Med. J. Cairo Univ., Vol. 82, No.
2, September: 7-13, 2014
www.medicaljournalofcairouniversity.net
Task-Specific Training with Trunk Restraint: Its Effect on Reaching
Movement Kinematics in Stroke Patients
SALAH A. SAWAN, Ph.D.*; HUSSEIN A. SHAKER, Ph.D.*; EBTESAM M. FAHMY, Ph.D.** and
NAGWA I. REHAB, M.Sc.*
The Department of Physical Therapy for Neuromuscular Disorder & Surgery*, Faculty of Physical Therapy, Cairo University
and Neurology** Department, Faculty of Medicine, Cairo University
Abstract
Background and Purpose: Hemiparesis is common fol-
lowing stroke. The ability to reach and grasp is a necessary
component of many daily life functional tasks, hence reduced
upper limb function has an impact on the ability to perform
activities of daily living. In hemiparetic patients, the unre-
stricted and unguided repetition of a motor task may reinforce
compensatory movements. Trunk restraint allowed the patients
to use joint ranges that were present but not recruited during
unrestrained reaching. This study aimed to compare the effect
of specific-task training with and without trunk restraint on
post-stroke reaching kinematics.
Patients and Methods: Thirty male chronic stroke patients
with age ranged between 40-55 years were included in this
study. Patients were divided into two equal group (Group I
and Group II). The first group (Group I) received reach to
grasp training during which compensatory movement of the
trunk was prevented by trunk restraint. The second group
(Group II) practiced the same task without trunk restraint.
Kinematics of reaching and grasping an object placed within
arm’s length were recorded before and after training using
two-dimensional analysis.
Results: Trunk-restraint group showed a statistically very
highly significant decrease in trunk displacement ( p=0.0001)
and increase in elbow extension voluntary range of motion
(ROM) (p=0.0001) post treatment while group II showed
significant increase in trunk displacement ( p=0.02) and highly
significant decrease in elbow extension ROM ( p=0.007) post
treatment. Also, there was very highly significant decrease in
trunk displacement (p=0.0001) and increase in elbow extension
ROM (p=0.0002) in the trunk-restraint group as compared to
the second group without trunk-restraint post treatment.
Conclusion: Task-specific training with trunk restraint
can be suggested as an effective method in improving reaching
kinematics and arm movement quality in patients with impaired
arm function post stroke.
Key Words: Stroke – Arm reaching – Grasping – Trunk
restraint – Task-specific training and Two-
dimensional analysis.
Correspondence to: Dr. Salah A. Sawan, The Department
of Physical Therapy for Neuromuscular Disorder & Surgery,
Faculty of Physical Therapy, Cairo University
7
Introduction
STROKE often impairs the ability to reach with
the affected upper extremity. Because reaching is
a necessary component of many tasks of daily
living, survivors experience decreased autonomy
and quality of life [1] . Indeed, many studies have
documented the presence of impaired reaching
ability and inefficient compensatory movement
after stroke [2] .
Difficulty extending the elbow after stroke is
common and this limitation is clinically observed
as part of a flexor synergy pattern that produces
concurrent flexion motions, and which also often
impairs the survivor of stroke’s ability to control
individual joints. Zackowski et al., [3] characterized
the difficulty in extending the elbow as part of a
“joint individuation deficit”, and hypothesized that
this deficit was more correlated with abnormal
reaching performance than other potential predic-
tors such as impaired sensation.
In order to compensate the upper limb impair-
ment, participants with hemiparesis can use alter-
native strategies to improve functional arm and
hand use. For example, when the active range of
arm motion (ROM) is decreased, individuals can
transport the hand to the object by using the trunk
[4] . This increased trunk recruitment is a compen-
satory mechanism by which the central nervous
system (CNS) may extend the reach of the arm
when the control of the active range of the arm
joints is limited [5] .
A functional quantitative analysis of upper
limb movement during arm reaching illustrated
that patients with hemiparesis used more trunk
flexion and shoulder abduction to compensate
for reduced elbow extension and demonstrated
8 Task-Specific Training with Trunk Restraint
abnormal shoulder abductor power to compensate
for reduced shoulder flexor power. These compen-
satory movement strategies are evident during
unilateral upper limb tasks [6] .
The compensatory involvement of the trunk is
greater for patients with more severe motor deficits
[4] and may be related to impairments of grasping
[7] . The presence of excessive trunk movement in
hemiparetic individuals while reaching may limit
the potential recovery of normal arm movement
patterns [5] . However, limiting trunk motion in
patients after stroke has been shown to encourage
more normal elbow and shoulder motion during
reach to grasp objects [8] .
No Studies have been conducted to investigate
the effect of trunk restraint on reaching movement
in chronic stroke patients in Eygpt. This study was
designed to investigate the effect of task specific
training with trunk restraint on reaching kinematics
in stroke patients.
Patients and Methods
Thirty male stroke patients aged from 45 to
55 years were enrolled in this study. Patients were
selected from the Out Patient Clinic of the Faculty
of Physical Therapy, Cairo University in the period
from the beginning of October 2013 to the end of
March 2014. Patients were divided into two equal
groups. The first group (Group I) received a pro-
gram of reach to grasp training with trunk restraint
and the second group (Group II) received the same
program without trunk restraint.
The patients were diagnosed as having stroke
in the domain of carotid system based on careful
clinical assessment by a neurologist and radiolog-
ical investigations including computed axial tom-
ography or magnetic resonance imaging of the
brain. Patients participated after signing a written
consent forms approved by the Ethics Committee
of the Faculty of Physical Therapy, Cairo Univer-
sity.
Inclusion criteria were duration of illness
ranged from six months to one year. The muscle
tone of affected upper limb ranged from 1 to 2
according to Modified Asworth Scale (MAS) [9]
for muscle tone grading. Moderate arm motor
impairement (between 30 and 49 scores) on the
Fugl-Meyer (FM) arm section scale according to
Michaelsen et al., [10] . Ability to reach to targets
within 80% of arm length without sliding hand
along table. Normal vision and hearing.
Exclusion criteria include patients who had
receptive aphasia, apraxia, unilateral spatial neglect,
visual or auditory defects, recurrent stroke, other
neurological disorders affecting the reaching to
grasping ability such as ataxia, orthopaedic disor-
ders affecting the reaching to grasping ability such
as stiffness of arm and peripheral nerve injuries,
shoulder pain, deep sensory loss, medically unstable
and uncooperative patients.
- For clinical evaluation:
Modified Asworth Scale for assessment of
muscle tone and upper extremity impairment for
all patients was evaluated as inclusion criteria with
the arm section of the FM scale. This scale includes
4 motor subitems. Each item was rated on a 3-
point scale (0 = Cannot perform; 1 = Partially
performs; 2 = Performs fully) for a 66-point max-
imum [10] . This test was done pre and post treat-
ment.
- For kinematic analysis:
Two-Dimensional (2D) Motion Analysis Sys-
tem: It required a digital video camera and a digi-
tizing soft ware program [11] . It was used to measure
trunk displacement and elbow extension ROM.
A- Evaluation session:
- Assessment of arm motor impairment using the
FM arm section scale. This test was done pre-
and post treatment.
- For kinematic analysis. On pre-and post-tests,
Patients seated on chair with their trunk unre-
strained. Sitting position is standardized: Hip and
knee joints flexed to 90º and feet supported on
the floor. In the initial position, the reaching arm
was close to the body, and rested on patient’s lab
with the forearm pronated at elbow height (elbow
flexed to 90). After a command, each patient
reached and grasped a target by the affected arm
at his preferred speed using whole-hand grasping.
The distance of the target corresponds to the
patient’s wrist crease with fully extended elbow
(80% arm’s length) [10] . Five markers were placed
on the following bony landmarkers; Ipsilateral
acromion, lateral epicondyle, centre of dorsal
aspect of the wrist, base of middle finger and
middle of iliac crest according to Mohammed et
al., [12] .
B- Training session:
All patients in the study group (GI) received
program of reach to grasp training for almost an
hour three times per week for five successive weeks
(total of 15 sessions) according to Michaelsen et
al., [10] . Trunk movements were prevented by body
and shoulder belts attached to the chair back.
Intervention was based on motor learning concepts
Salah A. Sawan, et al.
of type and scheduling of feedback and intensity
according to recommendations suggested by evi-
dence-based practice guidelines [13] using box and
block and Purdue Peg board training. Rest periods
of one to two minutes were permitted when neces-
sary to avoid fatigue. All patients in the second
group (GII) received the same program without
trunk restraint.
All patients in two groups received the selected
physical therapy program (Postural control and
balance activities, Bobath technique, upper extrem-
ity control, proprioceptive neuromuscular facilita-
tion (PNF), weight bearing and weight shift exer-
cises as modified plantigrade, lower limb control
and gait training).
Data analysis: Trunk displacement was calcu-
lated from sagittal movement of acromion marker
from the edge of the chair in millimeters. Elbow
extension ROM was formed by the vectors formed
between acromion and lateral epicondyle line and
lateral epicondyle and wrist line.
Statistical analysis:
Descriptive statistics were done in the form of
mean and standard deviation for age, duration of
illness, arm impairment, trunk displacement and
elbow extension ROM. Paired t-test was used to
assess changes within groups and un-paired t-test
used to assess the changes between the two groups.
Analysis was done using SPSS version 18. The
alpha point of 0.05 was used as a level of statistical
significance (when p !_ 0.05 is usually classed as
“significant”, p !_ 0.01 as “highly significant” and
p!_ 0.001 as “very highly significant”) [14] .
Results
Demographic and clinical characteristics of
the patients in both groups:
No statistically significant difference between
both groups regarding mean age, duration of illness
Table (1): Demographic and clinical characteristics of the patients in both groups (GI and GII).
Demographic and GI
clinical characteristics Mean SD
Age (year) 47 5.490
Duration of illness 9.670 1.543
(months)
FM score 39.33 3.519
SD : Standard deviation.
P : Probability.
S : Significance.
9
and motor impairment (p=0.436, p=0.1295 and
p=0.1821 respectively) (Table 1). In GI, nine pa-
tients had left sided hemiparesis and six patients
had Rt sided hemiparesis while in GII, Six patients
had left sided hemiparesis and nine patients had
right sided hemiparesis.
I- Comparison of trunk displacement and elbow
extension ROM within groups:
Group (I):
There was a statistically very highly significant
decrease in trunk displacement score post treatment
in GI (p=0.0001). The mean value of trunk displace-
ment was 116.50mm pre treatment and 45.60mm
post treatment. Also, there was a statistically very
highly significant increase in elbow extension ROM
score post treatment in GI ( p=0.0001). The mean
value of elbow extension ROM was 51.40º pre treat-
ment and 59.2º post treatment (Table 2, Figs. 1,2).
Group (II):
There was a statistically significant increase in
trunk displacement score post treatment in GII
(p=0.0227). The mean value of trunk displacement
was 129mm pre treatment and 145.60mm post
treatment. Also, there was a statistically very highly
significant decrease in elbow extension ROM score
post treatment in GII ( p=0.0001). The mean value
of elbow extension ROM was 53.53º pre treatment
and 50.27º post treatment (Table 2, Figs. 1,2).
II- Comparison between both groups as regarding
trunk displacement and elbow extension ROM
pre and post treatment:
There were no significant difference in the mean
values of trunk displacement and elbow extension
ROM between GI and GII pre treatment ( p=0.4967
and p=0.2223 respectively). There were a statistically
very highly significant difference in the mean values
of trunk displacement and elbow extension ROM
between GI and GII post treatment ( p=0.0001 and
p=0.0002 respectively) (Table 3, Figs. 3,4).
GII Comparison
S
Mean SD t-value p-value
48.33 3.559 0.7892 0.4366 NS
10.47 1.246 1.562 0.1295 NS
37.33 4.435 1.368 0.1821 NS
NS : Non-significant.
FM : Fugl-meyer.
10 Task-Specific Training with Trunk Restraint

Table (2): Comparison between pre and post treatment mean values of trunk displacement and elbow extension ROM in
both groups.

Pre-treatment Post-treatment
Variables Mean difference t-value p-value Significance
Mean±SD Mean± SD

Trunk displacement:
GI 116.50±34.85 45.60± 13.12 –70.91 5.627 0.0001 *** VHS
GII 129.0±31.55 145.60±31.57 16.59 2.558 0.0227 * S
Elbow extension ROM:
GI 51.40±2.823 59.20±5.519 7.800 5.954 0.0001 *** VHS
GII 53.53 ±5.986 50.27±5.688 2.600 3.129 0.0074 ** HS

ROM : Range of motion.

SD : Standard deviation.
P : Probability.
S : Significant at p≤0.05.
HS : Highly significant at p≤0.01.
VHS : Very highly significant at p≤0.001.

Table (3): Comparison of the mean values of trunk displacement and elbow extension ROM between both groups pre and post
treatment.

Trunk displacement Elbow extension ROM

Un paired t-test Pre-treatment Post-treatment Pre-treatment Post-treatment

GI GI GI GI GI GI GI GI

Mean 116.50 129.0 45.60 145.60 51.40 53.53 59.20 50.27

SD 34.85 31.55 13.12 31.57 2.823 5.986 5.519 5.688

Mean difference
–12.5 –100 –2.13 8.93
t-value
p-value 0.6887 9.897 1.248 4.366
S 0.4967 0.0001 *** 0.2223 0.0002 ***
NS VHS NS VHS
ROM : Range of motion.
SD : Standard deviation.
P : Probability.
NS : Non-significant.
VHS : Very highly significant at p≤0.001.

59.2
145.6 53.53
160 60 51.4
129 50.27
Elbow extension ROM (degrees)

140 116.5
Trunk displacement (mm)

50
120
100 40

80 30
45.6
60
20
40
20 10

0 0
GI GII GI GII

Pre-treatment Post-treatment Pre-treatment Post-treatment

Fig. (1): Comparison between pre and post treatment mean Fig. (2): Comparison between pre and post treatment mean
value of trunk displacement in both groups. value of elbow extension in both groups.
Salah A. Sawan, et al.
180
145.6
129
Trunk displacement (mm)
150
116.5
120
90
45.6
60
30
0 0
Pre-treatment Post-treatment
GI GII
Fig. (3): Comparison of the mean value of trunk displacement
between both groups pre and post treatment.
Discussion
In the present study, there was a significant
reduction of trunk displacement in GI, while there
was a significant increase of trunk displacement
in GII. This agreed with Cristea et al., [15] and
Schneiberg et al., [16] who reported that there was
an increase in compensatory movements with un-
restricted practice in stroke patients and in children
with mild cerebral palsy after 3 weeks of constraint-
induced therapy respectively. McCrea et al., [17]
also, mentioned that constraints from stroke im-
pairments can result in the need for additional
degrees of freedom at other joints such as move-
ment compensations of the trunk during reaching.
Michaelsen et al., [10] also found that the moderate
trunk restraint group had a significant reduction
of trunk displacement but moderate task specific
training groups had significant increase of trunk
displacement. Moreover, results of this study agreed
with Wee et al., [18] who concluded that trunk
restraint reduced excessive trunk movement during
reaching.
Results of this study contradict with Michaelsen
and Levin [19] who reported that task specific
training with trunk restraint and without trunk
restraint decrease trunk displacement post treat-
ment. The contradiction between studies may be
attributed to different methodology and training
used, as in this study, the second group practice
task specific training without trunk restraint nor
verbal instruction not to move trunk but in the
study of Michaelsen and Levin [19] practiced task
specific training while verbally instructed not to
move the trunk.
11
59.2
60 53.53
51.4 50.27
Elbow extension ROM (degrees)
50
40
30
20
10
Pre-treatment Post-treatment
GI GII
Fig. (4): Comparison of the mean value of elbow extension
ROM between both groups pre and post treatment.
The reduced scores of trunk displacement in
GI may be due to prevention of compensatory
forward trunk displacement by trunk restraint but
the increased score in GII may be to enable the
patients to adequately reach the target placed within
the length of the arm, accompanied with limited
shoulder flexion and elbow extension ROM. It has
been suggested that excessive trunk recruitment
may be an adaptation of the nervous system during
early recovery from stroke, to obtain a short-term
reduction of the disability [20] . However, this
compensatory strategy may be maladaptive and
detrimental in the long term since, by providing
an alternative method for the hand to reach an
object, the system is less motivated to use a solution
requiring recovery of lost movement elements
(such as elbow extension and shoulder flexion)
[4] .
Cirstea and Levin [4] mentioned that patients
with poorer motor recovery used more trunk dis-
placement to compensate limited active joint ranges
of the hemiparetic arm. The excessive trunk dis-
placement is thought to be due to the fact that the
control of trunk is bilaterally organized and there-
fore less affected than that of the arm by the uni-
lateral hemispheric lesion. Another possible expla-
nation is that the results of excessive trunk
displacements is thought to be a compensatory
behavior emerging from the efforts of spared cor-
tical and subcortical system systems to compensate
for lost control over motor functions such as elbow
extension [21] .
In the present study, there was significant in-
crease in elbow extension ROM in GI, while there
was a significant reduction of elbow extension
12
ROM in GII. The results of the present study come
in agreement with Michaelsen et al., [10] and Wood-
bury et al., [8] who reported that trunk restraint
group significantly increase elbow extension ROM
in trunk restraint group but the non restraint group
did not gain.
Significant increase of elbow extension ROM
in GI may be attributed to use of trunk restraint.
Hemiparetic patients use abnormal interjoint syn-
ergies to accomplish arm movement [22] . The arm
extension synergy is characterized by scapular
elevation and protraction together with shoulder
extension, adduction and internal rotation, elbow
extension, and wrist flexion. Limiting components
of this synergy (scapular protraction and elevation)
by trunk restraint may encourage the recovery of
combined shoulder flexion and elbow extension
[5] .
The effects of trunk restraint indicate that hemi-
paretic patients do not use their potential joint
range for free arm movements. A likely explanation
stems from the findings of Levin et al., [23] who
defined articular ranges in which hemiparetic pa-
tients could make isolated elbow flexion and ex-
tension movements by using a reciprocal muscle
activation pattern. The angular range was correlated
with the motor deficit such that the most severely
affected patients could only make isolated elbow
movements in midrange. With further encourage-
ment, movement beyond the defined ranges was
possible, but this required more effort and was
accompanied by a pattern of excessive agonist/
antagonist coactivation. For elbow extension, the
excessive coactivation occurred when patients
attempted to extend the elbow beyond the angular
position defined by the static stretch reflex threshold
for the antagonist elbow flexors. It may be postu-
lated that restriction of trunk movement enabled
patients to extend their reach by using the joint
range characterized by coactivation. The additional
energy cost of using more elbow extension probably
was avoided by hemiparetic individuals when
reaching without trunk restraint.
The increase in joint ranges with trunk restraint
may be partly due to an adaptation involving an-
ticipation of changed external load conditions or
the adaptation was triggered by somatosensory
input from the trunk or shoulder caused by the
trunk restraint [24] . The finding that trunk restraint
led to an increase in active angular range in hemi-
paretic patients suggests that patients may have
retained the ability to adapt their motor commands
to new external conditions [5] .
Task-Specific Training with Trunk Restraint
Reaching patterns (arm ROM and interjoint
coordination) changed during the period of trunk
restraint [5] . However, it is difficult to determine
whether improvements were a result of the stabi-
lizing effect of the external trunk support or to a
reorganization of the arm degrees of freedom by
the central nervous system to accomplish the task.
Results of the present study, showing an improve-
ment of reaching pattern after restraint removal,
support the latter mechanism. Trunk restraint al-
lowed patients with hemiparetic stroke to make
use of arm joint ranges that are present but not
normally recruited during unrestrained arm-
reaching tasks. Thus, the underlying “normal”
patterns of movement coordination may not be
entirely lost after stroke. In view of the results of
this study, recovery of reaching movement post
stroke differed according to therapeutic interven-
tion, motor compensation used for reaching move-
ments in the affected upper limb in stroke patients
are mainly to enable the patients to adequately
reach the target placed within the length of the arm
accompanied with limited shoulder flexion and
elbow extension ROM. Rrepetitive training of
unrestrained reaching may reinforce undesirable
compensatory strategies. Restriction of trunk should
be used even in patients with chronic hemiparesis
to encourage maximal use of available degrees of
freedom. Trunk restraint may also be a useful
technique in the acute phase of stroke to promote
maximal arm motor recovery.
Conclusion:
The present study showed that limitation of
compensatory trunk movement by trunk-restraint
may be an essential element to include during
training of reach to grasp for stroke patients with
moderate arm impairment. Also, the present study
showed that trunk restraint allowed patients with
stroke to make use of arm joint range (elbow
extension) that are present but not normally recruit-
ed during unrestrained reach to grasp task.
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