Trunk Impairment as a Predictor of Activities of Daily Living in Acute Stroke

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Trunk Impairment as a Predictor of Activities of Daily Living in Acute Stroke

Masahiro Ishiwatari^1,2*, Kaoru Honaga¹, Akira Tanuma¹, Tomokazu Takakura¹, Kozo Hatori¹, Akihiro Kurosu¹ and Toshiyuki Fujiwara^1,3

• ¹Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
• ²Department of Rehabilitation, Kiminomori Rehabilitation Hospital, Chiba, Japan
• ³Department of Physical Therapy, Juntendo University Faculty of Health Science, Tokyo, Japan

Background and purpose: Trunk function plays a key role in performing activities of daily living (ADL) including locomotion and sitting. Sitting and ADL should be performed as early as possible especially during the acute phase of stroke rehabilitation. Therefore, this study aimed to assess trunk function among patients with acute stroke using the Trunk Impairment Scale (TIS) and to predict its functional outcomes.

Methods: Overall, 67 patients with acute stroke (i.e., within 2 days of occurrence of the stroke) were included. The following clinical assessment items were obtained within 48 h after stroke onset and on the day before discharge from the hospital. Trunk function was examined using TIS and Trunk Control Test (TCT). The motor function of the upper and lower extremities was assessed using the stroke impairment assessment set motor (SIAS-M) score, and ADL was assessed using functional independence measure motor (FIM-M) items.

Results: Multiple regression analysis was performed using the stepwise regression method, using the total FIM-M score following discharge as the dependent variable and age, TIS, TCT, SIAS-M, and FIM-M within 48 h after stroke onset as the independent variables. Age, TIS, and FIM-M within 48 h after stroke onset were selected as the input variables and showed a high-adjusted determination coefficient (R² = 0.79; P < 0.001).

Conclusion: TIS is a reliable method for evaluating trunk control function and is an early predictor of ADL among patients with acute stroke.

Introduction

Trunk function is frequently impaired after stroke, affecting balance, gait, and activities of daily living (ADL) (1, 2). In stroke rehabilitation, trunk control is a fundamental motor skill that is essential for performing many functional tasks (3). In fact, the function of the trunk is not just ensuring the balance when sitting but also providing the ability to stabilize the proximal part of the body, allowing the movement of the distal part and selectively initiating trunk movements (4). There are several studies in the literature that investigated muscle strength in the extremities after stroke (5–7). There are also studies that have assessed the trunk muscle strength as the ability to control balance, trunk movement, and trunk muscle strength in the sitting and standing positions (1, 8–12). Verheyden et al. emphasize the importance of trunk performance, particularly that related to the static sitting balance, when predicting functional outcome after stroke (13). In the stroke rehabilitation process, the trunk function is an important predictor of the functional outcome (1, 8, 14). Therefore, the trunk function plays a key role in basic activities, such as sitting, transferring from the supine to the sitting position, and also rolling.

In acute stroke rehabilitation, it is important to prevent the decline of physical activity and to improve ADL. Acquisition of sitting ability and trunk performance are necessary to improve physical activity and ADL (2, 15). Fujiwara et al. developed the seven-item Trunk Impairment Scale (TIS) to assess trunk dysfunction in patients with stroke (3). Validity and reliability have already been examined. The TIS developed by Verheyden et al. was shown to be effective in predicting the functional outcome of subacute stroke (13). According to the Agency for Health Care Policy and Research guidelines, turning, sitting, and other activities should be started within 24–48 h after stroke onset, if medically possible (16). The group that started rehabilitation within 72 h of admission had a shorter length of stay and better walking status at discharge than the group that started rehabilitation >72 h after the admission (2). Although the mortality rate remained the same, the functional outcome tended to be better when patients increased the amount of training in the acute phase by starting sitting and standing rehabilitation within 24 h of the onset of illness (17).

van Nes et al. in their study of balance using individually adjustable chairs placed on a force platform considered 5–6 weeks after the onset as the subacute phase (18). Franchignoni et al. rather focused on patients with subacute stroke, with an average of 46 days between stroke onset and admission for rehabilitation (14). Other studies in the literature have included patients 1–2 weeks after stroke onset (19, 20) and patients who were transferred to a rehabilitation hospital 1–3 months after stroke onset, and these patients were able to maintain a sitting position (4, 9, 13, 18, 21). For the former reasons, we have classified the acute phase as within 2 weeks and the subacute phase as within 1–3 months after stroke onset. In our study, assessing trunk function with TIS within 48 h after stroke onset helped us assess the level of functional impairment in patients with stroke at the bedside in the acute phase, even if the patients were unable to safely maintain a seated position.

The most frequently identified variables predicting ADL after stroke include age and initial severity of motor and functional deficits (22). Trunk performance has also been identified as an important independent predictor of ADL after stroke (3, 9, 13, 22, 23). Fujiwara et al. conducted a multiple regression analysis to predict the Functional Independence Measure (FIM) motor score at discharge and confirmed that adding TIS as one of the predictors improved the explanation of variation in the FIM motor score at discharge from 66 to 75%, which can contribute to the prediction of functional status after stroke (3). Verheyden et al. examined the predictive validity of TIS and its subscales in predicting the Barthel Index score at 6 months after stroke onset in a multicenter study; the best predictors of the Barthel Index score were the TIS total score and the static sitting balance subscale score at admission (13). Collin and Wade (1) developed the Trunk Control Test (TCT) to assess the trunk function in patients with stroke. Franchignoni et al. (14) reported that using the TCT score at admission as one of the predictors better explains the FIM score at discharge than the FIM score at admission alone. The addition of trunk function assessment to ADL at discharge allowed the determination of a strong prognostic value. The clinical tools to assess the trunk performance include TCT (1, 14, 23), the trunk control items of the Postural Assessment Scale for Stroke (PASS) (9), TIS developed by Fujiwara et al. TIS (3), and TIS developed by Verheyden et al. (24). To better understand the recovery of the trunk function after stroke and to develop more effective treatment programs for patients with trunk imbalances, the trunk function needs to be assessed at the level of ability impairment and functional impairment.

A safe and less time-consuming evaluation method is desirable for patients with acute stroke. To the authors' knowledge, no previous study has reported the assessment of the trunk function and its prognosis within 48 h. Therefore, the purpose of this study was to investigate the prognosis prediction of patients with acute stroke using TIS for the assessment of the body trunk function.