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NeuroRehabilitation 35 (2014) 205–213 DOI:10.3233/NRE-141123 IOS Press
Does additional exercise improve trunk function recovery in stroke patients? A meta-analysis I.O. Sorinola∗ , I. Powis and C.M. White Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
Abstract. BACKGROUND: The restoration of trunk function following stroke is a key component of rehabilitation, however there is limited evidence of the efficacy of additional trunk training. OBJECTIVES: To evaluate the efficacy of trunk exercises added to conventional rehabilitation on functional outcomes. METHODS: Relevant randomised controlled trials (RCTs), published up to July 2012, evaluating the effect of the addition of trunk exercises to conventional rehabilitation on functional outcomes were identified in Medline, Cinahl, Embase, Pubmed, PEDro, Web of Science and Scopus databases. Findings were summarised across studies as mean or standardised mean differences (MD or SMD) with 95% confidence intervals. RESULTS: Six RCTs with 155 participants and a mean PEDro score of 6.5 (range 6 to 8) were included. Data from two to five studies were pooled in meta-analyses that showed a moderate, non-significant effect of additional trunk exercise on trunk performance, (SMD = 0.50; 95% CI −0.25, 1.25; P = 0.19); large effects on standing balance, SMD = 0.72 (95% CI −0.01, 1.45 P = 0.05); and walking ability, (SMD = 0.81; 95% CI 0.30, 1.33. P = 0.002) and a small, non-significant effect, MD = 10.03 (95% CI −15.70, 35.75. P = 0.44) on functional independence. CONCLUSIONS: There is moderate evidence that the addition of specific trunk exercise to conventional early stroke rehabilitation significantly improve standing balance and mobility after stroke; however the evidence was weak for the effect of additional trunk exercise on trunk performance and in functional independence. Keywords: Meta-analysis, stroke, rehabilitation, trunk exercise, functional recovery, mobility
1. Introduction Several studies have described specific impairments in trunk performance in people after stroke, including deficits in selective muscle activation, inter-segmental coordination and functional trunk performance (Bohannon, 1995; Bohannon, Cassidy, & Walsh, 1995; Dickstein, Sheffi, Ben Haim, Shabtai, & Markovici, 2000; Dickstein, Shefi, Marcovitz, & Villa, 2004a; ∗ Address
for correspondence: I.O. Sorinola, Ph.D., Rm. 3.24 Shepherd’s House, Division of Health and Social Care Research, School of Medicine, King’s College London, London SE1 1UL, UK. Tel.: +44 020 7848 8170; Fax: +44 020 7848 6325; E-mail: [email protected].
Hacmon, Krasovsky, Lamontagne, & Levin, 2012; Tanaka, Hachisuka, & Ogata, 1997, 1998; Verheyden et al., 2006). These trunk impairments have also been shown to have significant negative associations with measures of whole body performance of balance, gait and functional ability, suggesting that trunk performance is an important predictor of functional recovery and outcome after stroke with improved trunk performance associated with better functional recovery (Duarte et al., 2002; Ezure et al., 2010; Franchignoni, Tesio, Ricupero, & Martino, 1997; Hsieh, Sheu, Hsueh, & Wang, 2002; Verheyden et al., 2007). Thus rehabilitation programmes that incorporate specific trunk exercises alongside conventional rehabilitation, with
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the aim of improving overall functional recovery after stroke may be beneficial. However, there is limited evidence of the efficacy of additional specific trunk exercises on functional recovery after stroke. The available studies investigating the effects of trunk exercises on functional recovery post stroke recruited small sample sizes making the evidence from these early studies limited. In addition, the studies used different trunk training strategies that may have varying effects on the observed outcomes. Thus the impact of additional trunk exercises on important rehabilitation outcomes such as balance, mobility and functional independence is unclear. Therefore the aim of this systematic review is to examine the evidence from randomised controlled trials (RCTs) to establish the efficacy of additional trunk exercise on trunk function, as well as important rehabilitation outcomes such as balance, walking ability and functional independence early after stroke.
vivors of ischemic or haemorrhagic stroke within the first three months of stroke; 3) including specific trunk exercises in lying and sitting or other specific interventions such as sitting balance training, weight shifting in sitting and arm reaching in sitting) in addition to a conventional rehabilitation programme; 4) including a control group receiving conventional rehabilitation; 5) utilising at least one validated outcome measure of either functional independence, balance, mobility or trunk performance. 2.3. Methodological quality Included studies were assessed for methodological quality (internal validity) by two authors (IP & IS) independently, using the PEDro scale based on the Delphi Criteria List (Verhagen et al., 1998), and the Cochrane Risk of bias tool. 2.4. Data extraction and analysis
2. Methods This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (www.prismastatement.org) (Moher, Liberati, Tetzlaff, & Altman, 2010) and the Cochrane Handbook for Systematic Reviews. 2.1. Literature search methods Electronic searches were conducted in the following databases: Medline, Cinahl (Cumulative Index to Nursing and Allied Health Literature), Embase, Pubmed, PEDro (Physiotherapy Evidence Database), Web of Science and Scopus with no temporary limits up to July 2012. The following key words and search terms were employed using free text and subject heading searches: stroke, stroke patient, trunk exercise, truncal exercise, sitting balance, dynamic reaching, trunk control, activities of daily living, balance and function. A further manual search of reference lists of retrieved studies and citation tracking was conducted to identify additional articles. 2.2. Eligible studies Reports of studies meeting the following inclusion criteria were identified: 1) randomised controlled trials (RCTs) published in English; 2) involving adult sur-
This was completed independently by two authors and disagreements resolved via discussion. Data was extracted from each study using a standardised form detailing: authors, year, setting, phase, study design, number of participants (experimental/control group), mean age, interventions for both experimental and control groups (type, progression and duration), outcome measures (mean and standard deviations (SDs) of baseline and post measures at all measured time points). Where more than one standardised validated measure of the primary outcome of trunk performance and all secondary outcomes were used in each study, the outcome with the largest effect size for that outcome was selected for use in this review. This was premised on the fact that achieving a larger effect is the aim of post stroke rehabilitation, therefore choosing the outcome with the biggest effect size better reflects this. Treatment effect sizes were calculated as either mean or standardised mean differences (SMD) with 95% Confidence Intervals (CI), depending on whether study outcomes were measured using the same or different but similar instruments. A random effects model was adopted as some heterogeneity of effect is likely due to the complex nature of the interventions (Higgins, Thompson, & Spiegelhalter, 2009). Post-test scores were used to determine the MD/SMD. The Review Manager 5.1 software was used for all analysis. Overall effect size (SMD or MD) for each outcome measure was categorised according to the Cochrane Handbook for Systematic Reviews as fol-
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Fig. 1. Flowchart of study selection.
lows: less than 0.41 = small, 0.40 to 0.70 = moderate, greater than 0.70 = large. The critical level of significance was set at p = 0.05. Heterogeneity was assessed by calculating I² values and their associated significance. Where heterogeneity was substantial and significant, this was explored systematically in a sensitivity analysis.
3. Results A summary of the search procedure is presented in Fig. 1. A total of 173 studies were found, of these,
154 studies were excluded after reviewing titles and abstracts because they did not meet the inclusion criteria. Full copies of the remaining 19 studies were obtained and reviewed independently by two of the authors (IS, IP) and as a result a further 13 studies were excluded leaving six studies, which were included in the meta-analyses (De S`eze et al., 2001; Dean, Channon, & Hall, 2007; Howe, Taylor, Finn, & Jones, 2005; Saeys et al., 2012; Verheyden et al., 2009; Wiart et al., 1997). The sample size of selected studies ranged from 12 to 35 participants totalling 155 participants (68 females and 87 males). All participants were in the early poststroke phase with mean days post stroke ranging from
12 (6, 6)
Dean et al.
Saeys et al.
Verheyden et al.
35 (17, 18) Exp: 26.5 (15.7) Exp: 71.5 (10.9) Con: 23.1 (17.5) Con: 70.7 (7.6)
Howe et al.
Exp: 60.0 (7) Con: 74.0 (12)
Exp: 63.5 (17) Con: 67.7 (15)
Outcome measures
Ten, 30 minutes daily sessions for 2 weeks (5 hours), in addition to conventional therapy
TIS (Total) Tinetti Scale (Balance) FAC
TIS (Total)
Max reach forward (m) Walking speed during 10 m walk
1 hour daily sessions for 1 Upright equilibrium month (20 hours), in Index Trunk addition to 1 hour Control Test FAC conventional therapy FIM 1 hour sessions, 3 times a Lateral reach (% max week for over 4 weeks weight (6 hours), plus displacement) conventional therapy
1 hour daily sessions for 1 FIM month (20 hours), in addition to 2 hours of conventional therapy
Duration of experimental intervention
33 (17, 16) Exp: 53.0 (24.0) Exp: 55.0 (11.0) 5 weeks of 30 minutes Con: 49.0 (28.0) Con: 62.0 (14.0) supervised individual trunk exercises, four times a week (10 hours), plus conventional therapy. 33 (17, 16) Exp: 38.7 (15.1) Exp: 61.9 (13.8) 8 weeks of 30 minutes Con: 32.1 (25.9) Con: 61.1 (9.0) supervised individual trunk exercises, four times a week (16 hours), plus conventional therapy.
Exp: 21.0 (8) Con: 37.0 (23)
20 (10, 10) Exp: 36.8 (25) Con: 27.7 (15)
DeSeze et al.
Exp: 66.0 (8.0) Con: 72.0 (6.0)
22 (11, 11) Exp: 35.0 (9.0) Con: 30.0 (4.0)
Wiart et al.
Age (years) Mean (SD)
Sample size Time since stroke (Exp, Con) (days) mean (SD)
Author, year
Supervised, individual trunk training to improve trunk function (trunk flex/ext, lat flex, rotation, shuffling)
Conventional physical and occupational therapy +16 hours upper limb ex (30 min, 4 times weekly for 8 weeks). Upper limb exs: passive mobilisation and Transcutaneous Electrical Nervous Stimulation to hemiplegic shoulder.
Conventional therapy only
Conventional therapy +2 weeks sham reaching program 10 × 30 min sessions: cognitive manipulative tasks seated at a table (minimum balance perturbation).
Conventional therapy only.
Conventional neuro-rehabilitation for 2 hours daily
Conventional neuro-rehabilitation for same period
Interventions Control
Experimental protocol consisted of contacting targets with pointer suspended above head using trunk rotation Experimental protocol consisted of contacting targets with pointer suspended above head Additional sessions aimed at improving lateral weight transference in sitting and standing involving repetition of self- initiated goal orientated activities in various postures. Reaching program designed to improve sitting balance and emphasise loading of affected leg while reaching with unaffected arm to objects outside of arms reach. Distance, direction, seat height, object weight, movement speed and complexity of task progressed. Individual and supervised trunk exercises (trunk flex/ext, lat flex, rotation, shuffling).
Experimental
Table 1 Summary of studies: Exp: experimental, Con: control, FIM: Functional independence measure, TIS: Trunk Impairment Scale, FAC: Functional ambulation categories
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Table 2 √ Summary of PEDro criteria for included studies. ✕ and imply no and yes respectively Random allocation Concealment of allocation Comparability of groups at baseline Blinding of patients Blinding of therapists Blinding of assessors Adequate follow up Intention to treat analysis Between group statistical comparison Reports of point estimates and measures of variability PEDro score/10
Wiart et al. 1997 DeSeze et al. Howe et al. Dean et al. 2007 Verheyden et al. Saeys et al. √ √ √ √ √ √ √ √ √ ✕ ✕ ✕ √ √ √ √ √
✕ ✕ ✕ √
✕ ✕ ✕ √
✕ ✕ √
✕ ✕ √
√ √ √
✕ √
✕ √ √
√ √ √ √
6
6
7
7
√
√
√
✕ ✕ √
✕ ✕ √
✕ √
✕ √
6
7
√
√
√
√
Table 3 Summary of the risk of bias in individual studies Study
Random sequence generation
Allocation concealment
Blinding of participants
Blinding of outcome assessment
Incomplete outcome data
Selective reporting
Other bias
Overall risk of bias
Wiart et al. 1997 DeSeze et al. 2001 Howe et al. 2005 Dean et al. 2007 Verheyden et al. 2009 Saeys et al. 2011
low risk low risk low risk low risk unclear low risk
high risk high risk low risk low risk high risk low risk
high risk high risk low risk high risk high risk unclear
high risk low risk low risk low risk low risk low risk
low risk low risk low risk low risk low risk low risk
low risk low risk low risk low risk low risk low risk
low risk low risk high risk high risk high risk low risk
High Mod Low Mod High Low
12.1 to 53 days. The mean age of participants ranged from 55 to 72 years. A range of trunk training strategies were applied in addition to conventional rehabilitation, such as specific trunk exercises, (Saeys et al., 2012; Verheyden et al., 2009) reaching practice, (Dean et al., 2007) rotation practice using a fitted trunk frame (Bon Saint Come frame) (De S`eze et al., 2001; Wiart et al., 1997) and weight transference practice in sitting and standing (Howe et al., 2005). The details of each exercise regime in the included studies are presented in Table 1. Exercise sessions were delivered by qualified physiotherapists in rehabilitation centres or hospital settings. Trunk performance was assessed in 5 studies using the Trunk Impairment Scale (TIS), (Saeys et al., 2012; Verheyden et al., 2009) Trunk Control Test; (TST) (De S`eze et al., 2001), Forward Reach Test (FRT) and percentage of body weight shifted during lateral reach (Howe et al., 2005). The upright equilibrium test and Tinetti balance scale were utilised as measures of standing balance in two studies (De S`eze et al., 2001; Saeys et al., 2012) and mobility was assessed in three studies using walking velocity (De S`eze et al., 2001) and Functional Ambulation Classification (De S`eze et al., 2001; Saeys et al., 2012). Finally, functional independence was assessed in two studies using the Functional Inde-
pendence Measure; FIM (De S`eze et al., 2001; Wiart et al., 1997). Summary of the methodological quality assessments with PEDro scale and the authors’ judgement of the risk of bias of the included studies are presented in Tables 2 and 3 respectively. The 6 included studies had PEDro quality scores ranging from 6 to 7 (mean 6.5) out of 10 and risk of bias was judged to be low in two studies, moderate in two studies and high in two studies. Figure 2A shows that based on a meta-analysis from five studies (De S`eze et al., 2001; Dean et al., 2007; Howe et al., 2005; Saeys et al., 2012; Verheyden et al., 2009), a moderate effect of additional trunk exercises (SMD = 0.50; 95% CI −0.25, 1.25; P = 0.19) on global trunk performance is possible, although the confidence intervals suggest that a negative effect of additional trunk training is also possible. Significant heterogeneity was observed, (I2 = 76%, P < 0.002) and a sensitivity analysis removing studies that utilised trunk performance measures which assess a single aspect of trunk performance (maximum reach (Dean et al., 2007) and % weight shifted during reach (Howe et al., 2005)) rather than a composite measure such as TIS (Saeys et al., 2012; Verheyden et al., 2009) and TCT (De S`eze et al., 2001), was performed. However, there was no change in the effect size following this sensitivity
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Fig. 2. Forest plot of effect of additional exercises on global trunk performance compared to the control group. The plot B shows the sensitivity analysis of removing Dean et al. and Howe et al. from the meta-analysis.
Study or Subgroup
Experimental Control Std. Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI
DeSeze et al. 2001 Saeys et al. 2011
2.4 1.6 11.83 3.03
Total (95% CI)
10 18 28
2 0.8 8.13 3.87
10 15
44.5% 55.5%
0.30 [-0.58, 1.19] 1.05 [0.31, 1.79]
25 100.0%
0.72 [-0.01, 1.45]
Heterogeneity: Tau² = 0.11; Chi² = 1.63, df = 1 (P = 0.20); I² = 39% Test for overall effect: Z = 1.93 (P = 0.05)
Std. Mean Difference IV, Random, 95% CI
-4
-2 0 2 4 Favours control Favours experimental
Fig. 3. Forest plot of effect of additional exercises on standing balance compared to the control group.
Fig. 4. Forest plot of effect of additional exercises on mobility compared to the control group.
analysis; SMD = 0.58 (95% CI −0.27, 1.44; P = 0.18; I2 = 73%, P = 0.02) (Fig. 2B) and significant heterogeneity remained. Figure 3 shows the pooled effect size for the two studies (De S`eze et al., 2001; Saeys et al., 2012) with assessments of standing balance where the SMD = 0.72 (95% CI −0.01, 1.45 P = 0.05; I2 = 39% p = 0.2), indicates a large effect of additional trunk exercise on standing balance performance is possible.
Figure 4 shows the pooled effect size for the 3 studies that evaluated walking ability (De S`eze et al., 2001; Dean et al., 2007; Saeys et al., 2012) (SMD = 0.81 (95% CI 0.30, 1.33. P = 0.002; I2 = 0%)), indicating a large significant effect of the addition of trunk exercises to conventional rehabilitation on walking ability after stroke. Only two studies (De S`eze et al., 2001; Wiart et al., 1997) assessed functional independence as an outcome;
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Fig. 5. Forest plot of effect of additional exercises on Functional Independence compared to the control group.
Figure 5 shows the pooled effect size (MD = 10.03, 95% CI −15.70, 35.75. P = 0.44; I2 = 85%, P = 0.009) for FIM scores indicating that a moderate effect of additional trunk exercise is possible but the wide confidence intervals also suggest that a negative effect of additional trunk training of similar magnitude is also possible. In addition there is significant heterogeneity associated with this meta-analysis.
4. Discussion This is the first systematic review with meta-analysis evaluating the effect of incorporating additional trunk exercises in rehabilitation on recovery early after stroke. The results from a small number of mixed quality RCTs suggest a large significant effect of additional trunk exercises on standing balance and mobility. However, only moderate effects were seen for trunk performance and functional independence and the wide confidence intervals for these results mean that a negative effect of additional trunk exercises cannot be ruled out. Heterogeneity of studies included in the meta-analyses for trunk performance and functional independence as well as the inclusion of one study at high risk of bias due to lack of assessor blinding is likely to be a factor. Our findings suggest possible benefits of additional trunk exercises for patients early after stroke but further research is needed to add to this data and the impact of additional trunk exercise on health related quality of life and cost effectiveness on a long term basis should be considered. Trunk performance is significantly impaired following stroke with associated limitations in functional ability, both during early hospitalised rehabilitation and long after discharge into the community (Dickstein, Shefi, Marcovitz, & Villa, 2004b; Duarte et al., 2009). The consequence of impaired trunk performance on independence (Dickstein et al., 2004a) can be substantial and may also impact on quality of life. Whilst the results from this meta-analysis indicate that some
improvements in trunk performance with additional specific trunk training may be possible, the included studies were small and may have been underpowered to detect a significant difference. Of the five RCTs included in this meta-analysis, one was at high, two at moderate and two at low risk of bias and there was also substantial heterogeneity of reported effect sizes for each study when pooling data for meta-analysis. Factors likely to affect heterogeneity include the variations in type of additional trunk exercises and differences in the sensitivity of the outcome measures utilised in the different studies. Nevertheless a sensitivity analysis conducted to include only studies with similar types of outcome measures for trunk performance did not affect the observed levels of heterogeneity. Dosage of additional trunk exercise varied between 5hours to 20hours and two studies (Howe et al., 2005; Verheyden et al., 2009) did not match the additional dose of intervention given to the experimental subjects with additional conventional rehabilitation in the control group. Thus an over-estimation of the effect of the additional exercise compared to the control group is possible since there is evidence to indicate a dose response effect of exercise for lower limb function after stroke (Veerbeek, Koolstra, Ket, van Wegen, & Kwakkel, 2011). Despite the identified limitations of this review, recovery of balance and walking ability are important aims of rehabilitation post-stroke and it is interesting that the pooled effect size from the two small, moderate to high quality studies that assessed standing balance and the two moderate and one high quality studies that assessed walking, showed a large effect of additional trunk exercise. These effects were evident despite differences in the types of trunk exercises (trunk rotation with the Bon Saint Come frame (De S`eze et al., 2001), arm reaching exercises (Dean et al., 2007), specific trunk exercises (Saeys et al., 2012) and the outcome measures used in the included studies. This suggests a consistent effect across the included studies. Thus, it is possible that additional specific trunk exercise may
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promote trunk control resulting in earlier progression to balance and walking function training as shown here. Improved functional independence especially in the form of reduced dependence in ADLs is a key goal of rehabilitation post stroke. Only two of the included studies measured this, and a small non-significant 10 point change in FIM score was detected; this is well below the minimum clinically important difference for total FIM score of 22 identified previously (Beninato et al., 2006). This is similar to a previous systematic review (Veerbeek et al., 2011), where only a small non-significant effect of augmented exercises on activities of daily living measured by the Barthel Index, was found. Nevertheless, previous studies have found trunk performance to be a good predictor of functional independence following in-patient rehabilitation (Ezure et al., 2010; Hsieh et al., 2002; Macrohon & Suarez, 2006; Verheyden et al., 2007). Therefore it is important that future studies should include this important outcome in addition to measures such as balance and trunk performance.
5. Conclusions There is limited evidence from a small number of mixed quality RCTs to suggest that the addition of specific trunk exercises to conventional rehabilitation may facilitate improvements in standing balance and walking ability in patients early after stroke. There is insufficient evidence to evaluate the effect of additional trunk exercises on trunk performance and overall functional independence. However, most of the included studies did not evaluate this and this should be addressed in future research.
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Dean, C. M., Channon, E. F., & Hall, J. M. (2007). Sitting training early after stroke improves sitting ability and quality and carries over to standing up but not to walking: A randomised trial. Aust J Physiother, 53, 97-102. Dickstein, R., Sheffi, S., Ben Haim, Z., Shabtai, E., & Markovici, E. (2000). Activation of flexor and extensor trunk muscles in hemiparesis. American Journal of Physical Medicine & Rehabilitation, 79, 228-234. Dickstein, R., Shefi, S., Marcovitz, E., & Villa, Y. (2004a). Anticipatory postural adjustment in selected trunk muscles in poststroke hemiparetic patients. Arch Phys Med Rehabil, 85, 261-267. Dickstein, R., Shefi, S., Marcovitz, E., & Villa, Y. (2004b). Electromyographic activity of voluntarily activated trunk flexor and extensor muscles in post-stroke hemiparetic subjects. Clinical Neurophysiology, 115, 790-796. Duarte, E., Marco, E., Muniesa, J. M., Belmonte, R., Diaz, P., Tejero, M., & Escalada, F. (2002). Trunk control test as a functional predictor in stroke patients. Journal of Rehabilitation Medicine, 34, 267-272. Duarte, E., Morales, A., Pou, M., Aguirrezabal, A., Aguilar, J. J., & Escalada, F. (2009). Trunk control test: Early predictor of gait balance and capacity at 6 months of the stroke. Neurologia, 24, 297-303. Ezure, A., Harada, S., Ozawa, Y., Ogino, Y., Okuda, Y., & Uchiyama, Y. (2010). Relationship between trunk function and ADL of hemiplegic stroke patients. Rigakuryoho Kagaku, 25, 147-150. Franchignoni, F. P., Tesio, L., Ricupero, C., & Martino, M. T. (1997). Trunk control test as an early predictor of stroke rehabilitation outcome. Stroke, 28, 1382-1385. Hacmon, R. R., Krasovsky, T., Lamontagne, A., & Levin, M. F. (2012). Deficits in intersegmental trunk coordination during walking are related to clinical balance and gait function in chronic stroke. J Neurol Phys Ther, 36, 173-181. Higgins, J. P., Thompson, S. G., & Spiegelhalter, D. J. (2009). A reevaluation of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc, 172, 137-159. Howe, T. E., Taylor, I., Finn, P., & Jones, H. (2005). Lateral weight transference exercises following acute stroke: A preliminary study of clinical effectiveness. Clin Rehabil, 19, 45-53. Hsieh, C. L., Sheu, C. F., Hsueh, I. P., & Wang, C. H. (2002). Trunk control as an early predictor of comprehensive activities of daily living function in stroke patients. Stroke, 33, 2626-2630. Macrohon, J. G., & Suarez, C. G. (2006). Correlation between development of trunk control and functional improvement in stroke patients. Santo Tomas Journal of Medicine, 53, 31-36. Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2010). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Int J Surg, 8, 336-341. Saeys, W., Vereeck, L., Truijen, S., Lafosse, C., Wuyts, F. P., & Van De Heyning, P. (2012). Randomized controlled trial of truncal exercises early after stroke to improve balance and mobility. Neurorehabilitation and Neural Repair, 26, 231-238. Tanaka, S., Hachisuka, K., & Ogata, H. (1997). Trunk rotatory muscle performance in post-stroke hemiplegic patients. American Journal of Physical Medicine & Rehabilitation, 76, 366369. Tanaka, S., Hachisuka, K., & Ogata, H. (1998). Muscle strength of trunk flexion-extension in post-stroke hemiplegic patients. American Journal of Physical Medicine & Rehabilitation, 77, 288-290. Veerbeek, J. M., Koolstra, M., Ket, J. C., van Wegen, E. E., & Kwakkel, G. (2011). Effects of augmented exercise therapy on
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NeuroRehabilitation 35 (2014) 205–213 DOI:10.3233/NRE-141123 IOS Press
Does additional exercise improve trunk function recovery in stroke patients? A meta-analysis I.O. Sorinola∗ , I. Powis and C.M. White Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
Abstract. BACKGROUND: The restoration of trunk function following stroke is a key component of rehabilitation, however there is limited evidence of the efficacy of additional trunk training. OBJECTIVES: To evaluate the efficacy of trunk exercises added to conventional rehabilitation on functional outcomes. METHODS: Relevant randomised controlled trials (RCTs), published up to July 2012, evaluating the effect of the addition of trunk exercises to conventional rehabilitation on functional outcomes were identified in Medline, Cinahl, Embase, Pubmed, PEDro, Web of Science and Scopus databases. Findings were summarised across studies as mean or standardised mean differences (MD or SMD) with 95% confidence intervals. RESULTS: Six RCTs with 155 participants and a mean PEDro score of 6.5 (range 6 to 8) were included. Data from two to five studies were pooled in meta-analyses that showed a moderate, non-significant effect of additional trunk exercise on trunk performance, (SMD = 0.50; 95% CI −0.25, 1.25; P = 0.19); large effects on standing balance, SMD = 0.72 (95% CI −0.01, 1.45 P = 0.05); and walking ability, (SMD = 0.81; 95% CI 0.30, 1.33. P = 0.002) and a small, non-significant effect, MD = 10.03 (95% CI −15.70, 35.75. P = 0.44) on functional independence. CONCLUSIONS: There is moderate evidence that the addition of specific trunk exercise to conventional early stroke rehabilitation significantly improve standing balance and mobility after stroke; however the evidence was weak for the effect of additional trunk exercise on trunk performance and in functional independence. Keywords: Meta-analysis, stroke, rehabilitation, trunk exercise, functional recovery, mobility
1. Introduction Several studies have described specific impairments in trunk performance in people after stroke, including deficits in selective muscle activation, inter-segmental coordination and functional trunk performance (Bohannon, 1995; Bohannon, Cassidy, & Walsh, 1995; Dickstein, Sheffi, Ben Haim, Shabtai, & Markovici, 2000; Dickstein, Shefi, Marcovitz, & Villa, 2004a; ∗ Address
for correspondence: I.O. Sorinola, Ph.D., Rm. 3.24 Shepherd’s House, Division of Health and Social Care Research, School of Medicine, King’s College London, London SE1 1UL, UK. Tel.: +44 020 7848 8170; Fax: +44 020 7848 6325; E-mail: [email protected].
Hacmon, Krasovsky, Lamontagne, & Levin, 2012; Tanaka, Hachisuka, & Ogata, 1997, 1998; Verheyden et al., 2006). These trunk impairments have also been shown to have significant negative associations with measures of whole body performance of balance, gait and functional ability, suggesting that trunk performance is an important predictor of functional recovery and outcome after stroke with improved trunk performance associated with better functional recovery (Duarte et al., 2002; Ezure et al., 2010; Franchignoni, Tesio, Ricupero, & Martino, 1997; Hsieh, Sheu, Hsueh, & Wang, 2002; Verheyden et al., 2007). Thus rehabilitation programmes that incorporate specific trunk exercises alongside conventional rehabilitation, with
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the aim of improving overall functional recovery after stroke may be beneficial. However, there is limited evidence of the efficacy of additional specific trunk exercises on functional recovery after stroke. The available studies investigating the effects of trunk exercises on functional recovery post stroke recruited small sample sizes making the evidence from these early studies limited. In addition, the studies used different trunk training strategies that may have varying effects on the observed outcomes. Thus the impact of additional trunk exercises on important rehabilitation outcomes such as balance, mobility and functional independence is unclear. Therefore the aim of this systematic review is to examine the evidence from randomised controlled trials (RCTs) to establish the efficacy of additional trunk exercise on trunk function, as well as important rehabilitation outcomes such as balance, walking ability and functional independence early after stroke.
vivors of ischemic or haemorrhagic stroke within the first three months of stroke; 3) including specific trunk exercises in lying and sitting or other specific interventions such as sitting balance training, weight shifting in sitting and arm reaching in sitting) in addition to a conventional rehabilitation programme; 4) including a control group receiving conventional rehabilitation; 5) utilising at least one validated outcome measure of either functional independence, balance, mobility or trunk performance. 2.3. Methodological quality Included studies were assessed for methodological quality (internal validity) by two authors (IP & IS) independently, using the PEDro scale based on the Delphi Criteria List (Verhagen et al., 1998), and the Cochrane Risk of bias tool. 2.4. Data extraction and analysis
2. Methods This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (www.prismastatement.org) (Moher, Liberati, Tetzlaff, & Altman, 2010) and the Cochrane Handbook for Systematic Reviews. 2.1. Literature search methods Electronic searches were conducted in the following databases: Medline, Cinahl (Cumulative Index to Nursing and Allied Health Literature), Embase, Pubmed, PEDro (Physiotherapy Evidence Database), Web of Science and Scopus with no temporary limits up to July 2012. The following key words and search terms were employed using free text and subject heading searches: stroke, stroke patient, trunk exercise, truncal exercise, sitting balance, dynamic reaching, trunk control, activities of daily living, balance and function. A further manual search of reference lists of retrieved studies and citation tracking was conducted to identify additional articles. 2.2. Eligible studies Reports of studies meeting the following inclusion criteria were identified: 1) randomised controlled trials (RCTs) published in English; 2) involving adult sur-
This was completed independently by two authors and disagreements resolved via discussion. Data was extracted from each study using a standardised form detailing: authors, year, setting, phase, study design, number of participants (experimental/control group), mean age, interventions for both experimental and control groups (type, progression and duration), outcome measures (mean and standard deviations (SDs) of baseline and post measures at all measured time points). Where more than one standardised validated measure of the primary outcome of trunk performance and all secondary outcomes were used in each study, the outcome with the largest effect size for that outcome was selected for use in this review. This was premised on the fact that achieving a larger effect is the aim of post stroke rehabilitation, therefore choosing the outcome with the biggest effect size better reflects this. Treatment effect sizes were calculated as either mean or standardised mean differences (SMD) with 95% Confidence Intervals (CI), depending on whether study outcomes were measured using the same or different but similar instruments. A random effects model was adopted as some heterogeneity of effect is likely due to the complex nature of the interventions (Higgins, Thompson, & Spiegelhalter, 2009). Post-test scores were used to determine the MD/SMD. The Review Manager 5.1 software was used for all analysis. Overall effect size (SMD or MD) for each outcome measure was categorised according to the Cochrane Handbook for Systematic Reviews as fol-
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Fig. 1. Flowchart of study selection.
lows: less than 0.41 = small, 0.40 to 0.70 = moderate, greater than 0.70 = large. The critical level of significance was set at p = 0.05. Heterogeneity was assessed by calculating I² values and their associated significance. Where heterogeneity was substantial and significant, this was explored systematically in a sensitivity analysis.
3. Results A summary of the search procedure is presented in Fig. 1. A total of 173 studies were found, of these,
154 studies were excluded after reviewing titles and abstracts because they did not meet the inclusion criteria. Full copies of the remaining 19 studies were obtained and reviewed independently by two of the authors (IS, IP) and as a result a further 13 studies were excluded leaving six studies, which were included in the meta-analyses (De S`eze et al., 2001; Dean, Channon, & Hall, 2007; Howe, Taylor, Finn, & Jones, 2005; Saeys et al., 2012; Verheyden et al., 2009; Wiart et al., 1997). The sample size of selected studies ranged from 12 to 35 participants totalling 155 participants (68 females and 87 males). All participants were in the early poststroke phase with mean days post stroke ranging from
12 (6, 6)
Dean et al.
Saeys et al.
Verheyden et al.
35 (17, 18) Exp: 26.5 (15.7) Exp: 71.5 (10.9) Con: 23.1 (17.5) Con: 70.7 (7.6)
Howe et al.
Exp: 60.0 (7) Con: 74.0 (12)
Exp: 63.5 (17) Con: 67.7 (15)
Outcome measures
Ten, 30 minutes daily sessions for 2 weeks (5 hours), in addition to conventional therapy
TIS (Total) Tinetti Scale (Balance) FAC
TIS (Total)
Max reach forward (m) Walking speed during 10 m walk
1 hour daily sessions for 1 Upright equilibrium month (20 hours), in Index Trunk addition to 1 hour Control Test FAC conventional therapy FIM 1 hour sessions, 3 times a Lateral reach (% max week for over 4 weeks weight (6 hours), plus displacement) conventional therapy
1 hour daily sessions for 1 FIM month (20 hours), in addition to 2 hours of conventional therapy
Duration of experimental intervention
33 (17, 16) Exp: 53.0 (24.0) Exp: 55.0 (11.0) 5 weeks of 30 minutes Con: 49.0 (28.0) Con: 62.0 (14.0) supervised individual trunk exercises, four times a week (10 hours), plus conventional therapy. 33 (17, 16) Exp: 38.7 (15.1) Exp: 61.9 (13.8) 8 weeks of 30 minutes Con: 32.1 (25.9) Con: 61.1 (9.0) supervised individual trunk exercises, four times a week (16 hours), plus conventional therapy.
Exp: 21.0 (8) Con: 37.0 (23)
20 (10, 10) Exp: 36.8 (25) Con: 27.7 (15)
DeSeze et al.
Exp: 66.0 (8.0) Con: 72.0 (6.0)
22 (11, 11) Exp: 35.0 (9.0) Con: 30.0 (4.0)
Wiart et al.
Age (years) Mean (SD)
Sample size Time since stroke (Exp, Con) (days) mean (SD)
Author, year
Supervised, individual trunk training to improve trunk function (trunk flex/ext, lat flex, rotation, shuffling)
Conventional physical and occupational therapy +16 hours upper limb ex (30 min, 4 times weekly for 8 weeks). Upper limb exs: passive mobilisation and Transcutaneous Electrical Nervous Stimulation to hemiplegic shoulder.
Conventional therapy only
Conventional therapy +2 weeks sham reaching program 10 × 30 min sessions: cognitive manipulative tasks seated at a table (minimum balance perturbation).
Conventional therapy only.
Conventional neuro-rehabilitation for 2 hours daily
Conventional neuro-rehabilitation for same period
Interventions Control
Experimental protocol consisted of contacting targets with pointer suspended above head using trunk rotation Experimental protocol consisted of contacting targets with pointer suspended above head Additional sessions aimed at improving lateral weight transference in sitting and standing involving repetition of self- initiated goal orientated activities in various postures. Reaching program designed to improve sitting balance and emphasise loading of affected leg while reaching with unaffected arm to objects outside of arms reach. Distance, direction, seat height, object weight, movement speed and complexity of task progressed. Individual and supervised trunk exercises (trunk flex/ext, lat flex, rotation, shuffling).
Experimental
Table 1 Summary of studies: Exp: experimental, Con: control, FIM: Functional independence measure, TIS: Trunk Impairment Scale, FAC: Functional ambulation categories
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Table 2 √ Summary of PEDro criteria for included studies. ✕ and imply no and yes respectively Random allocation Concealment of allocation Comparability of groups at baseline Blinding of patients Blinding of therapists Blinding of assessors Adequate follow up Intention to treat analysis Between group statistical comparison Reports of point estimates and measures of variability PEDro score/10
Wiart et al. 1997 DeSeze et al. Howe et al. Dean et al. 2007 Verheyden et al. Saeys et al. √ √ √ √ √ √ √ √ √ ✕ ✕ ✕ √ √ √ √ √
✕ ✕ ✕ √
✕ ✕ ✕ √
✕ ✕ √
✕ ✕ √
√ √ √
✕ √
✕ √ √
√ √ √ √
6
6
7
7
√
√
√
✕ ✕ √
✕ ✕ √
✕ √
✕ √
6
7
√
√
√
√
Table 3 Summary of the risk of bias in individual studies Study
Random sequence generation
Allocation concealment
Blinding of participants
Blinding of outcome assessment
Incomplete outcome data
Selective reporting
Other bias
Overall risk of bias
Wiart et al. 1997 DeSeze et al. 2001 Howe et al. 2005 Dean et al. 2007 Verheyden et al. 2009 Saeys et al. 2011
low risk low risk low risk low risk unclear low risk
high risk high risk low risk low risk high risk low risk
high risk high risk low risk high risk high risk unclear
high risk low risk low risk low risk low risk low risk
low risk low risk low risk low risk low risk low risk
low risk low risk low risk low risk low risk low risk
low risk low risk high risk high risk high risk low risk
High Mod Low Mod High Low
12.1 to 53 days. The mean age of participants ranged from 55 to 72 years. A range of trunk training strategies were applied in addition to conventional rehabilitation, such as specific trunk exercises, (Saeys et al., 2012; Verheyden et al., 2009) reaching practice, (Dean et al., 2007) rotation practice using a fitted trunk frame (Bon Saint Come frame) (De S`eze et al., 2001; Wiart et al., 1997) and weight transference practice in sitting and standing (Howe et al., 2005). The details of each exercise regime in the included studies are presented in Table 1. Exercise sessions were delivered by qualified physiotherapists in rehabilitation centres or hospital settings. Trunk performance was assessed in 5 studies using the Trunk Impairment Scale (TIS), (Saeys et al., 2012; Verheyden et al., 2009) Trunk Control Test; (TST) (De S`eze et al., 2001), Forward Reach Test (FRT) and percentage of body weight shifted during lateral reach (Howe et al., 2005). The upright equilibrium test and Tinetti balance scale were utilised as measures of standing balance in two studies (De S`eze et al., 2001; Saeys et al., 2012) and mobility was assessed in three studies using walking velocity (De S`eze et al., 2001) and Functional Ambulation Classification (De S`eze et al., 2001; Saeys et al., 2012). Finally, functional independence was assessed in two studies using the Functional Inde-
pendence Measure; FIM (De S`eze et al., 2001; Wiart et al., 1997). Summary of the methodological quality assessments with PEDro scale and the authors’ judgement of the risk of bias of the included studies are presented in Tables 2 and 3 respectively. The 6 included studies had PEDro quality scores ranging from 6 to 7 (mean 6.5) out of 10 and risk of bias was judged to be low in two studies, moderate in two studies and high in two studies. Figure 2A shows that based on a meta-analysis from five studies (De S`eze et al., 2001; Dean et al., 2007; Howe et al., 2005; Saeys et al., 2012; Verheyden et al., 2009), a moderate effect of additional trunk exercises (SMD = 0.50; 95% CI −0.25, 1.25; P = 0.19) on global trunk performance is possible, although the confidence intervals suggest that a negative effect of additional trunk training is also possible. Significant heterogeneity was observed, (I2 = 76%, P < 0.002) and a sensitivity analysis removing studies that utilised trunk performance measures which assess a single aspect of trunk performance (maximum reach (Dean et al., 2007) and % weight shifted during reach (Howe et al., 2005)) rather than a composite measure such as TIS (Saeys et al., 2012; Verheyden et al., 2009) and TCT (De S`eze et al., 2001), was performed. However, there was no change in the effect size following this sensitivity
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Fig. 2. Forest plot of effect of additional exercises on global trunk performance compared to the control group. The plot B shows the sensitivity analysis of removing Dean et al. and Howe et al. from the meta-analysis.
Study or Subgroup
Experimental Control Std. Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI
DeSeze et al. 2001 Saeys et al. 2011
2.4 1.6 11.83 3.03
Total (95% CI)
10 18 28
2 0.8 8.13 3.87
10 15
44.5% 55.5%
0.30 [-0.58, 1.19] 1.05 [0.31, 1.79]
25 100.0%
0.72 [-0.01, 1.45]
Heterogeneity: Tau² = 0.11; Chi² = 1.63, df = 1 (P = 0.20); I² = 39% Test for overall effect: Z = 1.93 (P = 0.05)
Std. Mean Difference IV, Random, 95% CI
-4
-2 0 2 4 Favours control Favours experimental
Fig. 3. Forest plot of effect of additional exercises on standing balance compared to the control group.
Fig. 4. Forest plot of effect of additional exercises on mobility compared to the control group.
analysis; SMD = 0.58 (95% CI −0.27, 1.44; P = 0.18; I2 = 73%, P = 0.02) (Fig. 2B) and significant heterogeneity remained. Figure 3 shows the pooled effect size for the two studies (De S`eze et al., 2001; Saeys et al., 2012) with assessments of standing balance where the SMD = 0.72 (95% CI −0.01, 1.45 P = 0.05; I2 = 39% p = 0.2), indicates a large effect of additional trunk exercise on standing balance performance is possible.
Figure 4 shows the pooled effect size for the 3 studies that evaluated walking ability (De S`eze et al., 2001; Dean et al., 2007; Saeys et al., 2012) (SMD = 0.81 (95% CI 0.30, 1.33. P = 0.002; I2 = 0%)), indicating a large significant effect of the addition of trunk exercises to conventional rehabilitation on walking ability after stroke. Only two studies (De S`eze et al., 2001; Wiart et al., 1997) assessed functional independence as an outcome;
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Fig. 5. Forest plot of effect of additional exercises on Functional Independence compared to the control group.
Figure 5 shows the pooled effect size (MD = 10.03, 95% CI −15.70, 35.75. P = 0.44; I2 = 85%, P = 0.009) for FIM scores indicating that a moderate effect of additional trunk exercise is possible but the wide confidence intervals also suggest that a negative effect of additional trunk training of similar magnitude is also possible. In addition there is significant heterogeneity associated with this meta-analysis.
4. Discussion This is the first systematic review with meta-analysis evaluating the effect of incorporating additional trunk exercises in rehabilitation on recovery early after stroke. The results from a small number of mixed quality RCTs suggest a large significant effect of additional trunk exercises on standing balance and mobility. However, only moderate effects were seen for trunk performance and functional independence and the wide confidence intervals for these results mean that a negative effect of additional trunk exercises cannot be ruled out. Heterogeneity of studies included in the meta-analyses for trunk performance and functional independence as well as the inclusion of one study at high risk of bias due to lack of assessor blinding is likely to be a factor. Our findings suggest possible benefits of additional trunk exercises for patients early after stroke but further research is needed to add to this data and the impact of additional trunk exercise on health related quality of life and cost effectiveness on a long term basis should be considered. Trunk performance is significantly impaired following stroke with associated limitations in functional ability, both during early hospitalised rehabilitation and long after discharge into the community (Dickstein, Shefi, Marcovitz, & Villa, 2004b; Duarte et al., 2009). The consequence of impaired trunk performance on independence (Dickstein et al., 2004a) can be substantial and may also impact on quality of life. Whilst the results from this meta-analysis indicate that some
improvements in trunk performance with additional specific trunk training may be possible, the included studies were small and may have been underpowered to detect a significant difference. Of the five RCTs included in this meta-analysis, one was at high, two at moderate and two at low risk of bias and there was also substantial heterogeneity of reported effect sizes for each study when pooling data for meta-analysis. Factors likely to affect heterogeneity include the variations in type of additional trunk exercises and differences in the sensitivity of the outcome measures utilised in the different studies. Nevertheless a sensitivity analysis conducted to include only studies with similar types of outcome measures for trunk performance did not affect the observed levels of heterogeneity. Dosage of additional trunk exercise varied between 5hours to 20hours and two studies (Howe et al., 2005; Verheyden et al., 2009) did not match the additional dose of intervention given to the experimental subjects with additional conventional rehabilitation in the control group. Thus an over-estimation of the effect of the additional exercise compared to the control group is possible since there is evidence to indicate a dose response effect of exercise for lower limb function after stroke (Veerbeek, Koolstra, Ket, van Wegen, & Kwakkel, 2011). Despite the identified limitations of this review, recovery of balance and walking ability are important aims of rehabilitation post-stroke and it is interesting that the pooled effect size from the two small, moderate to high quality studies that assessed standing balance and the two moderate and one high quality studies that assessed walking, showed a large effect of additional trunk exercise. These effects were evident despite differences in the types of trunk exercises (trunk rotation with the Bon Saint Come frame (De S`eze et al., 2001), arm reaching exercises (Dean et al., 2007), specific trunk exercises (Saeys et al., 2012) and the outcome measures used in the included studies. This suggests a consistent effect across the included studies. Thus, it is possible that additional specific trunk exercise may
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promote trunk control resulting in earlier progression to balance and walking function training as shown here. Improved functional independence especially in the form of reduced dependence in ADLs is a key goal of rehabilitation post stroke. Only two of the included studies measured this, and a small non-significant 10 point change in FIM score was detected; this is well below the minimum clinically important difference for total FIM score of 22 identified previously (Beninato et al., 2006). This is similar to a previous systematic review (Veerbeek et al., 2011), where only a small non-significant effect of augmented exercises on activities of daily living measured by the Barthel Index, was found. Nevertheless, previous studies have found trunk performance to be a good predictor of functional independence following in-patient rehabilitation (Ezure et al., 2010; Hsieh et al., 2002; Macrohon & Suarez, 2006; Verheyden et al., 2007). Therefore it is important that future studies should include this important outcome in addition to measures such as balance and trunk performance.
5. Conclusions There is limited evidence from a small number of mixed quality RCTs to suggest that the addition of specific trunk exercises to conventional rehabilitation may facilitate improvements in standing balance and walking ability in patients early after stroke. There is insufficient evidence to evaluate the effect of additional trunk exercises on trunk performance and overall functional independence. However, most of the included studies did not evaluate this and this should be addressed in future research.
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