Mary Lynch Ellerington FCSP Helen Lindfield MCSP MSc Pgcert HI Learning Outcomes To understand the biomechanics of the trunk To understand the role of the trunk in daily activities Sit to stand ID: 934007
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Slide1
Trunk Symposium
Copenhagen 2018
Mary Lynch-
Ellerington
FCSP
Helen Lindfield MCSP MSc
Pgcert
HI
Slide2Learning Outcomes
To understand the biomechanics of the
trunk
To understand the role of the trunk in daily activities
.
Sit to stand
Arm function
Walking
To discuss the role of the trunk and the implications of intervention research for rehabilitation decisions and training
.
Interventions used in trunk rehabilitation
Case report and video presentation
Slide3Why the Trunk??
Slide4Why the Trunk??
Trunk is the central key point of the body, proximal stability of the trunk is a pre requisite for distal limb mobility, balance, gait and functional activities
(
Gadhvi
2016)
Slide5Trunk Control
Trunk
control
is the ability of the trunk muscles to allow the body, to remain upright, adjust weight shift, and perform selective movements of the trunk so as to maintain the center of mass within the base of support during static and dynamic postural
adjustments
(
Karthikbabu
et al. 2011)Trunk performance implies more than just keeping an upright sitting posture.
Stabilisation and selective movements of the trunk towards flexion, extension, lateral flexion and rotation are also important aspects
Anatomical core defined as the axial skeleton (which includes the pelvic girdle and shoulder girdles) and all soft tissues
(i.e., articular and fibro-cartilage, ligaments, tendons, muscles, and fascia) with a proximal attachment
originating on the axial skeleton, regardless of whether the soft tissue terminates on the axial or appendicular skeleton (upper
and lower extremities). These soft tissues can act to generate motion (concentric action) or resist motion (eccentric
and isometric actions). (Behm 2010)
Postural control
is viewed as the organization of stability, mobility and orientation of the multi-joint kinetic chain, which is reflective of the individual’s body schema in order to maintain, achieve or restore a state of equilibrium during any posture or activity”
. (
Vaughan Graham 2016)
Slide6Kinetic Chain
(
Sciascia
2012)
Slide7Three Subsystems
Panjabi 1992,
Behm
2010,
Castanharo
2014
Slide8Anatomical and Passive Subsystem
Slide9Active Subsystem
Multifidus
Quadratus
lumborum
Erector
Spinae
Slide10Active Subsystem
(
Multifidus
,
Rotatores
, I
nterspinalis, Intertransversalis)
Slide11Active Subsystem
Abdominals
Slide12Active Subsystem
Pelvic floor
Slide13Control Systems
Neural control
Descending control
Medial
Lateral
Proprioceptive feedback
Muscle spindle
GTOCutaneous receptorsVestibular systemGraviceptors
Slide14Descending Systems
Ventro
Medial
Systems
Medial (
pontine
)
reticulospinal
Vestibulospinal
Tectospinal
Interstitiospinal
Anterior
corticospinal
Lateral Systems
Corticospinal
Rubrospinal
Lateral (medullary) reticulospinal
Shrewsbury Advanced Course 2018
Slide15Shrewsbury Advanced Course 2018
Slide16Trunk deficits post stroke
Contralateral and
Ipsilateral
.
Considering the ventromedial system disposal, which although bilateral, presents a predominant
ipsilateral
projection, the ipsilateral defiits can no longer be ignored.” (Silva , 2018)
Slide17Reticular
Formation
Originates
in the
pontomedullary
reticular
formation (PMRF) in the brainstem
Recieves convergent and
divergent input
from both
hemispheres
in widely separate areas
of
the
cortex
,
mainly
PMC and M1
Felton e Jozefowicz 2003
Shrewsbury Advanced Course 2018
Slide18Tectospinal
&
interstitiospinal
Systems
Felten e Shetty 2009 – Ruhlan e Van Kan 2003
Shrewsbury Advanced Course 2018
Slide19Postural
Adjustments
1000-400ms
300-200ms
150-100ms
ASA’s
70-300ms
APA’s
aAPA’s
pAPA’s
100ms
(
Schepens
& Drew,
2004)
(
Schepens
e Drew
2004
;
Krishnamoorthy
and
Latash
,
2005;
Olafsdottir
et al., 2005;
Klous
et al.
2011,
2012;
Krishnan et al.,
2011
;
Latash
2015
Aruin
2016,
Latash
&
Zatsiorsky
,
2016;
Piscitelli
et
al
2017
)
Feedforward
Feedback
EPA's
Task
Slide20Postural Adjustments
Task Specific
Minimise
COM displacement?
Tuned for movement initiation.
(
Stamenkovic
2016)Activity contralateral to limb movement?Reciprocal action of
Transverse abdominis within a synergy of axial rotators of the trunk is the dominant control mechanism during rapid arm movements.
(Morris 2012)
Rehabilitation
Specific and isolated muscle training?Trained through function and activity level.
(Lederman
2010, Saito 2014)Muscles recruited is dependent on the demands of the task.Task specific training
(
Behm
2010)
Slide21Trunk Control in Stroke
Trunk function has been identified as an early predictor of functional outcomes post stroke. (
Hacmon
et al.
2012
Verheyden et al. 2006
) Hemiplegic patients, show a decrease in thickness of trunk muscle fibers and the rate of motor unit firing as well as shrinkage of muscle fibers that result in weakness of the
muscle ( Gadhvi 2016)
Trunk muscle strength is impaired multi-directionally in hemiplegic patients. Isokinetic dynamometric testing reported weakness of trunk flexors and extensors
and peak torques of these muscles were significantly smaller in chronic hemiplegic patients than in healthy
controls. (Silva 2015, Karthikbabu
et al. 2011)
The anticipatory postural adjustment of trunk muscles activity is impaired in patients with stroke (Gadhvi 2016)
Anticipatory Postural Adjustments are impaired with people with neurological conditions. This is associated with larger compensatory strategies and increased likely-hood of falls.
(
Aruin
2016)
Slide22Role of trunk in function.
UL
Sit to stand
Walking and balance
Slide23Systematic review.
People after stroke
, compared with healthy adult participants,
demonstrate: longer
movement time, decreased peak velocity, greater
trunk contribution
, less smooth movement, and a more curved reach path when performing reach-to-target in all areas of the workspace.
People after stroke exhibit less accurate reaches and decreased elbow and shoulder
flexion extension reaching to objects in the ipsilateral and contralateral workspace.
Individuals with stroke demonstrated greater trunk displacement during reaching, less upper limb range of motion in all areas
of the workspace and reduced reaching accuracy.
(Collins 2018)
Slide2410 controls and 8 post stroke individuals
EMG from range of muscle groups influencing shoulder girdle during a task reaching while standing
Delayed activation in all muscles tested in post stroke group both
ipsi-lesional
and contra-
lesional
.
The shoulder girdle cannot be viewed as a separate segment, since it is attached to the
spine via the trunk musculature and it is influenced by the neuromuscular activity of the trunk (
Silva 2018)
Slide25Randomised
pre-test and post test design.
29 participants 15 selective trunk exercises 14 control.
Significant relationship between weak trunk muscles and efficiency of sit to stand. Lower values of trunk muscle strength the worse the STS performance.
Identified weak trunk flexors and extensors.
More noticeable in Phase 1 of sit to stand using reciprocal activation flexors and extensors to initiate and maintain the movement.
(
Seung-Heon
2016)
Slide26Trunk Strength is associated with sit to stand performance in both stroke and healthy subjects
Exploratory study 18 stroke patients and healthy matched controls.
Stroke
subjects showed poorer sit to stand (STS)
performances
Significant
and negative correlations were found between STS performance and trunk strength variables
Phase 1 was most effected transition to bottom off.
Evaluation and interventions involving trunk strength should be included in rehabilitation of stroke subjects, who show limitations in STS performances.
(Silva 2015)
Slide2722 stroke patients divided into control and experimental group.
Trunk control, gait and balance were tested.
30
mins
additional trunk stability exercises 3x week/ for 4 weeks.
Trunk
stabilisation
improved gait speed and balance. (
Gadhvi 2016)
Slide28Randomized Controlled Trial of
Truncal
Exercises Early After Stroke to Improve Balance and Mobility
33 participants 18 experimental and 15 control.
Experimental group received 16 extra hours of trunk exercises.
In
addition to conventional therapy, truncal
exercises have a beneficial effect on truncal function, standing balance, and mobility in people after stroke. (
Saeys 2012)
Slide29Pilot study 17 subjects with stroke
Trunk
movement control and symmetry is an important prerequisite for functional walking
gait
.
F
ound significant asymmetry in trunk motion between the affected and unaffected sides that varied across the gait cycle. This suggests the trunk may need to be targeted in clinical gait retraining post-stroke.
(Titus 2018)
Slide30Specific Trunk Training in Rehab
Trunk support (
Pain 2015,
Kwee
Wee 2015)
APA training (
Aruin 2016)Functional training (Lederman 2010, Hyun Kim 2015)Establish optimal postural alignment address impairments (Sciascia
2012)Specific core exercises (Saeys 2012, Gadhvi 2016)
Slide31Key References
Allison,
G.(2008).
Transversus
abdominis
and core stability: has the pendulum swung
? Br. J. Sports Med. 42, 930–931.Behm D (2010) The use of instability to train the
core musculature Appl. Physiol. Nutr. Metab. 35: 91–108 Cabanas-Valdes R (2013) Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke. A systematic review. Neuroreahbilitation 33 575-592
Castanharo R (2014) Corrective sitting strategies: An examination of muscle
activity and spine
loading. Journal of Electromyography and Kinesiology 24
114–119Gadhvi (2016) Additional effect of trunk stabilization exercises on gait and balance in
chronc stroke patients: An experimental study. International Journal of Therapies and Rehabilitation Research 5 (4): 33-38 Jang JY, Kim SY
.(2016)
Effects of trunk control exercise
performed on
an unstable surface on dynamic balance in
chronic stroke
patients. J Korean
Soc
Phys
Med
.;11
(1)
:1
-9.
Karthikbabu
(2018)
Efficacy of Trunk Regimes on Balance, Mobility, Physical Function, and Community Reintegration in Chronic Stroke: A Parallel-Group Randomized
Trial
Volume 27, Issue
4
Slide32Key References
Karthikbabu
(2012). A review on assessment and treatment of the trunk in stroke: A need or luxury NEURAL REGENERATION RESEARCH Volume 7, Issue 25
Karthikbabu
(2011). Role of trunk rehabilitation on trunk control, balance and gait in patients with chronic stroke. A pre-post design.
Neurosci
Med.;2:61-67.
Masse´ -Alarie H (2014) Task-specificity of bilateral anticipatory activation of the deep abdominal muscles in healthy and chronic low back pain populations. Gait and Posture.
Pain L.M. et al (2015) “Effect of trunk restraint trunk restraint training on function and compensatory shoulder and elbow patterns during post stroke reach: a systematic review” Disability and Rehabilitation 37(7): 553-62Panjabi M (1992) The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement.
J Spinal Disord. 1992 Dec;5(4):383-9Saito H et al (2014 ) Relationship between improvements in motor performance and changes in anticipatory postural adjustments during whole-body reaching training. Human Movement Science 37 69–86
Slide33Key References
Saeys
W (2012) Randomized controlled trial of
truncal
exercises early after stroke to improve balance and mobility.
Neurorehabilitation
Neural Repair 26 (3) 231-8 Sciascia A and Cromwell R (2012) Kinetic Chain Rehabilitation: A Theoretical Framework Rehabilitation Research and Practice
Silva, C (2018): Anticipatory postural adjustments in the shoulder girdle in the reach movement performed in standing by post-stroke subjects, Somatosensory & Motor Research.Silva P (2015) Trunk Strength is associated with sit to stand performance in both stroke and healthy subjects. European Journal of Physical and Rehabilitation Medicine
Stamenkovic A (2016) Trunk muscles contribute as functional groups to directionality of reaching during stance Experimental Brain ResearchVaughan-Graham and
Cott C (2016) Defining a Bobath clinical framework-A modified e-Delphi study. Physiotherapy Theory and Practice. An international journal of physical therapy Wee S.K. (2015) “Effect of Trunk Support on Upper Extremity Function in People With Chronic Stroke and People Who Are Healthy”
Phys Ther.95:1163-1171