Stroke is still the second leading cause of death worldwide and the second-most common cause of disability-adjusted life years. It can affect multiple body functions, including perception, cognition, speech, and motor function. The range of mobility deficit is very wide, ranging from very minor to bilateral paralysis. A frequent condition found in stroke patients is reduced trunk function, including coordination, proprioception, and weaknesses. This leads to impairment in reaching and maintaining the sitting position. Trunk function also enables a person to perform reaching to manipulate the environment, and it influences transfers and gait, thus heavily affecting daily activities performance. In this scenario, rehabilitation aims to maximize functional independence through trunk training, promoting control, coordination, and muscle strengthening. Training has a positive effect on muscle thickness, symmetry, activation patterns, and anticipatory adjustments to perturbations. This review investigated whether in stroke patients trunk training compared to both dose-matched and non-dose-matched controls improved activities of daily living (ADL), trunk function, upper-limb function or activity, standing balance, leg function, walking, and quality of life.
This review is important for:
Patients who had a stroke and who have a wide range of trunk-control difficulties that longitudinally affect their daily activities, their caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.
Outcomes of this review
This is a new Cochrane Systematic Review (CSR) published in 2023. The outcomes analyzed were activities of daily living, trunk function, arm-hand function or activity, standing balance, leg function, walking ability, and quality of life. The CSR included 68 trials published and/or registered up to October 25, 2021, with 2,585 participants. Results showed that, although it showed a positive effect, it is uncertain whether trunk training, compared with dose and non-dose-matched control therapy, improves ADL, trunk function, arm-hand activity, balance in standing, life quality, walking ability, adverse events, including death and falls. On these last two outcomes, trunk training may make a slight improvement compared to dose-matched controls.
These results must be interpreted cautiously because of the (i) limited number of studies and the different methodologies between the two study groups; (ii) almost none of the studies evaluated and reported adverse events; (iii) it was also not possible to determine the phase post-stroke when the intervention would be most appropriate; (iv) in some cases standard therapy information was lacking for certain therapy approaches; (v) the number of registrants was limited, and it was not specified whether adjustments were made to the study-design methodology and outcomes; (vii) people with multiple strokes and other neurological conditions were not included, making the results not generalizable to the overall stroke population; (viii) the results of this review are less applicable to the home setting since only one study included this setting as well as nursing homes or other residential settings, (ix) no trials included participants two weeks after the stroke event; thus, the results are not applicable early after the stroke which, in accordance with other studies, is the most important period for improvement through interventions, (x) interventions were not described in detail, limiting repeatability, (xii) there was large variability between the control interventions, (xiii) bias was mostly unclear in each domain, (xiv) dropouts were mostly not reported, and when they were reported, but the reason was not described.
Author’s conclusion of the review
Trunk training may have a positive effect on ADL, trunk function, and standing balance, although the quality of evidence was very low. It probably also improves walking ability. Limited evidence was available for the other outcomes, suggesting a positive effect of trunk training on quality of life and function of the limbs; however, there was no difference between trunk training and control of arm-hand activity. In conclusion, these results favor the inclusion of trunk training in stroke rehabilitation in subacute and chronic phases, but no studies analyzed it in the acute phase. The evidence for strong recommendations was lacking.
Future recommendations
The authors recommended that large well-designed and well-reported phase III randomized controlled trials with a parallel-group design are needed, in particular (a) to find out the intervention’s effectiveness in the acute phase post-stroke; (b) to strengthen the evidence on the intervention in sub-acute and chronic phases; and (c) to record long-term follow-up effects. The authors recommend that future trials adhere to Consort guidelines and the TIDieR checklist to describe interventions. These interventions should move toward uniformity in therapy and measurement outcomes. Future research should prioritize the assessment of adverse events and the effects of the intervention on daily living and quality of life, with changes in score values with standard deviations. A detailed description of training protocols should be provided and readily accessible. Studies should be registered before the actual start of the trials to minimize selective reporting and maximize transparency. Dose-matched control interventions should be prioritized.
summary by Robin Kuruvila Sentinella