Geert Verheyden

The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke

Objective: To examine the clinimetric characteristics of the Trunk Impairment Scale (TIS). This newly developed scale evaluates motor impairment of the trunk after stroke. The TIS scores, on a range from 0 to 23, static and dynamic sitting balance as well as trunk co-ordination. It also aims to score the quality of trunk movement and to be a guide for treatment. Design: Two physiotherapists observed each patient simultaneously, but scored independently. Each patient was re-examined by one of the therapists. Subjects: Twenty-eight patients in a rehabilitation setting. Results: Kappa and weighted kappa values for item per item reliability ranged for all but two, from 0.62 to 1. All percentages of agreement exceeded 81%. Intraclass correlations (ICC) for the summed scores of the different subscales were between 0.85 and 0.99. Test–retest and interobserver reliability for the TIS total score (ICC) was 0.96 and 0.99, respectively. The 95% limits of agreement for the test–retest and interexaminer measurement error were -2.90, 3.68 and -1.84, 1.84, respectively. Cronbach alpha coefficients for internal consistency ranged from 0.65 to 0.89. Content validity was defined. Spearman rank correlations with the Barthel Index (r5=0.86) and the Trunk Control Test (r5=0.83) was used to examine construct and concurrent validity, respectively. Conclusions: Analysis of different clinimetric parameters support the use of the TIS in both clinical use and future stroke research. Guidelines for treatment and level of quality of trunk activity can be derived from the assessment.

Trunk performance after stroke and the relationship with balance, gait and functional ability

Objective: To evaluate trunk performance in non-acute and chronic stroke patients by means of the Trunk Control Test and Trunk Impairment Scale and to compare the Trunk Control Test with the Trunk Impairment Scale and its subscales in relation to balance, gait and functional ability after stroke. Subjects: Fifty-one stroke patients, attending a rehabilitation programme, participated in the study. Main measures: Subjects were evaluated with the Trunk Control Test, Trunk Impairment Scale, Tinetti balance and gait subscales, Functional Ambulation Category, 10-m walk test, Timed Up and Go Test and motor part of the Functional Independence Measure. Results: Participants obtained a median score of 61 out of 100 on the Trunk Control Test and 11 out of 23 for the Trunk Impairment Scale. Twelve participants (24%) obtained the maximum score on the Trunk Control Test; no subject reached the maximum score on the Trunk Impairment Scale. Measures of trunk performance were significantly related with values of balance, gait and functional ability. Multivariate linear regression analysis showed an additional, significant contribution of the dynamic sitting balance subscale of the Trunk Impairment Scale in addition to the Trunk Control Test total score for measures of gait and functional ability (model R2 = 0.55-0.62). Conclusions: This study clearly indicates that trunk performance is still impaired in non-acute and chronic stroke patients. When planning future follow-up studies, use of the Trunk Impairment Scale has the advantage that it has no ceiling effect.

Time course of trunk, arm, leg, and functional recovery after ischemic stroke

Background. Patterns of recovery provide useful information concerning the potential of physical recovery over time and therefore the setting of realistic goals for rehabilitation programs. Objective. To compare the time course of trunk recovery with the patterns of recovery of arm, leg, and functional ability. Methods . Consecutive stroke patients were recruited in 2 acute neurology wards. Participants were evaluated at 1 week, 1 month, and 3 and 6 months after stroke. Patients were assessed with the Trunk Impairment Scale, Fugl-Meyer arm and leg test, and Barthel Index. Results. Thirty-two patients were included in the study. There were no dropouts. Repeated measures analysis of the recovery patterns of motor and functional performance revealed the most striking improvement for all measures from 1 week to 1 month (P value between .0021 and <.0001) and a significant improvement from 1 month to 3 months after stroke (P value ranges from .0008 to <.0001). No significant improvement was found between 3 and 6 months after stroke for any of the measures. Statistical analysis revealed no significant difference between time course of trunk, arm, leg, and functional recovery (P = .2565). No significant differences in level of motor and functional recovery were found at the different time points. Conclusions. Separate analyses of motor and functional recovery patterns after stroke confirm the importance of the first month for recovery. Contrary to common belief, the time course of recovery of the trunk is similar to the recovery of arm, leg, and functional ability.

Trunk performance after stroke: an eye catching predictor of functional outcome

Background and aim: Trunk performance is an important predictor of functional outcome after stroke. However, the percentage of explained variance varies considerably between studies. This may be explained by the stroke population examined, the different scales used to assess trunk performance and the time points used to measure outcome. The aim of this multicentre study was to examine the predictive validity of the Trunk Impairment Scale (TIS) and its subscales when predicting the Barthel Index score at 6 months after stroke. Methods: A total of 102 subjects were recruited in three European rehabilitation centres. Participants were assessed on admission (median time since stroke onset 20 days) and 6 months after stroke. Correlation analysis and forward stepwise multiple regression analysis were used to model outcome. Results: The best predictors of the Barthel Index scores at 6 months after stroke were total TIS score (partial R2 = 0.52, p<.0001) and static sitting balance subscale score (partial R2 = 0.50, p<.0001) on admission. The TIS score on admission and its static sitting balance subscale were stronger predictors of the Barthel Index score at 6 months than the Barthel Index score itself on admission. Conclusions: This study emphasises the importance of trunk performance, especially static sitting balance, when predicting functional outcome after stroke. The TIS is recommended as a prediction instrument in the rehabilitation setting when considering the prognosis of stroke patients. Future studies should address the evolution of trunk performance over time and the evaluation of treatment interventions to improve trunk performance.

Additional Exercises Improve Trunk Performance After Stroke: A Pilot Randomized Controlled Trial:

Background. Sitting balance and the ability to perform selective trunk movements are important predictors of functional outcome after stroke. However, studies evaluating the effect of exercises aimed at improving trunk performance are sparse. Objective. To examine the effect of additional trunk exercises on trunk performance after stroke. Methods. An assessor-blinded randomized controlled trial was carried out at an inpatient stroke rehabilitation center. In total 33 participants were assigned to an experimental group (n = 17) or a control group (n = 16). In addition to conventional therapy, the experimental group received 10 hours of individual and supervised trunk exercises; 30 minutes, 4 times a week, for 5 weeks. Trunk performance was evaluated by the Trunk Impairment Scale (TIS) and its subscales of static and dynamic sitting balance and coordination. A general linear repeated measures model was used to analyze the results of our study. Results. No significant differences were found pretreatment between the 2 groups for the collected demographic variables, stroke-related parameters, clinical measures, number of therapy sessions received, and primary outcome measure used. Posttreatment, a significantly better improvement was noted in the experimental group compared to the control group for the dynamic sitting balance subscale only; measuring selective lateral flexion initiated from the upper and lower part of the trunk, (P = .002, post hoc power calculation = .90, effect size = 1.16). Conclusions. Our results suggest that, in addition to conventional therapy, trunk exercises aimed at improving sitting balance and selective trunk movements have a beneficial effect on the selective performance of lateral flexion of the trunk after stroke.

A clinical tool to measure trunk control in children with cerebral palsy: the Trunk Control Measurement Scale.

In this study the psychometric properties of the Trunk Control Measurement Scale (TCMS) in children with cerebral palsy (CP) were examined. Twenty-six children with spastic CP (mean age 11 years 3 months, range 8-15 years; Gross Motor Function Classification System level I n = 11, level II n = 5, level III n = 10) were included in this study. To determine the discriminant ability of the TCMS, 30 typically developing (TD) children (mean age 10 years 6 months, range 8-15 years) were also included. For inter-rater reliability, two testers scored all children simultaneously. To determine test-retest reliability, participants were reassessed on a second test occasion. For construct validity, the Gross Motor Function Measure (GMFM) was administered. Intraclass correlation coefficients (ICC) ranged from 0.91 to 0.99 for inter-rater and test-retest reliability. Kappa and weighted kappa values ranged for all but one item from 0.45 to 1. The standard error of measurement was 2.9% and 3.4%, and the smallest detectable difference for repeated measurements was 8% and 9.43% between raters and test-retest, respectively. Cronbachs alpha coefficients ranged from 0.82 to 0.94. Spearman rank correlation with the GMFM was 0.88 and increasing coefficients were found from dimension B to E. Subscale and total TCMS scores showed significant differences between children with CP and TD children (p < 0.0001). The results support the reliability and validity of the TCMS in children with spastic CP. The scale gives insight into the strengths and weaknesses of the childs trunk performance and therefore can have valuable clinical use.

How Do Somatosensory Deficits in the Arm and Hand Relate to Upper Limb Impairment, Activity, and Participation Problems After Stroke? A Systematic Review

Background The association between somatosensory impairments and outcome after stroke remains unclear. Purpose The aim of this study was to systematically review the available literature on the relationship between somatosensory impairments in the upper limb and outcome after stroke. Data Sources The electronic databases PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, and Web of Science were systematically searched from inception until July 2013. Study Selection Studies were included if adult patients with stroke (minimum n=10) were examined with reliable and valid measures of somatosensation in the upper limb to investigate the relationship with upper limb impairment, activity, and participation measures. Exclusion criteria included measures of somatosensation involving an overall score for upper and lower limb outcome and articles including only lower limb outcomes. Data Extraction Eligibility assessment, data extraction, and quality evaluation were completed by 2 independent reviewers. A cutoff score of ≥65% of the maximal quality score was used for further inclusion in this review. Data Synthesis Six articles met all inclusion criteria. Two-point discrimination was shown to be predictive for upper limb dexterity, and somatosensory evoked potentials were shown to have predictive value in upper limb motor recovery. Proprioception was significantly correlated with perceived level of physical activity and social isolation and had some predictive value in functional movements of the upper limb. Finally, the combination of light touch and proprioception impairment was shown to be significantly related to upper limb motor recovery as well as handicap situations during activities of daily living. Limitations Heterogeneity of the included studies warrants caution when interpreting results. Conclusions Large variation in results was found due to heterogeneity of the studies. However, somatosensory deficits were shown to have an important role in upper limb motor and functional performance after stroke.

Discriminant ability of the Trunk Impairment Scale: A comparison between stroke patients and healthy individuals

Purpose. The Trunk Impairment Scale (TIS) is a standardized scale to evaluate the trunk function in stroke patients. It was the aim of this study to determine the discriminant ability of the TIS by comparing stroke patients with healthy individuals. Further, the variables that had an influence on obtaining a high score on the TIS in healthy subjects were examined. Method. Forty stroke patients and 40 age- and sex-matched healthy individuals were included in the study. TIS scores from the stroke patients and healthy individuals were compared using the Wilcoxon ranked sum test. Results. Sub-scale and total TIS scores showed significant differences between stroke patients and healthy individuals (P < 0.0001). Univariate analysis and logistic regression analysis further revealed that younger persons, women and people who are more active in daily life have a higher chance of obtaining a high score on the TIS. Conclusions. The TIS discriminates between stroke patients and healthy individuals. A submaximal score on the TIS was found in 45% of the healthy subjects suggesting that a lower score on the TIS still indicates normal trunk function and full participation in daily life.

Clinical characteristics of impaired trunk control in children with spastic cerebral palsy.

This study aimed to identify clinical characteristics of impaired trunk control in hundred children with spastic CP (mean age 11.4 ± 2.1 years, range 8-15 years). Assessment of trunk control was performed with the Trunk Control Measurement Scale (TCMS). Trunk control was clearly impaired, indicated by a median total TCMS score of 38.5 out of 58 (66%). Median subscale scores were 18 out of 20 (90%) for the subscale static sitting balance, 16 out of 28 (57%) for the subscale selective movement control and 6 out of 10 (60%) for the subscale dynamic reaching. Total TCMS and subscale scores differed significantly between topographies and severity of motor impairment according to the Gross Motor Function Classification System (GMFCS). Children with hemiplegia obtained the highest scores, followed by children with diplegia and children with quadriplegia obtained the lowest scores. TCMS scores significantly decreased with increasing GMFCS level. In conclusion, trunk control is impaired in children with CP to a various extent, depending on the topography and severity of the motor impairment. The findings of this study also provide specific clues for treatment interventions targeting trunk control to improve their functional abilities.

Multiple sessions of transcranial direct current stimulation and upper extremity rehabilitation in stroke: A review and meta-analysis

OBJECTIVE To systematically review the methodology in particular treatment options and outcomes and the effect of multiple sessions of transcranial direct current stimulation (tDCS) with rehabilitation programmes for upper extremity recovery post stroke. METHODS A search was conducted for randomised controlled trials involving tDCS and rehabilitation for the upper extremity in stroke. Quality of included studies was analysed using the Modified Downs and Black form. The extent of, and effect of variation in treatment parameters such as anodal, cathodal and bi-hemispheric tDCS on upper extremity outcome measures of impairment and activity were analysed using meta-analysis. RESULTS Nine studies (371 participants with acute, sub-acute and chronic stroke) were included. Different methodologies of tDCS and upper extremity intervention, outcome measures and timing of assessments were identified. Real tDCS combined with rehabilitation had a small non-significant effect of +0.11 (p=0.44) and +0.24 (p=0.11) on upper extremity impairments and activities at post-intervention respectively. CONCLUSION Various tDCS methods have been used in stroke rehabilitation. The evidence so far is not statistically significant, but is suggestive of, at best, a small beneficial effect on upper extremity impairment. SIGNIFICANCE Future research should focus on which patients and rehabilitation programmes are likely to respond to different tDCS regimes.