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Session 206: The Key to Restoring Balance, Gait, & ADLs FasterMichelle Green, PT, DPT, c/NDT, NCS

Leading the Way in Continuing Education and Professional Development. www.Vyne.com

OBJECTIVES:

1. Participants will be able to discuss the evidence supporting the role 

of trunk in basic functional task completion

2.Partipants will be able to identify and name various trunk motions 

and correlate each to associated functional tasks

3.Participants will be able to develop interventions aimed at 

restoration of specific trunk motions as needed for task 

completion useful for a variety of diagnosis in any clinical 

setting

HAVE FUN. THINK OUTSIDE THE BOX. BE BETTER.

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PROXIMAL CONTROLBEFORE

DISTAL MOBILITY

TRUNK LIMBS

WHAT IS ‘THE TRUNK”

Skeletal

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WHAT IS ‘THE TRUNK”

MusclesMore important will be the discussion of the MOVEMENTS these muscles produce in synchronous movement control, versus identification of individual muscles

ROLE OF THE TRUNK IN FUNCTION

STABILITY• Provides stability through lumbopelvic region to prevent

collapse of the vertebral column• Allow to body to be upright • Pre-requisite for distal limb movement

MOBILITY• Sustain equilibrium during perturbations• Restore equilibrium following perturbations (reactionary control)• Adjust weight shifts for function (anticipatory control)• Control the lumbopelvic segments during movement/gravity

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Schenkman M et al. PHYS THER 2006;86:1681-1702

©2006 by American Physical Therapy Association

The temporal sequence identifies 5 stages of task performance that can be considered during task

analysis and the specific features of importance for each stage.

Each task we assess and write a goal for will improve to a greater degree when the whole system is taken into consideration

Application of limb strength

Body has to be ready to move-

aligned for success

Needs control, activation of trunk, ROM

TRUNK LIMBS

FOUNDATIONAL TRUNK MOVEMENTSSEATED REACHING TASKS

Note how much movement occurs that is NOT UE or

LE?

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FOUNDATIONAL TRUNK MOVEMENTSTransitioning to Single-Limb Standing

Successful weight transfer is PRECEDED by the ability of the

CONTRALTERAL trunk muscles to activate

for initiation of movement

FOUNDATIONAL TRUNK MOVEMENTSGAIT: Transitioning into and through mid-stance

To get ONTO the foot (mid-terminal stance)

Contralateral trunk

muscles activate to

drive weight shift

And STAY on for successful swing

Without excessive anterior or posterior pelvic tilt.

BRIEF SUMMARY OF LITERATURE SUPPORTING ROLE OF TRUNK IN MOVEMENT

Recruitment of trunk precedes recruitment of limbs Latissimus Dorsi has role in ipsilateral stabilization as well as contralateral

movement Rectus Abd / Ext oblique activation precedes hip flexion, to a higher degree

on same side-Dickstein 2004

Movement of the deltoid is preceded by core muscle activation- Hodges 1996

Lower trunk more correlated to maintaining/planning balance and upper more correlated to responding to external forces

-Van der fits 1998

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ICF MODELInternational Classification of Function

Werner AS, Use of the ICF Model as A Clinical Problem-Solving Tool in Physical Therapy and Rehabilitation Medicine. Phys Ther 2002: 82:11; 1098-1107

What can’t they do

The reason WHY they can’t do EACH specific

task

Impairment(s) Activity Limitations

Participation Restrictions

Impact of Neurological Conditions and Aging on Trunk and Pelvis Delayed trunk activation in response to limb movement (Palmer 1996, Horak 1984) Bilaterally trunk muscles are weak, contralateral lateral trunk most involved (Karthikbabu 2012) More spasticity in limbs when LESS proximal control is present (Karthikbabu 2012) Impaired multidirectional peak torque in flexors, extensors and rotary muscles, lateral trunk flexors

weaker on hemi side (Bohannon 1995) Excessive use of upper versus lower trunk to initiate movement (neuro Messier 2004) Stroke pts with excessive pelvic instability and asymmetry in gait (Tyson 1999) Trunk function predicts outcome after stroke (Franignoni 1997, Duarte 2002, Hsieh 2002) W/S asymmetry due to frontal plane asymmetry is common, should include pelvis assessment in neuro

patients (Szopa 2017) Postural righting responses delayed in MS significant contributor to falls (Huisinga 2014) Trunk control in stroke predicts outcomes in gait, balance and ADL’s (Verheyden 2006) Static control is more impacted in Huntington's (Kegelmeyer 2017) Trunk motor impairment in stroke is linked to poor mobility and trunk instability. Treatment should

target trunk control (Isho 2016) Improved trunk control via external support improves hem arm function, RX should address pelvic

and trunk control to improve arm function in stroke (Wee 2015) Reduction in head and trunk mobility increases fall risk and decreases balance confidence in aging

adults (Hewtson 2018)

Schenkman M et al. PHYS THER 2006;86:1681-1702

©2006 by American Physical Therapy Association

The temporal sequence identifies 5 stages of task performance that can be considered during task

analysis and the specific features of importance for each stage.

The TRUNK and PELVIS are the BASE of all functional movements and improvement in task performance has to begin with an understanding of how the trunk and pelvis are impacted by the neurological diagnosis or aging process.

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HOW TO DO A TRUNK

ASSESSMENT

A VALID AND RELIABLE FORMAL OUTCOME

MEASURE DOES EXIST!!

TRUNK IMPAIRMENT SCALECorrelates to ADL, Gait and Balance Outcomes

after stroke (Verheyden)WHAT IS IT:Measures motor impairment of the trunk after stroke through the evaluation of static and dynamic sitting balance and coordination of the trunk (Verheyden 2004)

Score is 0-23. Over 20 is considered normal.17 Items. Only need score sheet, stop watch and treatment table without back/arm support

FIND IT:Verheyden, G., Nieuwboer, A., et al. The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke." Clin Rehabil 2004;18(3): 326-334

www.youtube.com and search for TIS (Trunk Impairment Scale) to watch execution of the test

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TRUNK IMPAIRMENT SCALE

RECOMMENDED for patients following a STROKE and those with Multiple Sclerosis only if their EDSS is greater than 4.0 (all the way to 9.5) -Academy of Neurologic Physical Therapy

LIMITED STUDIES supporting its use in patients with TBI, Parkinson’s, Aging and Spinal Cord

Alternative: MANUAL ASSESSMENT OF TRUNK MOVEMENT PATTERNS

What to Include??16 motions

8 Upper Trunk & 8 Lower Trunk4 Planes of Motion

SAGITTAL, FRONTAL, TRANSVERSE, DIAGONALS2 in each plane (ant/post or side/side)

Alternative: MANUAL ASSESSMENT OF TRUNK MOVEMENT PATTERNS

“I’m going to move you. Don’t help me or fight me, just let me see how easily you move in these directions”

Begin with Upper Trunk

Move to Lower Trunk

Check passive (to see how much range/length is available)

Check active-assisted (to see if motor control is available to help)

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Correlate limited trunk motions and limited motor control with LIKELY DEFICITS in function.

This will DIRECTLY guide treatment selection and prioritization. This is the beginning of understanding

WHY your patient is unsuccessful with a task.

TRUNK MOVEMENT PATTERNS

UPPER TRUNK INITIATED MOVEMENTSSAGITTAL

•Flexion: bend down to pick up pen•Extension: look at clouds above

DIAGONAL•Flexion: reach to opposite side foot; sit- supine•Extension: reach up and behind (seatbelt)

FRONTAL•Flexion: place glass on floor to side

TRANSVERSE•Rotation: look over shoulder behind you

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NORMAL TRUNK MOVEMENTUPPER TRUNK INITIATED MOVEMENT

NOT Point of Initiation for Most Tasks in Patient Goals

Need LOTS of this!!!NOT a Weight shift

TRUNK MOVEMENT PATTERNS

LOWER TRUNK INITIATED MOVEMENTSSAGITTAL

•Anterior Tilt: sit – stand•Posterior Tilt: lifting foot to tie shoes

DIAGONAL•Anterior Tilt: Reach outside BOS at angle •Posterior Tilt: crossing legs to put on shoes

FRONTAL•Lateral reach outside of base of support

TRANSVERSE•Rotation: scooting forward and back on mat in sitting

NORMAL TRUNK MOVEMENTLOWER TRUNK INITIATED MOVEMENT

Point of Initiation of Transfers,

Balance, ADL’s and W/S for

Gait/steps and dynamic gait

Single Plane and Multi Directional Pelvic and Trunk Control = FUNCTION

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LET’S RECONSIDER…

If OT’s only work the arms and PT’s only work the legs, will any true retraining of tasks occur?

PSSSS….. The answer is NO!!

LET’S TREAT THE TRUNK & PELVIS

Sit- StandSit – supineAnticipatory and Reactionary BalanceADL’s (multi-directional pelvic and trunk)Gait

TREATMENT PRINCIPLES:

Start Small- But Relevant!

Gradually ADD IN Degrees of Freedom for Demand and Progression (TASK SPECIFIC)

Make the activity look more and more like the task

EACH SESSION should be a step in the RIGHT direction… toward goal attainment!!!

General, non-specific movements of limbs will not improve function for our neurologically impaired patients (Kleim 2011)

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TREATMENT PRINCIPLES:

InitialTreatment

Goal Achieved

Establish Initial Conditions (postural

support against gravity)

Train for Point of Initiation for EACH

specific task

Integrate motor pattern of postural control and

initiation and challenge with range and time holds

Add limbs as they are used in task on STABLE

trunk/pelvis

Simulate task.

Support as needed

Challenge for real-life: speed, direction, height, dual-tasking, surface, lighting

Apply Motor Control/learning Theories for Relevant

ProgressionExecution- note the prep work that needs to be done for success

Example…. WIPING FROM REAR

MISSING: POINT OF INTITIATION

Unable to push right foot into ground AND unable to activate right side of trunk and neck for left weight shift:

basic foundational movement of task.Positioned to force weight and

demand on right LE and provided cues to activate right side of trunk

ACTIVATE lateral trunk muscles for lower trunk lateral movement.

Example….WIPING FROM REARRight LE now active.

Next….Add another degree of

freedom…moving toward the task of wiping from the rear.

Need right cervical rotation and right trunk rotation on active right LE.

Worked those muscles, rotate – hold. Release. Push, rotate, hold, release.

Emphasis on building endurance, focus on quality and on sustaining

needed trunk stability.

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Example….WIPING FROM REAR

Added shoulder extension on rotated trunk.

For extra demand… add TheraBand from the front….to

pull (activating shoulder extensors) Change color of TheraBand for progression.

Note: If no shoulder extension available- would have gone back to soft tissue work, joint mobs, activation in

isolation before adding to this task.

EXECUTION: Added use of limbs on now active and stable trunk.

2 Weeks s/p acute ACA stroke. This

change made in 45 minute session.

Required one more session to “glue” the movement

patterns

SIT - STANDTask Initiates: Anterior Pelvic Tilt

Common Impairments of the TRUNK/PELVIS: Unable to sustain neutral trunk through transition Weak cervical neck flexors to isometrically hold in neutral Lacks Range of motion to achieve successful anterior pelvic tilt Utilizes upper trunk versus lower trunk to initiate task Therapist uses cue “nose over toes” or pulls on gait belt, both of

which influence upper trunk over lower trunk activation

Common Strategy Limitation: Lift off, Sequencing, hips extend before knees extend, lack ant pelvic tilt/trunk control for transition

Functional Needs: Speed, different heights, surfaces, holding items in UE, up and go

Sit – stand task

BOTH NEED

“MOD ASSIST” FOR SIT TO STAND.

BUT….THE TREATMENTS ARE VERY DIFFERENT!!!

Ther Ex to improve ant pelvic tilt, Anterior tibial translation and knee/hip

extension in closed chain..

BUT….not NuStep/bike/LAQ and UBE!!!!!!

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Working on “lift-off” in

safe, controlled

setting

The HIP ABDUCTION is key to unlocking the tightness in the adductors and re-establishing pelvic on femoral motion as

needed for many functional task.

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FRONTAL and SAGITTAL PLANE ASYMMETRY

Placed patient in reverse chair position, wedged hip to find midline, then did activation of LEFT side trunk muscles with right side reaching and left side cervical

rotation, L LE press into ground and left UE reach behind.

Address Them Together: address weight shift AND do lift offs and trunk stability

NMR in reverse chair sitting position for right weight shift and left side trunk shortening as needed for terminal stance in gait (dressing). Wedged left pelvis enhanced right weight transfer and potential for left side trunk activation, guided reaching tasks with right UE for demand on left side trunk and neck postural muscles. Mod assist required for sequence of activation and to reduce compensations.

SUPINE - SIT Task Initiates: Cervical Flexion

Common Impairments of the TRUNK/PELVIS Lacks initiation of cervical flexion Loss of upper trunk flexion Loss of upper on lower trunk rotation Limited open chain hip flexion/scooping motion on STABLE trunk

Common Strategy Limitation: Sequencing

Functional Needs: Speed, different heights, both sides

Supine- Sit: Note the ERROR

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Focus on Re-educating Cervical and Trunk flexors- symmetrically then asymmetrical from higher than lower surface

Then, REPEAT to varied directions and heights for selective trunk muscle

recruitment

DOCUMENT:

“NMR to retrain initiation of cervical flexion for supine to sit. Added reaching task to improve rotation as needed for bed mobility”

This documentation shows how treatment is related to specific goal.

Can be done in any setting

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ADL’s/ Multi-Directional Pelvic Motions

Task Initiates: All upper and lower trunk patterns(lower trunk more for ADL’s) REACHING TASKS & OPEN CHAIN HIP FLEXION

Common Impairments: Unable to access ROM!!! Fix first Lack of lateral trunk and cervical neck muscle activation for basic postural

righting reactions Lack of closed chain isometric/concentric LE hip engagement Lack of symmetrical rectus activation Inactive Posterior trunk rotation/ trunk extensors on stable pelvic positionCommon Strategy Limitation: Sequencing of weight shift and postural righting reactions to look like a specific task (initiation of threading LE into pants)

Functional Needs: Stable trunk in multi directional weightshifts with open chain UE and LE movements

FRONTAL and SAGITTAL PLANE ASYMMETRY

This could be used here as well to re-establish foundational range of motion and activation

Lateral Reaching Task: Lift OFF, not put on (increased demand on targeted lateral trunk muscles.

If adding PLACEMENT of object, do so in rotational/diagonal PNF pattern (opposite hip)

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Use of ESTIM to Enhance Lateral Trunk Muscles during reaching task. WHY NOT!?

Before: note length of left

side

After: Note shortening of left side trunk and “wrinkle”

“penny in the bucket”- alternating sides putting item under bottom (tissues, pegs, penny). If have hemi-side, train univolved side to access and reach to hemi side.

TheraBand Manipulation:Use loop of TheraBand“Place over one foot then the other and walk it up the legs and body until it comes off the head. You can not full stand up”

NMR in sitting for multidirectional weight shifting as needed for LB dressing (Gait, Transfers, hygiene…) PT provided mod manual cues for visual attention and rotation to involved side, tolerated no more than 8 minutes at a time before needing rest break, multiple bouts performed with improved left side attention noted.

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GAIT TWO BIG PROBLEMS:1. Stance2. Swing

Both require the SUSTAINED transfer of weight to one limb, requiring the ACTIVTION of lateral neck and trunk muscles on side CONTRALATERAL to weight shift for terminal stance and swing to occur

Active Trunk Side

Lateral Reaching Task

Get pelvis rolling over femur and pelvic lateral tilting and trunk activation as needed for gait

Encourage push through involved LE to drive weight shift, sets up for terminal stance-push off

Can be progressed to standing

Active Side

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CASE STUDY: Beginning of Session (eval)

Day 1 Evaluation for PT: Bob 78 y.o. male right MCA hemorrhage 5 months ago. Went to acute rehab, home with HHS, now 2nd acute rehab stay

WHAT MIGHT YOU HYPOTHESIZE ARE SOME

OF HIS ACTIVITY LIMITATIONS AND

ASSOCIATED IMPAIRMENTS?

1st Time Walking 

Hypothesize possible limiting impairments from this video:

GAIT: 30 feet, max assist x 2 with strong left lean, failure to weight transfer right of midline to achieve terminal stance right for effective clearance left LE, Short stance time right, short step length left. Assistance provided for left lean, no evidence of buckling left LE or loss of positional sense left LE.

FRONTAL and SAGITTAL PLANE ASYMMETRY

Treatment Addressed PRIMARY dysfunction of trunk alignment and activation- prohibiting appropriate use

of available strength

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Improved anterior pelvic tilt, will assist with anterior weight transfer and sit- stand

FRONTAL and SAGITTAL PLANE ASYMMETRY

Beginning of Session 45 minutes later…..

FRONTAL and SAGITTAL PLANE ASYMMETRY

When foundational trunk/pelvic alignment and

activation is layered into treatment, the potential for

movement changes

Improved right weight transfer and left side trunk activation/resting muscle length

45-minutes later

One hour later….

Gait: Prior to interventions, max assist x 2, strong left lean, lack of right weight shift, following NMR interventions, min assist x 2 60 feet, less left lean, improved right w/s and left LE clearance, demonstrated full left cervical rotation and improved attention and awareness to left side. (charges for this session: 1 GT/ 3 NMR)

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ANTICIPATORY BALANCE REACTIONS

Task Initiates: APPROPRIATE TRUNK RIGHTING REACTIONS

Common Impairments: See Dynamic Sitting- need these trunk responses, all directions Lack of synchronized muscle activation of neck and trunk Loss of needed ROM in neck and trunk for opposing muscle group

to effectively activate

Common Strategy Limitation: Control of trunk during cross over motions or sidestepping motions, lack of correlated trunk righting reactions with multi directional stepping

Functional Needs: Reactionary and anticipatory abilities in all directions, dual task, carrying objects in UE, different surfaces and speeds

ANTICIPATORYBALANCE REACTIONS

NORMAL: In normal movement, postural adjustments occur BEFORE movement of the limbs. The goal is to prepare the trunk with stability to handle the destabilizing force

Following stroke and neurological injury, this process is disrupted!• Impaired anticipatory muscle activation on hemi-side following stroke (Dickstein 2004)• Asymmetry in activation of anticipatory muscles following stroke (Dickstein 2004)• During upper and lower limb movements following stroke, trunk was noted to have dec.

muscle activation, delayed onset of muscle activation, impaired synchronization (Bohannon 1995)

• MS patients have delayed anticipatory muscle activity (Aruin 2015) and benefit from training (Kanekar 2015)

• Anticipatory postural responses improve with training in older adults (Aruin 2015)

CONSIDERATIONS FOR TREATMENT:

Initial Conditions:Trunk needs to have

symmetrical activation and stability.

• Supine core work• Prone core work• Side lying core work• Seated neutral core*Align for symmetrical activation

Initiation:Trunk/pelvis needs to be able

to initiate in all planes(lower > upper)

• All activities for sit- stand• All activities for multi-

directional weight shifts• Dynamic weight shifts in

standing as well (laterally)

Execution:Practice tasks with manual

cues/visual cues and ensure proper sequence of

activation is occurring(if not, go back and re-establish foundational control and movement

initiation)• Tap ups• Side stepping• Cross Over Stepping• Stepping in clock

pattern• Wide steps and out and

in• Step up and over (front

and side and diagonal)• Tall kneeling <> ½

Kneeling• Reaching• ADL’s

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EXAMPLES OF COMMONLY USED COMPENSATIONS with ASYMMETRICAL

TRUNK

Normal Pattern when shifting onto

INVOLVED side

Highly Compensated when attempting to load the UNINVOLVED side

Weaker side

Relies on STRONGER side for trunk control to stabilize

Difficult to sustain stability on STRONGER side due to reliance on weaker left side Foot “kickstand”

for wider BOS

Arm for support in absence of trunk

EXAMPLES OF COMMONLY USED COMPENSATIONS IN PATIENTS WITH

TRUNK ASYMMETRY

Much more difficult to sustain SLS on GOOD side due to lack of

INVOVLED side (contralateral side)

activation of trunk and neck for sustained

stability

Normal Movement

to INVOLVED side

Ineffective Anticipatory Reaction for SLS due to Trunk NOT LE or UE strength.

DO PATIENT’S BENEFIT FROM ADDITIONAL OF TRUNK STABILIZATION AND MOBILITY EXERCISES?

Core stability exercises in sub-acute stroke patients improved TIS, BERG and Barthel Index (Cabanas-Valdes 2015)

4 weeks of anticipatory balance training improved proximal activation before distal limb movements in aging adults (Jagdhane 2016)

Addition of trunk stabilization exercises improved gait and balance in patients following stroke (Gadhvi 2016)

Balance training alone is not enough for ataxic persons with MS, specific core stabilization exercises and task specific for balance recovery are needed (Salci 2016)

And many more…..

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SUMMARY: Movement starts proximally Proximal stability before distal mobility Add pelvic and trunk assessment to your

evaluations Limitations correlate with functional deficits-

match them up! Treat limiting impairment(s) in pelvis and trunk

stability, symmetry and mobility as needed for desired task improvement

QUESTIONS?You can reach me here:

Michelle Green PT, DPT, c/NDT, NCS

mgreen@campbell.edu