Elsevier

Gait & Posture

Volume 36, Issue 3, July 2012, Pages 419-424
Gait & Posture

Arm training in standing also improves postural control in participants with chronic stroke

https://doi.org/10.1016/j.gaitpost.2012.03.025Get rights and content

Abstract

Purpose

To prove the concept that postural control will improve without specific balance control training during arm training in standing with individuals with chronic stroke.

Methods

Nine participants (mean age 64 ± 7) received training involving hand orthotic assisted grasp, reach and release in standing 1 h, 3×’s/week for 6 weeks. Training focused on task completion with no explicit instructions provided for postural alignment, weight shift or balance strategy. Testing consisted of quantified measures using NeuroCom™ Balance Master, Berg Balance Scale (BBS) and Activities-specific Balance Confidence Scale (ABC).

Results

Post training participants demonstrate increased (p < .05) composite stability scores for sensory organization testing (mean 71.55 ± 12.7–75.55 ± 11). Velocity and directional control of COP weight shift improved for all 9 subjects with 6/9 achieving 100% target acquisition. Directional control improved (p < .05) for medial/lateral movements for all speeds and composite score. Anterior/posterior rhythmic weight shifting increased significantly in COP velocity control at moderate and fast velocities and composite score. Increases in mean BBS (p < .01) from 41.33 ± 10.1–46.88 ± 8.03 exceeded the clinically important cutoff for the scale. Balance confidence improved with ABC mean scores 70.22 ± 14.5–79.55 ± 12.86 (p < .05). Seven participants demonstrated changes above the minimally important difference for this scale.

Conclusions

Postural control improved following task oriented arm training in standing without explicit postural control goals, instruction or feedback challenging current training paradigms of isolated postural control training with conscious attention directed to center of pressure location and movement.

Highlights

► We examine the implicit training of postural control during arm training in standing. ► Gains are seen in both quantitative and functional measures of postural control. ► Arm training in standing improves both arm function and postural control.

Introduction

Stroke is the leading cause of long term adult disability in the United States and continues to be a major health care issue with a 40–70 billion dollar yearly economic impact [1]. Permanent disability resulting from stroke affects over 260,000 adults each year with 30,000 requiring nursing-home admission. When considering physical disability post stroke, less than 20% of stroke survivors regain functional use of the their paretic arm [2], almost 50% lack independence in activities of daily living [3] and while 82% regain standing and ambulatory abilities [4], postural instability persists which can lead to falls, injury and further disability [5]. Lamb et al. has shown that impaired balance is a predictor of falls for elderly community dwelling women post stroke [6]. Effective rehabilitation interventions to remediate the multifactorial deficits contributing to postural instability and prevent falls is an important challenge for rehabilitation.

Despite the presence of multifactorial deficits, in the literature, the majority of interventions post stroke typically target isolated impairments or functional limitations. For example, arm training approaches are conducted in the seated position [7], [8], [9]. Likewise, postural training studies, while conducted in standing, rarely include concurrent functional arm training in reaching or manipulatory tasks [10], [11]. To our knowledge, only Combs et al. report a training program that has a component of task oriented skills training in patients post stroke but without specific quantification of postural control outcomes [12]. Training the arm and postural control in isolation, may not restore integrated functional use necessary for independent skilled performance of activities of daily living. For example, activities such as food preparation, bathing and dressing, require integrated postural control, ambulatory skills, reaching, grasping and manipulation of objects in the standing position [13].

When combining reaching for an object in standing, components that contribute to performance of the task include anticipatory postural responses to stabilize posture, weight shift to move the body center of mass (COM) towards the object, visual fixation on the object, as well as the voluntary grasp, reach and release of the object [14], [15]. Anticipatory postural control and voluntary arm movement are thought to be controlled by different, but parallel descending pathways [16]. These parallel control mechanisms need to be integrated for effective activity completion [17] without loss of postural control or a fall. Hence, reach training should be carried out in the context of the task demands and may be essential for the implicit engagement of the underlying neural control networks for integration of the different mechanical, sensory, motor and goal oriented systems that contribute to arm function and postural regulation. Combining explicit cues for both arm function as well as postural control, however, would constitute a dual task situation that individuals with stroke would find quite difficult. In this study we propose the use of explicit cues only for the arm during training in standing with no cueing for postural control to facilitate an implicit learning process for the latter (see Pohl et al. [18] for details on implicit learning after stroke).

The purpose of this single cohort study was to provide a proof of concept that combining explicit cues for goal oriented arm training, while standing will result in implicit training of postural control. Such findings would suggest that clinical practice may benefit from this combined explicit/implicit learning approach for more efficient training of both arm function and postural control in a biologically integrated manner.

Section snippets

Methods

This study recruited 9 participants with chronic hemiparetic stroke. See Table 1 for subject characteristics. Participants were a sample of convenience recruited consecutively from a larger study. It is unlikely the larger study impacted data reported in this manuscript. All subjects presented with chronic upper extremity hemiparesis determined to be of moderate severity based on the Fugl-Meyer upper extremity test (mean FM 27 ± 10; range 0–66). Inclusion criteria included, chronic unilateral

Sensory organization test

Table 2 shows the composite “stability” score for the SOT testing at pre and post training. Mean scores were significantly increased (p < .05) from pre (71.55 ± 12.7) to post training (75.55 ± 11).

Limits of stability

In Table 3, pre and post training individual scores are shown for the velocity and directional control during the limits of stability test. Observational findings were lack of visible ankle strategy to produce a transfer of center of pressure (COP) during weight shift to target in all directions especially

Discussion

The purpose of this proof of concept study was to demonstrate that focused arm training in standing would result in implicit training of postural control. Our cohort of participants had baseline deficits in postural control consistent with other reports [5], [24] and, our primary finding was that postural control improvements were seen following a hemiparetic arm training intervention performed in standing without explicit postural control instruction, suggesting implicit postural learning had

Conclusions

Quantitative and clinical measures of postural control improved following task oriented arm training in standing without explicit postural control goals, instruction or feedback. This finding challenges current training paradigms of isolated postural control training that have conscious attention directed to center of pressure location and that promote movement in the absence of integrated arm function.

Conflict of interest statement

No conflict of interest exists for any author of this manuscript.

Acknowledgements

This work has been presented in part, at the APTA Combined Sections Meeting 2010 in San Diego, CA.

This work was partially funded by a University of Maryland Claude D. Pepper Core Development Project Grant (PI: McCombe Waller). I would like to acknowledge the support of the Geriatric Research and Education Center in subject screening, Jill Whitall for her review and consultation, Melissa Mulcahy and Toye Jenkins for their contributions to testing and training respectively, and finally each of

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