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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

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Trunk Reposition Error (TRE) is common in patients following acute stroke, but does inpatient stroke rehabilitation improve TRE?

April 26, 2017

RESEARCH COMMENTARY

Jacob A. Wright, PT, DPT, COMT
MAPS Orthopedic Manual Therapy Fellow in Training

This month’s Research Commentary describes a recent paper authored by MAPS Senior Faculty Advisor Ken Learman, and MAPS Orthopedic Manual Therapy Fellowship, Fellow in Training, Jacob Wright. The reviewed paper is titled: “An exploration of trunk reposition error in subjects with acute stroke: An observational design” Learman KE1, Benedict JA1, Ellis AR2, Neal AR3, Wright JA4, Landgraff NC1. The Abstract and active Hyperlink can be found below.


Background (Learman et al. 2016)

According to Learman et al. (2016), acute stroke affects approximately 795,000 people each year in the US and the prevalence is expected to rise with the current population’s increasing age­­­ (Roger et al. 2012). The increasing prevalence correlates with increasing healthcare cost; attempting to curb the human suffering, and reduce the burden of cost with more effective treatment is essential. 

It has been widely assumed that proprioception may be important in stroke rehabilitation, more specifically trunk and extremity motor control. Since proprioception is inherently an afferent process, it can be difficult to measure clinically.  However, subcomponents, such as trunk reposition error (TRE), can be more accurately assessed. 

A comprehensive literature search revealed that:

  1. NO prior studies could be found that quantified TRE following acute stroke
  2. TRE deficits have NOT been directly measured across time to determine if traditional rehabilitation programs may positively impact TRE (Cabanas-Valdés et al. 2013)

However, two studies were found to that examined TRE in chronic stroke:

·Ryerson et al. (2008) documented TRE in individuals with chronic stroke and found approximately double the amount of TRE in subjects experiencing hemi-paresis compared to non-neurological, age-matched controls.

·Shruti et al. (2012) concurred with the Ryerson et al (2008) findings.

These two studies (Ryerson et al. 2008 and Shruti et al. 2012) suggested that there is a need to improve TRE following chronic stroke to provide a stable base for extremity task performance and functional activity.    


LEARMAN ET AL. (2016) OBSERVATIONAL COHORT DESIGN STUDY EXAMINES TRE IN ACUTE STROKE PATIENTS

Research Design

A descriptive observational cohort design compromised of both between and within subjects’ components.

1.  Part 1: compared TRE in 30 subjects with an acute stroke and 30 sex and age-matched healthy (non-stroke) control subjects.

2.  Part 2: compared TRE and function before and after an inpatient stroke rehabilitation program. 

TRE was assessed in 3 sessions, whereby sessions 1 and 2 occurred on day one and were approximately 5 minutes apart for both stroke and control groups. Session 3 occurred within 72 hours of discharge for the inpatient stroke patients. 


Outcome Measures

Primary outcome measures used in the Learman et al. (2016) study were: 1) Berg Balance Scale, 2) Postural Assessment Scale for Stroke, 3) Functional Independence Measures and 4) TRE.

TRE was measured using an electromagnetic tracking device (Liberty System, Polhemus, Colchester, VT.) using the follow procedure:

1. Sensors were place on the spinous process of the T1 and SI vertebrae and secured with surgical tape.

2. Subjects were seated with neutral spine with arms crossed and blindfolded.

3. They were ask to flex forward and cued to “stop” at mid-range point and held for 5 seconds (target position 1) and then were asked to remember this position.

4. The subject returned to neutral and asked to rotate left/right to minimize recollection of trunk position.

5. Subject was asked to return to previous identified position and was recorded as (target position 2).

6. TRE was measured between both target positions in three dimensions.   


Results 

Learman et al. (2016) found there were significant differences (p < 0.001) between groups (acute vs. controls) for 3 functional outcome measures and (p = 0.001) for three-dimensional TRE.  There were significant improvements (p < 0.001) in all functional outcome measures following an inpatient stroke rehabilitation program.  Although all measures of TRE were reduced following rehabilitation, they did not achieve statistical significance (p > 0.05).  


Conclusions

TRE was not as severely impaired as anticipated and was variable based upon the plane in which it was measured in three-dimensional space.  Throughout the course of the inpatient rehabilitation program, there were significant improvements in functional outcomes measures but TRE improvements were not as robust.


IMPORTANT TAKE HOME MESSSAGE & SUGGESTIONS:

  1. Learman et al. (2016) is the FIRST STUDY to examine TRE in acute stroke patients

  2. Stroke patients demonstrate significantly greater TRE (p < 0.001) than normal matched controls.

  3. TRE is increased, and therefore trunk motor control is negatively affected following acute stroke.

  4. Inpatient stroke rehabilitation resulted in significant improvements in functional outcome measures (p < 0.001), but improvements in TRE were not statistically significant (p > 0.05)

  5. Further understanding of the relationship between TRE and trunk control may be important as therapists identify specific areas for rehabilitation.

  6. It has been established that trunk control may be improved with standard rehabilitation interventions (Cabanas-Valdés et al. 2013) but further studies are needed to investigate specifically WHICH interventions impact TRE and thus potentially improve physical therapy management for acute stroke. 

 

Cheers and enjoy!

Jake Wright


Article

https://www.ncbi.nlm.nih.gov/pubmedterm=an%20exploration
%20of%20trunk%20position%20error

Abstract

BACKGROUND & OBJECTIVE:
Trunk reposition error (TRE) is a component of trunk control, yet has not been reported in acute stroke. The purpose of this study was to quantify TRE in acute stroke and report this with related rehabilitation outcomes.

METHODS:
Sixty subjects, 30 with acute stroke and 30 healthy controls, completed this study. Subjects with acute stroke were measured before and after an in-patient acute rehabilitation stay.

MEASURES:
TRE using an electromagnetic tracking device, Berg Balance Scale, Postural Assessment Scale for Stroke, and Functional Independence Measures. Pre-post measures were analyzed with paired t-tests. Between-group measures were analyzed with independent w-tests.

RESULTS:
There were significant between group differences (acute stroke vs. controls) for all functional outcome measures (P < 0.001) and for three-dimensional TRE (P = 0.001). There were significant improvements in all functional outcome measures following an in-patient rehabilitation stay (P < 0.001). All measures of TRE reduced but did not achieve significance.

CONCLUSION:
TRE was not as severely impaired as anticipated and was variable based on plane of measure. Time in a rehabilitation setting produced significant improvements in functional outcomes but TRE improvements were not as robust. These results indicate a need for further investigation of the strength of the interrelationship between TRE and function.

KEYWORDS: Proprioception; Rehabilitation; Stroke

PMID: 27077979

DOI: 10.1080/10749357.2016.1138671


References

1. Cabanas-Valdés, R., Cuchi, G. U., & Bagur-Calafat, C. (2013). Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. NeuroRehabilitation, 33(4), 575–592. https://doi.org/10.3233/NRE-130996 


2.  Learman, K. E., Benedict, J. A., Ellis, A. R., Neal, A. R., Wright, J. A., & Landgraff, N. C. (2016). An exploration of trunk reposition error in subjects with acute stroke: An observational design. Topics in Stroke Rehabilitation, 23(3), 200–207. https://doi.org/10.1080/10749357.2016.1138671


3.  Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics- 2012 update: A report from the American Heart Association. Ciculation/ 2012;125(1):e2-e220. https://www.ncbi.nlm.nih.gov/pubmed/22179539


4.  Ryerson, S., Byl, N. N., Brown, D. A., Wong, R. A., & Hidler, J. M. (2008). Altered trunk position sense and its relation to balance functions in people post-stroke. Journal of Neurologic Physical Therapy: JNPT, 32(1), 14–20. https://doi.org/10.1097/NPT.0b013e3181660f0c


5.  Shruti S, Alagumoorthi G, Suresh K. Impairment of spinal proprioception following stroke. Ind J Physio Occ Ther. 2012;6(3):266-270.
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