7:939-42.
17.	Rai RK, Arora L, Sambyal S, Arora R. Efficacy of trunk rehabilitation and balance training on trunk control, balance and gait in post stroke hemiplegic patients: A randomized controlled trial. J Nurs Health Sci 2014;3:27-31.
18.	Saeys W, Vereeck L, Truijen S, Lafosse C, Wuyts FP, Heyning PV. Randomized controlled trial of truncal exercises early after stroke to improve balance and mobility. Neurorehabil Neural Repair 2012;26:231-8.
19.	Han J, Kim Y, Kim K. Effects of foot position of the nonparetic side during sit-to-stand training on postural balance in patients with stroke. J Phys Ther Sci 2015;27:2625-7.