In hemiparetic patients, the unrestricted and unguidedrepetition of a motor task may reinforce compensatorymovements. Thus, in the short term, althoughcompensatory movements may improveperformance of the paretic arm, in the long term,these may be maladaptive by preventing recovery orreappearance of more efficient arm movementpatterns.Trunk restraint allowed the patients to use joint rangesthat were present but not recruited during unrestrainedreaching.1,2,3 Later, studies combined the trunk restrainttraining with additional therapeutic interventions.4,5

With the growing number of studies on this interventionin stroke population, there is a need to consolidate thisevidence to determine the potential use of trunk restrainttraining in improving arm reaching in neurologicalrehabilitation particularly for stroke patients.

1. The primary aim is, to assess the effectiveness of trunk restraint training on the recovery of reaching movements in stroke patients.

2. Secondary aim is, to find out the effectiveness of trunk restraint training combined with other therapeutic interventions.

Randomized controlled trials Descriptive studies in the absence of RCTs Adult person with stroke, except those with pathology

of the cerebellum or the basal ganglia Trunk restraint training, Trunk restraint training

combined with other interventions

3D Motion Analysis (Kinematic Analysis)1. Anterior trunk displacement2. Elbow extension3.Smoothness & Hand trajectory straightness

Senthilkumar Jeyaraman,PT1; Ganesan Kathiresan, PT2; Kavitha Gopalsamy,PT3

1 , 2 Lecturer, Masterskill University college of Health sciences, Malaysia ;3 Physiotherapist, Malaysia

The effect size for the outcome measure was calculated byCohen’s d. The effect sizes are especially importantbecause they allow us to compare the magnitude ofexperimental treatments from one experiment to another.

Reaching ability is an important component forindependent living. However, survivors of stroke often relyon compensatory movement strategies to accomplishreaching tasks. Carr and shepherd suggest thatcompensatory strategies are the result of usingavailable movements given the post stroke state of thecentral system, which leads to long – term functionallimitations. Hence Michaelsen et al studied theeffectiveness of trunk restraint training on arm recovery instroke patients and demonstrated that trunk restraint is atreatment paradigm which decreases the compensatorystrategies.1,2,3

Trunk restraint training is similar to the strategy ofconstraining the unaffected arm to force the patient tomake more use of the affected arm with the additionalfeature that reduction of compensatory movement patternsis also targeted. This was proved by the recent findings ofML. Woodbury et al.5 He suggests that under lying“normal” patterns of movement coordination are notentirely lost after stroke and that appropriatetreatments may be applied to uncover them tomaximize function.5

Since task related training and resisted exercise21

demonstrated enhanced recovery in stroke patients,Thielman et al 4 compared the effects of task relatedtraining and resisted exercise combined with trunk restrainttraining in his recent trial. Extensive practice using taskrelated training with truncal restraint appears to be a moreeffective approach to rehabilitate reaching with thehemiparetic arm.4

Due to an adaption involving anticipation ofchanged external load conditions.1

The adaptation was triggered by somato sensoryinput from the trunk or shoulder caused by thetrunk restraint.1

External feedback, that is, explicit information wasinherently built into the task practice with trunkrestraint context both as knowledge of results(KR) and knowledge of performance (KP).5

Future studies should emphasize someinterventions to the hemiplegic lower limbwhile giving trunk restraint training to thehemiplegic upper limb.

In daily living, reaching is more likely to beperformed in a standing position. In future, werecommend to study the influence of trunkrestraint training in arm reaching in standingposition.

Young and Schmidt6 showed that less retention oflearning occurs when continuous feedback isgiven compared with less frequent feedback.Hence further studies are necessary to determinethe efficacy of faded trunk-restraint program.

The results of our review demonstrated that the useof trunk restraint as a treatment paradigm aimed atdecreasing compensatory strategies has thepotential of becoming an effective therapy. Furtherresearches with randomized control trials arenecessary to determine the long term effect andclinical efficacy of the trunk restraint training inhemiparetic patients.

1. Michaelsen SM, Lutta A, Roby – Brami A, LevinMF. Effect of trunk restraint on the recovery ofreaching movements in hemiparetic patients.Stroke. 2001; 32: 1875 – 1883

2. Michaelsen SM, DEA, Levin MF. Short termeffects of practice with trunk restraint onreaching movements in patients with chronicstroke. Stroke. 2004; 35: 1914 – 1919

3. Michaelsen SM, Ruth Dannenbawn, Levin MF:Task – specific training with trunk restraint onarm recovery in stroke. Stroke. 2006; 37: 186 –192

4. Thielman G, Terry Kaminski, Gentile AM:rehabilitation of reaching after stroke:comparing 2 training protocol utilizing trunkrestraint. Neurorehabil Neural Repair. 2008; 22:697 – 705

5. Woodbury ML, Howland DR, Mcguirk TE, DavisSb, Senesac CR, Kautz S, Richards LG. Effectsof trunk restraint combined with intensive taskpractice on post stroke upper extremity reachand function: A pilot study. Neurorehabil Neuralrepair. 2009; 23: 78 – 91

6. Young DE, Schmidt RA. Augmented kinematicfeedback for motor learning. J Mot Behav.1992; 24: 261-273.

A SYSTEMATIC REVIEW : TRUNK RESTRAINT TRAINING AFTER STROKE

Titles and abstracts

identified (n = 6)

Studies retrieved for evaluation of full text

(n = 6)

Potentially relevant studies meeting the

inclusion criteria (n = 5)

Studies excluded after evaluation of full text (n = 1) Single group

design

Studies included in systemic review

(n = 5)

Background

Inclusion criteria

Outcome measure

Search Outcome

Discussion

Purpose of the Review

Results

How trunk restraint training improves reaching?

Conclusions

References

Trunk Restraint Training in Future

Michaelsen SM et al (2001)

Michaelsen SM et al (2004)

Michaelsen SM et al (2006)

Thielman G et al (2008)

WoodburyML et al (2009)

Anterior Trunk

Displacement

- 0.58 medium

effect

- - 5.53 huge effect

Elbow Extension

1.24 very largeeffect

0.29 small effect

- 0.27smalleffect

0 negligible

effect

Smoothness - - 0.22 small effect

- -

Hand trajectory

straightness

- - 0 negligible effect

- -

Data analysis