|Year : 2016 | Volume
| Issue : 3 | Page : 127-134
Effects of truncal motor imagery practice on trunk performance, functional balance, and daily activities in acute stroke
Priyanka Shah1, S Karthikbabu1, Nafeez Syed1, Ellajosyula Ratnavalli2
1 Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Bengaluru Campus, Bengaluru, Karnataka, India
2 Department of Neurology, Manipal Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||14-Sep-2016|
Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Bengaluru Campus, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Motor imagery is beneficial to treat upper and lower limbs motor impairments in stroke patients, but the effects of imagery in the trunk recovery have not been reported. Hence, the aim is to test the effects of truncal motor imagery practice on trunk performance, functional balance, and daily activities in acute stroke patients. Methods: This pilot randomized clinical trial was conducted in acute stroke unit. Acute stroke patients with hemodynamic stability, aged between 30 and 70 years, first time stroke, and scoring <20 on trunk impairment scale (TIS) were included in the study. Patients in the experimental group practiced trunk motor imagery in addition to physical training. Control group was given conventional physical therapy. The treatment intensity was 90 min/day, 6 days a week for 3 weeks duration. Trunk control test, TIS, brunel balance assessment (BBA), and Barthel index (BI) were considered as the outcome measures. Results: Among 23 patients included in the study, 12 and 11 patients, respectively, in the control and experimental groups completed the intervention. Repeated measures ANOVA, i.e., time* group factor analysis and effect size showed statistically significant improvements (P = 0.001) in the scores of TIS (1.64), BBA (1.83), and BI (0.67). Conclusion: Motor imagery of trunk in addition to the physical practice showed benefits in improving trunk performance, functional balance, and daily living in acute stroke.
Keywords: Function, motor imagery, recovery, stroke, trunk impairment
|How to cite this article:|
Shah P, Karthikbabu S, Syed N, Ratnavalli E. Effects of truncal motor imagery practice on trunk performance, functional balance, and daily activities in acute stroke. J Sci Soc 2016;43:127-34
|How to cite this URL:|
Shah P, Karthikbabu S, Syed N, Ratnavalli E. Effects of truncal motor imagery practice on trunk performance, functional balance, and daily activities in acute stroke. J Sci Soc [serial online] 2016 [cited 2019 Oct 14];43:127-34. Available from: http://www.jscisociety.com/text.asp?2016/43/3/127/190524
| Introduction|| |
Stroke is one of the major causes for physical and functional disability in adult population globally.  Motor imagery is considered to be one of the latest rehabilitation strategies to treat the poststroke disabilities. It is the covert cognitive process of imagining a movement of one's own body (-part) without actually moving that body (-part); i.e. the imagined rehearsal of a movement with the specific intent of improving that movement. , The imagery helps in activating the mirror neuron system located in the primary motor cortex both, while observation and execution of an observed movement in turn enhancing the corticospinal facilitation and cortical reorganization. ,,
Motor imagery has shown improvement in the motor and functional performance of upper and lower limbs when administered along with the conventional therapy in acute,  sub-acute,  and chronic , stroke patients. Studies retrieved showing the improvements in patients with acute stroke were limited. The motor imagery showed upper limb improvements in the scores of Fugl Meyer assessment, action research arm test, color trail test, grip strength, arm functional test, motor activity log, activities of daily living (ADL). ,,, Improved lower limb activities such as gait and outdoor activities quantified using tests such as spatial and temporal parameters, weight loading on affected leg, dynamic gait index, and Berg Balance Scale support the findings in lower limbs. ,,
Research was directed to understand the effects on limbs considering their impact on the daily function in an individual after stroke. Despite the fact that an effective limb function depends on better postural control in sitting and standing postures,  studies in the past did not focus on the effect of motor imagery in postural control. However, many recent studies emphasized the role of trunk in attaining a good postural control.  Trunk muscles not only help in maintaining an erect trunk/posture but also allow effective weight shifts during dynamic postures.  Thus, the trunk activity came into advent in the rehabilitation of patients with stroke which underwent the rigorous tests of time for its uses not only in functional ability but also in balance and gait. In this effect, researcher also demonstrated a positive correlation between trunk performance and balance, functional ability  and gait, which in turn reduces the fall risks.
Trunk rehabilitation strategies to improve postural control in turn improving trunk performance evolved from basic approaches such as proprioceptive neuromuscular facilitation,  Bobath approach, , angular biofeedback  to task-related motor training program.  Task-specific motor programs focused on the movement components which are in coherence to the tasks performed as a part of daily routine.  It has been shown that the administration of task-specific training on various platforms such as plinth  and physio ball  resulted better trunk performance poststroke. Despite the known importance of the trunk performance following stroke and the various strategies administered in isolation to improve the same have been documented, studies focusing on the combined effect of motor imagery with trunk rehabilitation have not been reported. The aim of the study is to test the effect of truncal motor imagery practice on trunk performance, functional balance, and daily activities in acute stroke patients. We hypothesized that the motor imagery practice in addition to conventional therapy will have better trunk performance, functional balance, and daily activities over the conventional therapy in acute stroke patients.
| Methods|| |
The ethical clearance was obtained from the Institutional Review Board of Manipal University. A written informed consent was obtained after explaining the study protocol at the beginning of the trial. This assessor blinded randomized controlled trial was conducted in the neurological physiotherapy unit of Manipal Hospital, Bengaluru. Patients with acute stroke were referred from neurology unit between February 2011 and April 2013. Block randomization method was used to allocate the patients into two groups. Concealed allocation was followed throughout the study, and the observer who performed the randomization was not involved in either conducting the interventions or collecting the outcome measures. Assessor blinding was done, and the assessor was not a part of the intervention. The inclusion criteria were as follows: Acute stroke patients with hemodynamic stability, aged between 30 and 70 years, 1 st time stroke with unilateral supratentorial lesion, and capable of following simple verbal commands. The exclusion criteria were as follows: Trunk impairment scale (TIS) score >20 at baseline, history of multiple stroke, and other neurological diseases (Parkinson's disease, vestibular disturbances) or musculoskeletal problems (low back pain, arthritis) affecting the balance.
TIS, an ordinal scale assesses static sitting balance, dynamic sitting balance, and trunk coordination with its scores ranging from 0 to 23. The dynamic sitting balance subscale evaluates the lateral flexion initiated from upper and lower parts of the trunk. Trunk coordination is assessed by selectively rotating the upper and lower part of the body. Adequate rotation and compensations are evaluated as mentioned above. Test-retest and interobserver reliabilities of TIS total score (inter-class correction [ICC]) were 0.96 and 0.99, respectively. Cronbach's alpha coefficients for internal consistency ranged from 0.65-0.89. Spearman rank correlations with the Barthel index (BI) (r = 0.86) and the trunk control test (TCT) (r = 0.83) were used to examine the construct and concurrent validities, respectively. 
TCT was used to measure the motor performance of trunk by evaluating the basic bed mobility. The TCT consists of four items such as rolling from supine to the weak and strong side, sitting up from lying down, and sitting balance, which are assessed on a 3-point ordinal scale. Total score ranges from 0 to 100 points with a higher score indicating a better performance. The TCT was found to be a reliable and valid tool for measuring trunk performance. ,
Brunel balance assessment (BBA) was used to assess the functional balance in sitting, standing, and stepping. This is a 12-point ordinal hierarchical scale encompassing the components of static sitting balance, walking, weight shifts, and changing of base of support. This scale showed to be reliable and valid to measure the functional balance in acute patients. 
BI is a reliable and valid scale to measure the functional ability of the subjects with a maximal function at 100 points and minimum functional ability when the patient scores zero point. The index incorporates daily activities such as feeding, transfer, grooming, toileting, bathing, ambulation, stair climbing, dressing, bowel control, and bladder control. 
Patients in the control and experimental groups received the conventional acute stroke rehabilitation protocol recommended by the neurological physiotherapy unit. The protocol constituted basic physiotherapy techniques such as range of motion exercises, facilitation techniques, bridging, and weight bearing strategies. Intervention was given by a qualified physical therapist pursuing master's in neurological physiotherapy for either group. Both groups received intervention for 90 min a day, 6 days a week for 3 weeks. Patients in the control group received 45 min of conventional therapy during the first session for the day and 15 min were spent to advice the patient on how to improve the performance of the previous session. They were administered additional 30 min of conventional exercises in the second session of the day totaling the treatment time to 90 min in a day. The treatment sessions were spaced for approximately 4 h.
The patients were instructed to view a 15-min trunk exercises video on an audio-visual display terminal (motor imagery video). They were given 45 min of trunk exercises during the first session and 30 min of conventional therapy during the second session. The imagery video showing the task-specific trunk exercises had a total of 11 exercises similar to those which patients had to perform during the physical practice sessions. It had basic exercises such as bridging and upper-lower trunk rotations in supine progressing to unilateral bridging with single arm or leg raises and upper and lower trunk flexion with rotation, respectively. Exercises in sitting were forward reach outs, lateral trunk flexion, and pelvic lifts, which were progressed to forward reach outs in multiple directions, increasing the lateral flexion arc of movement and pelvic shuffling, respectively. Exercises were shown based on the patient's ability to perform or replicate the same and the progression was determined based on the performance in the practice sessions [Figure 1].
All the exercises shown were looped to repeat for six to seven times. While projecting the video on the laptop screen, it was ensured that the patients were in a comfortable position and the screen is in the patient's visual field. They were commonly positioned in semi-reclined sitting or high sitting with feet supported. Adequate rest periods were given between and after the video sessions as required. Patients were asked to perform exercises similar to those shown in the motor imagery video. Repetition of the exercises was based on their ability which could be a minimum of five repetitions per session to a maximum of ten repetitions per exercise session. All the outcomes were evaluated at five time points - baseline, end of 1 st week, 2 nd week, 3 rd week (discharge), and 6 th week (follow-up) except BI.
Data were analyzed using the SPSS version 16.0 (SPSS Inc.). Baseline data was compared between the groups using Chi-square test for qualitative variables (gender, type of stroke, and hemiplegic side) and the same for quantitative data (age, poststroke duration, TCT, TIS, and BBA) was analyzed using an independent t-test. Values of TCT, TIS, BBA, and BI collected at baseline, 1 st , 2 nd , 3 rd , and 6 th week were analyzed using repeated measures ANOVA. Equality of variances was assessed for continuous measures using Levene's test and corresponding "P" values were reported.
The repeated measurements of baseline, posttreatment, and follow-up were considered as within-subjects variable "time," and the groups were considered for between-subjects factor "group." Changes in pretreatment and posttreatment assessments are indicated by the respective P values for the variable "time." A significant interaction of "time * group" indicates that the change seen through time is statistically significantly different between the two groups. The change scores between discharge to baseline and follow-up to discharge were analyzed using descriptive statistics for between the groups. Effect size was calculated for each outcome and it subscales with the formula (X E − X c )/pooled standard deviation, where X E is the mean of the experimental group and X C is the mean of the control group. The level of significance for all the analyses was set at P < 0.05. 
| Results|| |
The enrolment and allocation of the patients including the drop-outs in this study are shown in [Figure 2]. Among the eighty patients screened for eligibility, a total of 23 patients included in the study. About 12 of the 23 patients were allocated to control group and 11 patients to the experimental group. The baseline variables were comparable between-groups [Table 1]. Outcomes when compared for the changes at different time intervals showed significant improvement with time in both the groups [Table 2]. Time * group factor showed significant improvements in TIS-total score (P = 0.001), dynamic balance (P = 0.004), and coordination (P = 0.003) subscales of TIS, BBA-total score (P ≤ 0.001), stepping (P = 0.001) subscale of BBA and BI (P ≤ 0.001).
|Table 2: Comparison of outcome measures in the experimental and control groups|
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The between-groups change score from baseline to discharge showed better improvement in the TIS-total score (6.3/23), dynamic balance (2.48/10), and coordination (2.68/6) subscales of TIS, stepping (3/6) subscale of BBA, and BI (3.67/100) supporting the experimental group. For the experimental group, the change score from baseline to discharge improved significantly in the TIS-total score (18.3/23), dynamic balance (8.1/10), and coordination (5.1/6) subscales of subscales compared to the controls (12, 4.9, and 2.42 points, respectively). From discharge to follow-up, the improvements in the above listed parameters though were small but were found to be retained in both the groups.
Within group change score from baseline to discharge for BBA-total score showed better improvement in the experimental group compared to control groups. The stepping subscale of BBA showed more improvement (4.5/6) in experimental group compared to control group (1.5/6). We also found that the patients in the experimental group attained the maximum possible score (5.3/6) in this subscale at follow-up as compared to control group (2.33/6). Within group change score of BI showed improvement in the experimental group both at discharge (82/100) and follow-up (94/100) when compared to control group (52 and 60.42 points, respectively). Large effect sizes of 1.65, 1.46, 1.83, 0.99, and 1.40 were seen at discharge for TIS-total score, TIS-coordination, BBA-total score, standing and stepping subscales of BBA, respectively; whereas the effect sizes between discharge and follow-up were small in all the outcomes except BI showed moderate effect size of 0.67 [Figure 3],[Figure 4],[Figure 5] and [Figure 6].
|Figure 3: Mean (standard deviation) scores of trunk control test from baseline to follow-up in the experimental and control groups|
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|Figure 4: Mean (standard deviation) scores of trunk impairment scale from baseline to follow-up in the experimental and control groups|
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|Figure 5: Mean (standard deviation) scores of Brunel balance assessment from baseline to follow-up in the experimental and control groups|
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|Figure 6: Mean (standard deviation) scores of Barthel index from baseline to follow-up in the experimental and control groups|
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| Discussion|| |
The aim of the study was to compare the effect of truncal motor imagery in addition to conventional therapy on trunk performance in acute stroke patients. To the best of our knowledge, this is the first study of its kind using task-specific trunk motor imagery to improve trunk control in acute stroke. We have also attempted to find the carry over effects of improved trunk performance on ADL using BI.
Trunk rehabilitation found an evolution of clinical measurement tools (TCT and TIS) considering the importance of trunk control. Outcomes of rehabilitation were assessed from the acute stage of stroke when the patients are bed bound and have limited mobility. TCT, a tool sensitive enough to record the basic bed mobility, quantifies the trunk impairment at the early stage of stroke and hence was used in this study.  On the other hand, TIS was an evolved tool to measure the truncal involvement of the patients once they attain independent sitting ability.  Evidence till date on trunk rehabilitation with TIS as an outcome considered the patients with sitting balance ability; , however, no literature studying its efficacy on patients without sitting balance could be retrieved. As this study enrolled patients for trunk rehabilitation very early poststroke, outcomes capable of recording the effects both in early and sub-acute stages was a mandate. Since TCT emphasizes on early assessment and treatment of trunk,  we opted it alongside TIS as our outcome measure.
When compared between-groups, the difference in TIS-total score from baseline to discharge showed 26% (6/23) improvement in the experimental group. A large effect size of 1.65 was noticed at discharge which is in favor of the experimental group. The between-group mean differences in this study were 6.3 as compared to the recent study (3.06).  This improvement may be due to better lower trunk lateral flexion (2.48) and rotation (2.68) and could be attributed to the enriched motor learning caused by motor imagery practice. The findings in this study are in similar lines to those of the neuroimaging studies where it has been reported that motor imagery enhanced the cortical reorganization indicating wider representation of corresponding homunculus poststroke. , We believe that the motor imagery program with a focus on lateral flexion (dynamic sitting) and rotation (coordination) of trunk would have contributed in creating motor framework in turn enhancing the improved truncal representation in the cortex. 
At discharge, the between-group change score on the BBA-total score showed 31% (3.68) improvement in experimental group compared to the control group. This is due to the three levels increment in the stepping subscale of BBA in the experimental group. Ability of the patients in the experimental group to maintain dynamic single stride standing (BBA stepping score of 4.5) at discharge might be due to an enhanced lower trunk performance with motor imagery practice. A previous study reported that the acute stroke patients could attain the dynamic double support standing (BBA stepping score of 2.8) following 3 weeks of trunk training a plinth.  The between-group mean differences in this study was 3.68 compared to previous research (1.8)  suggesting a better carry over effect of trunk imagery treatment protocol.
The improvements in the stepping subscale of BBA indicate that the stable pelvis following trunk training in stroke patients might have enhancing their weight shift ability, , functional balance, and walking. ,, This is in support to the findings on the improved trunk performance leading to better pelvic stability allowing appropriate trunk pelvic dissociation  and better weight bearing during single limb support on the affected leg.  A large effect size of 1.83 for BBA-total score supports the experimental group postintervention. Attaining functional balance level 11 at follow-up in the experimental group supports the experimental group.
BI displayed lower score at baseline owing to their reduced motor abilities or restriction by the patient in performing the daily activities to prevent from fall risks. BI showed 30% improvement in experimental group at discharge and follow-up. Both the groups improved equally during their stay at home, but the experimental group showed to have better independent functional ability (94/100). The improvement in BI indicates better functional ability in transfers from bed to chair, mobility on the level ground, and stair climbing in experimental group.  Positive correlation between the improved trunk performance with better functional ability and gait reported in the past supports our findings.  Trunk performance has been considered an early predictor for comprehensive ADLs. , Daily activity assessment in acute stroke at the time of discharge is considered to be an predictor of the functional ability progress at the of the follow-up and after the 6 months of the stroke.  A moderate effect size of 0.64 in the BI favors the experimental group.
The improvements in all outcomes and its subscales of experimental group at discharge were found to have retained at follow-up. However, the mean differences between discharge and follow-up were very minimal. This could be due to the fact that most of the patients attained the submaximal score at discharge. This study has few limitations that warrant caution when generalizing the results. We included small number of patients but did not document any autonomous changes ensuring the process of imagination. We are not sure whether the trunk imagery alone or physical practice of trunk exercised in addition to the imagery resulted an improvement in the experimental group. We belief that clinical trial comparing the trunk imagery practice to trunk exercises regime and conventional physical therapy might provide the genuine benefits of trunk motor imagery practice. Future randomized controlled trial using the functional magnetic resonance imaging and positron-emission tomography scan in large number of patients is recommended to confirm the benefits of trunk motor imagery practice.
| Conclusion|| |
Trunk motor imagery practice is a clinically important early rehabilitation strategy along with the routine trunk rehabilitation in improving trunk performance, which in turn improves functional balance and daily activity in subjects with acute stroke.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]