Trunk control in stroke. Aspects of measurement, relation to brain lesion, and change after rehabilitation

Stroke is a leading cause of disability worldwide and affects mostly elderly people. Neurorehabilitation is important for reducing the long-term consequences of stroke, aiming to achieve an optimal functional recovery for home and community reintegration. Physiotherapy is the most common rehabilitation intervention, and the role of the physiotherapist is mainly focussed on improvement in motor function. One of the most important functions of the central nervous system is to coordinate posture and movement to stabilise the body during movements and perturbations. Trunk control is a central aspect of postural control, and has been found to be impaired after stroke. There is limited knowledge on trunk control after stroke, and further studies are warranted. The thesis comprises three studies; one methodological, one translational and one intervention study. The overall aim was to broaden our understanding and knowledge of trunk control in patients with stroke. The objective of Paper I was to translate the Trunk Impairment Scale (TIS), a measure of trunk control in patients with stroke, into Norwegian and to explore its construct validity, internal consistency, intertester and test-retest reliability. Data from 201 patients with stroke were used to explore construct validity by Item Response Theory and factor analysis. In this process, one of the subscales, static sitting balance, was omitted, and the remaining 14 items were included in six ordinal scales, and named the Trunk Impairment Scale – modified Norwegian version, TIS-modNV. After this modification, the TIS-modNV fitted well to a locally dependent unidimensional Item Response Theory model with one general factor which we call trunk control, and two content specific factors: lower and upper trunk stability. The scale demonstrated excellent construct validity, high internal consistency (alpha 0.85) and high intertester (ICC 0.77) and test-retest (ICC 0.85) reliability for the total score, supporting its use to evaluate trunk control in patients after stroke as well as other central nervous system disorders. We believe that we achieved a satisfactory translation and cross-cultural adaptation. The objective of Paper 2 was to explore the relationship between middle cerebral artery lesion locations (MCA) and trunk control post stroke, and to compare trunk control between patients with lesions in different single and multiple locations, and between left and right hemispheres. A total of 109 patients with acute stroke in the MCA territory were examined using magnetic resonance imaging (MRI) and tested for trunk control using TIS-modNV. To determine the location and extent of the lesion, the MRI scans were scored using the Alberta Stroke Program Early CT Score (ASPECTS), which scores 10 areas in the supply area of the MCA. Single lesion locations were found in 38 of the patients, and data from these formed the basis for further analyses. We found that an ASPECT lesion location in the anterior part of the MCA territory, called M5, demonstrated a hemispheric differentiation for trunk control. Patients with right M5 lesion locations achieved significantly poorer scores on trunk control as compared to left, p = 0.030. However, there were few patients with M5 lesion locations (n = 19), and too few patients to investigate a relationship between other ASPECT locations and trunk control. The results indicate that there is a cortical regulation of trunk control and that the two hemispheres may have different roles in this regard. Paper III was a group comparison study in the context of a randomised controlled trial. Three different rehabilitation models: two for early supported discharge either in a day-unit or in the patients’ own homes, and one traditional uncoordinated treatment were compared for change in physical function after acute stroke. Several outcome measures for balance and walking were used. The Postural Assessment Scale for Stroke was the primary outcome, and TIS-modNV one of the secondary outcome measures. We used data from 167 patients at baseline, 52 in the day-unit group, 60 in the home-rehabilitation group and 55 in the control group. There were no differences between the groups for baseline characteristics or physical function, and no differences between the groups for length of stay in the stroke unit; mean (SD), min-max: 8.6 (3.3) days, 3-17, p = 0.948. The patients had an overall mild to moderate disability, and high scores on PASS. There was a substantial loss to follow-up with 62.9% of the patients being retested at three months, but no significant differences between the retested groups for baseline characteristics. We found no differences in change between the groups for PASS, p > 0.05. We did find differences between the groups for some secondary measures: trunk control, median (95%CI): day-unit, 2 (0.28, 2.31); home-rehabilitation, 4 (1.80, 3.78); control, 1 (0.56, 2.53), p = 0.044, and self-report on walking, p = 0.021, and ADL, p = 0.016, with a tendency to favour the intervention groups over the control group. Mean walking speed improved above minimally important change only in the day-unit group. Bonferroni adjusted pairwise comparisons gave no differences between the groups for trunk control; for self-report on walking, the day-unit group improved more than control, p = 0.004. For self-report on ADL there was a difference between the home-rehabilitation and the control group, p = 0.006. We concluded that with regard to secondary outcomes, multidisciplinary, coordinated rehabilitation tended to be more effective than traditional treatment. In summary, we found that the TIS-modNV has satisfactory measurement properties and can be recommended for use in clinical practice as well as in research. Using the TIS-modNV and ASPECTS, we found indication for a cortical regulation of trunk control, as well as a relationship between lesion location, hemispheric differentiation and trunk control. PASS demonstrated a substantial ceiling effect, and three months after acute stroke no difference was found in change between the groups. On a group level, rehabilitation using coordinated multidisciplinary rehabilitation favoured trunk control, and self-reported walking and ADL

Early supported discharge after stroke in Bergen (ESD Stroke Bergen): three and six months results of a randomised controlled trial comparing two early supported discharge schemes with treatment as usual

Background: Stroke causes lasting disability and the burden of stroke is expected to increase substantially during the next decades. Optimal rehabilitation is therefore mandatory. Early supported discharge (ESD) has previously shown beneficial, but all major studies were carried out more than ten years ago. We wanted to implement and study the results of ESD in our community today with comparisons between ESD and treatment as usual, as well as between two different ESD models. Methods: Patients with acute stroke were included during a three year period (2008–11) in a randomised controlled study comparing two different ESD models to treatment as usual. The two ESD models differed by the location of treatment: either in a day unit or in the patients’ homes. Patients in the ESD groups were followed by a multi-disciplinary ambulatory team in the stroke unit and discharged home as early as possible. The ESD models also comprised treatment by a multi-disciplinary community health team for up to five weeks and follow-up controls after 3 and 6 months. Primary outcome was modified Rankin Scale (mRS) at six months. Results: Three-hundred-and-six patients were included. mRS scores and change scores were non-significantly better in the two ESD groups at 3 and 6 months. Within-group improvement from baseline to 3 months was significant in the ESD 1 (p = 0.042) and ESD 2 (p = 0.001) groups, but not in the controls. More patients in the pooled ESD groups were independent at 3 (p = 0.086) and 6 months (p = 0.122) compared to controls and there also was a significant difference in 3 month change score between them (p = 0.049). There were no differences between the two ESD groups. Length of stay in the stroke unit was 11 days in all groups. Conclusions: Patients in the ESD groups tended to be more independent than controls at 3 and 6 months, but no clear statistically significant differences were found. The added effect of supported discharge and improved follow-up seems to be rather modest. The improved stroke treatment of today may necessitate larger patient samples to demonstrate additional benefit of ESD

The Postural Assessment Scale for Stroke Patients: translation into Norwegian, cultural adaptation, and examination of reliability

<p><b>Background:</b> To translate the Modified Swedish version of Postural Assessment Scale for Stroke (SwePASS) into Norwegian (SwePASS-NV) and assess its intra- and interrater reliability.</p> <p><b>Methods:</b> Translation and cross-cultural adaptation was accomplished according to international guidelines. Forty-seven adults, suffering a stroke within the last 6 months, were strategically recruited and allocated into groups according to five different levels of function. Their performance on SwePASS-NV was video-recorded and then scored by three raters twice, with a minimum of 4 weeks between sessions. Relative reliability was investigated by calculating intraclass correlation coefficients (ICC_1.1 and ICC_3.1). Absolute reliability was analysed using within-subject SD (S_w) and smallest detectable difference (SDD). For individual items, Cohen’s kappa (<i>k</i>) and percentage of agreement were calculated.</p> <p><b>Results:</b> The study showed excellent intra- and interrater reliability (ICC_1.1 and ICC_3.1 ≥0.99) for SwePASS-NV. <i>K</i>-values for the individual items ranged between 0.68 and 1.00. Percentages of agreement ranged from 77% to 100%. SDD at 95% confidence interval was ≤2 points for intrarater assessments and ≤3 points for interrater assessments.</p> <p><b>Conclusions:</b> This study demonstrated very high intra- and interrater reliability of the SwePASS-NV in adults within the first 6 months after stroke. All items showed very high or high agreement.</p

The Trunk Impairment Scale - modified to ordinal scales in the Norwegian version

Purpose: To translate the Trunk Impairment Scale (TIS), a measure of trunk control in patients with stroke, into Norwegian (TIS-NV), and to explore its construct validity, internal consistency, intertester and test-retest reliability. Method: The TIS was translated according to international guidelines. 201 patients with acute stroke were recruited for the validity study, and 50 inpatients with acquired brain lesions were recruited for the study of intertester and test-retest reliability. Construct validity was analysed using explorative factor analysis, confirmatory factor analysis and item response theory, internal consistency with Cronbach’s alpha test, and intertester and test-retest reliability with kappa and intraclass correlation coefficient tests. Results: The back-translated version of TIS-NV was validated by the original developer. The subscale Static sitting balance was removed from the test. Six testlets were hierarchically constructed by combining items from the subscales Dynamic sitting balance and Coordination, and renamed modified TIS-NV (TIS-modNV). After these modifications the TIS-modNV fitted well to a locally dependent unidimensional item response theory model. The test demonstrated good construct validity, excellent internal consistency, as well as high intertester and test-retest reliability for the total score. Conclusions: The TIS-modNV is a valid and reliable scale for use in clinical practice and research

Trunk Control and Lesion Locations According to Alberta Stroke Program Early CT Score in Acute Stroke: A Cross-Sectional Study

Background: Stroke is a leading cause of disability in elderly people. Lesion location and size, and trunk control early after stroke have been found predictive of functional outcome. Trunk control is an important aspect of postural control, and commonly found to be impaired. A hemispheric difference in the regulation of postural control has been suggested, but limited knowledge of a relationship between specific lesions and trunk control exists. Objective: To explore the relationship between middle cerebral artery (MCA) lesion locations and trunk control post stroke, and compare trunk control between patients with lesions in single and multiple locations, and between left and right hemispheres. Methods: A cross-sectional design was used. Patients were recruited from a hospital stroke unit. Assessment tools: Trunk Impairment Scale–modified Norwegian version and Alberta Stroke Program Early CT Score (ASPECTS). Statistics: Descriptive, Independent t-test, Mann-Whitney’s U-test, Chi-Square test. Results:109 patients with first time middle cerebral artery lesions were included, 71 with multiple and 38 with single ASPECT locations. Trunk control was poorer in multiple (median 8.0) than in single (median 11.0) lesion locations, P=0.011. The most common single lesion locationswereM5 (50%) and internal capsule (18.4%). M5 is situated in the anterior parts of the MCA territory and hypothesized to represent sensory and motor areas of the cortex. Patients with lesions of M5 locations in the right hemisphere achieved poorer scores on trunk control than patients with left sided locations, P=0.030. Conclusions: The results indicate that patients with lesions in multiple ASPECT locations have poorer trunk control than patients with single locations, and that trunk control is poorer after single right M5 lesions as compared to left. We recommend therapists to have specific attention towards trunk control in rehabilitation of patients with MCA lesions and especially with a right M5 location early post stroke

Balance and walking after three different models of stroke rehabilitation: early supported discharge in a day unit or at home, and traditional treatment (control)

Objective: To compare the effects on balance and walking of three models of stroke rehabilitation: early supported discharge with rehabilitation in a day unit or at home, and traditional uncoordinated treatment (control). Design: Group comparison study within a randomised controlled trial. Setting: Hospital stroke unit and primary healthcare. Participants: Inclusion criteria: a score of 2–26 on National Institutes of Health Stroke Scale, assessed with Postural Assessment Scale for Stroke (PASS), and discharge directly home from the hospital stroke unit. Interventions: Two intervention groups were given early supported discharge with treatment in either a day unit or the patient’s own home. The controls were offered traditional, uncoordinated treatment. Outcome measures: Primary: PASS. Secondary: Trunk Impairment Scale—modified Norwegian version; timed Up-and-Go; 5 m timed walk; self-reports on problems with walking, balance, ADL, physical activity, pain and tiredness. The patients were tested before randomisation and 3 months after inclusion. Results: From a total of 306 randomised patients, 167 were tested with PASS at baseline and discharged directly home. 105 were retested at 3 months: mean age 69 years, 63 men, 27 patients in day unit rehabilitation, 43 in home rehabilitation and 35 in a control group. There were no group differences, either at baseline for demographic and test data or for length of stroke unit stay. At 3 months, there was no group difference in change on PASS ( p>0.05). Some secondary measures tended to show better outcome for the intervention groups, that is, trunk control, median (95% CI): day unit, 2 (0.28 to 2.31); home rehabilitation, 4 (1.80 to 3.78); control, 1 (0.56 to 2.53), p=0.044; and for self-report on walking, p=0.021 and ADL, p=0.016. Conclusions: There was no difference in change between the groups for postural balance, but the secondary outcomes indicated that improvement of trunk control and walking was better in the intervention groups than in the control group