675431

research-article2016
NNRXXX10.1177/1545968316675431Neurorehabilitation and Neural RepairHaruyama et al

Original Research Article

Neurorehabilitation and

Effect of Core Stability Training on

Neural Repair
2017, Vol. 31(3) 240­–249
© The Author(s) 2016
Trunk Function, Standing Balance, Reprints and permissions:
sagepub.com/journalsPermissions.nav

and Mobility in Stroke Patients: DOI: 10.1177/1545968316675431

journals.sagepub.com/home/nnr

A Randomized Controlled Trial

Koshiro Haruyama, RPT, MSc1, Michiyuki Kawakami, MD, PhD2,

and Tomoyoshi Otsuka, MD, PhD1

Abstract
Background. Trunk function is important for standing balance, mobility, and functional outcome after stroke, but few studies
have evaluated the effects of exercises aimed at improving core stability in stroke patients. Objective. To investigate the
effectiveness of core stability training on trunk function, standing balance, and mobility in stroke patients. Methods. An
assessor-blinded, randomized controlled trial was undertaken in a stroke rehabilitation ward, with 32 participants randomly
assigned to an experimental group or a control group (n = 16 each). The experimental group received 400 minutes of
core stability training in place of conventional programs within total training time, while the control group received only
conventional programs. Primary outcome measures were evaluated using the Trunk Impairment Scale (TIS), which reflects
trunk function. Secondary outcome measures were evaluated by pelvic tilt active range of motion in the sagittal plane, the
Balance Evaluation Systems Test–brief version (Brief-BESTest), Functional Reach test, Timed Up-and-Go test (TUG), and
Functional Ambulation Categories (FAC). A general linear repeated-measures model was used to analyze the results. Results.
A treatment effect was found for the experimental group on the dynamic balance subscale and total score of the TIS (P =
.002 and P < .001, respectively), pelvic tilt active range of motion (P < .001), Brief-BESTest (P < .001), TUG (P = .008), and
FAC (P = .022). Conclusions. Core stability training has beneficial effects on trunk function, standing balance, and mobility in
stroke patients. Our findings might provide support for introducing core stability training in stroke rehabilitation.

Keywords
stroke, rehabilitation, abdominal muscles, exercise therapy, postural balance, gait

Introduction According to a recent review, optimal specific training

Disorders of trunk function are common in stroke
patients.1-9 Previous studies have reported muscle weak-
ness and delayed activity of the trunk muscles,1-4 signifi-
cant error of trunk position sense,5 inadequate center of
pressure control when sitting,6,7 decreased trunk perfor-
mance,8 and trunk asymmetry during gait.9 Trunk function
is associated with balance and walking ability in stroke
patients,10,11 and has also been found to offer a useful pre-
dictor of balance and walking ability12 and activities of
daily living (ADL) outcomes.13-17 Several randomized con-
trolled trials have focused on trunk performance in stroke
populations,18-20 and trunk training has reportedly improved
trunk performance in experimental groups.20-22 However,
those studies either have not equalized the amount of exer-
cise provided with a control group,20,21 or used an overly
wide variety of trunk training interventions.20-23 As such, it
is not yet clear which types of trunk training are more use-
ful to improve trunk performance in stroke patients.
remains unclear, and evidence is insufficient.18,19
To improve performance of the trunk muscles, stabiliza-
tion training is generally employed along with muscle
strength and muscular endurance training.24 The concept of
the “core” and the need to retrain “core stability” has been a
recent focus in the fields of low back pain and sports.25 The
1
Department of Rehabilitation Medicine, Higashisaitama National
Hospital, Saitama, Japan
2
Department of Rehabilitation Medicine, Keio University School of
Medicine, Tokyo, Japan
Supplementary material for this article is available on the
Neurorehabilitation & Neural Repair website at http://journals.sagepub
.com/doi/suppl/10.1177/1545968316675431
Corresponding Author:
Koshiro Haruyama, Department of Rehabilitation Medicine,
Higashisaitama National Hospital, 4147 Kurohama, Hasuda, Saitama
349-0196, Japan.
Email: koshiroharuyama@gmail.com
Haruyama et al 241
“core muscles” include many muscles supporting the
lumbo-pelvic-hip complex.25 Bergmark26 classified the
muscles acting on the lumbosacral spine as either “local” or
“global.” The “local” muscles work for segmental stability
system, while the “global” muscles work for movement of
the spine. Faries and Greenwood27 described the transver-
sus abdominis (TrA), diaphragm, pelvic floor muscles, and
deep fibers of the lumbar multifidus as local muscles and
the rectus abdominis, erector spinae, psoas major, and the
like as global muscles. They also provided definitions of
“core stability,” referring to the ability to stabilize the spine
as a result of local muscle activity. Key28 emphasized stabi-
lizing co-contraction increasing intra-abdominal pressure
via the control of local core muscles as the “stabilization
synergy” of the core. “Core stability training” is introduced
from the activation of the TrA as a primary local muscle in
the “core” muscles. For this purpose, abdominal drawing-in
maneuver (ADIM) training is usually used.29 ADIM train-
ing has been found to selectively activate the TrA,30-32 and
have the effect of stabilizing spinal segments.33 Hodges and
Jull34 and Comerford and Mottram35 proposed stepwise
exercises from local muscles to global muscles and integra-
tion of these groups in stability training. Some researchers
have reported that core stability training could improve not
only trunk function but also balance and mobility.20,36
However, the effects of a protocol based on core stability
training have yet to be sufficiently verified in stroke patients.
Although core stability training is expected to offer
effective trunk training, evidence for its application in
stroke is scarce. Since the innervation of the trunk muscles
is bilateral,37 complete paralysis of the trunk seems unlikely
to occur in stroke hemiplegia.38 Based on the core stability
theory, the combination of ADIM as a deep muscle move-
ment and selective pelvic exercises providing superficial
muscle movements would be more effective trunk training.
Selective pelvic exercises were employed in our protocol
because high feasibility for stroke patients has been reported
in previous studies showing positive effects of stroke reha-
bilitation including selective pelvic exercises.20-23 We
developed a step-by-step core stability training program
using selective pelvic exercises customized for stroke reha-
bilitation. This program was defined as “core stability train-
ing” in the present study.
The novelty of this study lies in the focus on core sta-
bility training and the development of an intervention pro-
tocol based on the theory that an original, detailed protocol
using selective pelvic exercises would benefit patients
who had experienced stroke. Participants in the control
group received a conventional physical therapy program,
including general trunk exercises. In addition, rehabilita-
tion intervention time for the experimental and control
groups were comparable, with the time in which partici-
pants in the experimental group received core stability
training lying within the time allocated for physical
therapy. If specific core stability training in this study
were to show efficacy in stroke rehabilitation, this
approach could represent an effective therapeutic strategy
for stroke rehabilitation. The purpose of this study was
thus to investigate the effectiveness of core stability train-
ing in improving trunk function, standing balance, and
mobility among patients showing hemiplegia after stroke.
Our hypothesis was that customized and specific core sta-
bility training for stroke patients would improve not only
trunk function but also balance and mobility, to a greater
extent than seen with a conventional comprehensive reha-
bilitation program.
Methods
Patients
Patients were recruited from among subacute stroke patients
hospitalized in Higashisaitama National Hospital between
September 2013 and December 2014. Inclusion criteria
were a history of first stroke, definite diagnosis of stroke
based on computed tomography and/or magnetic resonance
imaging, a supratentorial and hemispheric lesion, and more
than 1 month and less than 6 months since onset. Exclusion
criteria were age 80 years or more, inability to keep a sitting
position for 30 seconds, communication problems, comor-
bidities affecting motor performance such as orthopedic
and neurological disorders that could influence postural
control, maximum score (score = 23) for trunk performance
as assessed by the Trunk Impairment Scale (TIS)39 at the
start of the study, or lack of provision of consent to partici-
pate. All participants were asked to provide informed con-
sent before participation. Approval was given by the ethics
committee at Higashisaitama National Hospital (Approval
Number: 13-6).
Design
This study was designed as an assessor-blinded randomized
controlled trial. The number of patients required for this
study was calculated a priori to ensure sufficient statistical
power. Power estimates were based on a prior study inves-
tigating the effect of improvements in TIS.21 This revealed
that a sample size of 28 patients would be necessary to
achieve an 80% chance (effect size = 0.39, α = 0.05, power
= 0.80). We performed interim analysis as soon as the sam-
ple size reached the prescribed number based on the adap-
tive sequential design, confirming sufficient power to
identify significant differences in primary outcome mea-
sures. However, differences at baseline were observed in
some secondary outcome and recruitment was therefore
continued. When baseline equalization was confirmed on
continual interim analysis at the inclusion of 32 partici-
pants, recruitment to the study was ended.
242 Neurorehabilitation and Neural Repair 31(3)
Subjects were randomly assigned to 2 groups: the exper-
imental group, receiving specific core stability training; and
the control group, receiving only the conventional rehabili-
tation program. To allocate patients to one of these groups,
occupational therapists who were blinded to the research
performed assignments based on a computer-generated ran-
dom number. To exclude the influence of effects due to dif-
ferences in trunk function at baseline, we adopted a
permuted-block method combined with stratified random-
ization using the total TIS score. The block size was 2. Total
TIS score was stratified to ≥14 or <14, based on the median
score reported for stroke patients.39
The conduct and report of this trial followed the
Consolidated Standards of Reporting Trials (CONSORT)
statement for Randomized Trials.40,41 The study was regis-
tered with the UMIN Clinical Trials Registry (UMIN-CTR
number: UMIN000018667).
Intervention
Patients in the experimental and control groups received the
conventional multidisciplinary stroke rehabilitation pro-
gram provided by the rehabilitation hospital. This conven-
tional treatment program is patient specific and consists
mainly of physical therapy, occupational therapy, speech
therapy, and nursing care. The physical therapy program
takes a comprehensive approach, such as improvement of
functions and disabilities, including trunk movement, basic
activity, task-directed training, and a compensatory
approach using supplementary devices. In both groups,
activities such as bridge, pelvic movement, and reaching
exercises commonly performed in clinical settings were
included in the conventional program. We provided physi-
cal therapy for approximately 60 min/day, five times a week
in both groups. The experimental group intervention was
carried out within this time, so overall rehabilitation time
provided did not differ between groups.
In the experimental group, patients received 20 minutes
of core stabilization exercises within each daily training
session, 5 times a week, for 4 weeks. In total, each patient
in this group received 400 minutes of training time. Based
on previous studies of trunk exercises that showed effects
on stroke rehabilitation, we set the amount of core stability
training in the experimental group as about 30% of the total
time allocated to physical therapy. The core stability train-
ing consisted of ADIM as a selective contraction of TrA,
selective movements of the pelvis, and pelvic movements
with ADIM. In this training, we increased the level of exer-
cise in stages according to our protocol (Supplementary
Figure 1).
For ADIM, subjects were instructed to draw the lower
part of the abdomen up and in toward the spine, without
movement of the trunk or pelvis while continuing to breathe
normally. ADIM was performed in a crook lying position,
then in a sitting position. Pelvic control exercises were
composed from the following three planes of movement:
anterior-posterior tilt; lateral lift; and transverse rotation.
Any selective movement of the pelvis was conducted in the
sitting position, and compensatory movements were inhib-
ited. Furthermore, motions were performed repeatedly to
the maximum range voluntarily possible at a low load. In
pelvic control exercises with ADIM, selective pelvic move-
ment was performed while drawing in the abdomen. If any
movement was insufficient, the physical therapist provided
additional verbal instructions, manipulative induction, or
assistance. Propriety of ADIM was judged based on palpa-
tion of TrA contraction.29 All exercises in the sitting posi-
tion emphasized an upright sitting posture (Supplementary
Figure 2).
Eleven physical therapists with no direct involvement in
the design and reporting of the present study carried out the
treatment and intervention. These therapists were provided
an explanations based on the protocol (Supplementary
Figures 1 and 2) and practiced that protocol for 1 month prior
to performing therapy for the study. In the control group,
while not intending to restrict approaches involving trunk
function, ADIM and the combination exercises were not per-
formed. Common trunk exercises were thus acceptable.
Outcome Measures
Patient characteristics such as age, sex, side of lesion, type
and onset of stroke, and comorbidities were registered.
Patients were evaluated before and after the intervention.
We collected durations of physical therapy and occupa-
tional therapy during the intervention, to check whether any
differences existed in the amount of training. Clinical eval-
uations were performed by an independent assessor who
was blinded to group assignment and not involved in treat-
ment. The TIS and its subscales were the primary outcome
measures to assess the effects on trunk function. Secondary
outcome measures were introduced to elucidate the results
of the primary outcome measures.
As the primary outcome measure, the TIS consists of 3
subscales of static and dynamic sitting balance and trunk
coordination, scored up to 7, 10, and 6 points, respectively.38
The static sitting balance subscale assesses whether a per-
son can sit independently and remain seated when the legs
are either passively or actively crossed. The dynamic sitting
balance subscale evaluates the ability to actively shorten
each side of the trunk, first initiated from the shoulder and
subsequently initiated from the pelvic girdle. Trunk coordi-
nation tests the ability to independently rotate the shoulder
girdle and pelvic girdle. Total TIS score ranges between 0
and 23 points, with a higher score indicating better trunk
function. Reliability, validity, measurement error, and inter-
nal consistency of the TIS for stroke patients have been
reported.11,17,39
Haruyama et al 243
For secondary outcome measures, selective motor ability
and flexibility of the lower trunk using pelvic tilt active
range of motion in the sagittal plane (pelvic AROM), com-
prehensive balance ability using the Balance Evaluation
Systems Test–brief version (Brief-BESTest), standing stabil-
ity using the Functional Reach test (FRT), performance of
gait using the Timed Up-and-Go test (TUG), and level of
dependency during walking using the Functional Ambulation
Categories (FAC) were assessed. Pelvic AROM was the
range of angles (angle between the horizontal plane and a
line connecting the anterior and posterior superior iliac
spines) at which the subject had been tilted between anterior
and posterior to the maximum sustainable pelvis when sit-
ting on the treatment table at a height permitting the subject
to place the foot flat on the ground. Range of angle was mea-
sured on the paralyzed-side pelvis using a digital inclinom-
eter (HORIZON; YU-KI Trading, Tokyo, Japan). Although
pelvic AROM is not generally used as an evaluation method
internationally, we adopted this measure as a secondary out-
come because we wanted to ascertain the effect of training
for core stability using a continuous variable. The Brief-
BESTest42 is an 8-item balance assessment containing 1 item
from each of the 6 subsections of the BESTest.43 The inter-
rater reliability, internal consistency, and construct validity
of the Brief-BESTest have been evaluated and noted to be
high in a mixed group that included individuals with/without
neurological diagnoses.42 This text has also been confirmed
as useful in patients with Parkinson’s disease.44 In this study,
the item for evaluating the left and right sides is shown as
the average of right and left scores, so as not to change the
ratio of the total score. Total score thus ranged from 0 to
18, with higher scores denoting better balance ability. The
FRT was measured by asking the participant to reach for-
ward with the non-paretic arm as far as possible without
taking a step. The validity and reliability of the FRT have
already been reported.45,46 The TUG measures the time a
subject takes to stand up from an armchair at height 45 cm,
walk a distance of 3 m, turn, walk back to the chair, and sit
down. This tool was originally developed as a clinical
measure for elderly individuals by Mathias et al47 and later
modified by Podsiadlo et al48 for use as a short test of basic
mobility skills among frail, community-dwelling, elderly
individuals. TUG offers good reliability and validity in
individuals who have experienced stroke.49 FAC50 was
assessed as ranging from 0 (requiring continuous support
from 2 individuals) to 5 (able to walk in- and outdoors
without supervision). The reliability of the FAC score has
been reported.51,52
Statistical Analysis
Descriptive data analysis was performed for the collected
variables of the participants. Patient characteristics mea-
sured on a continuous scale were examined using the
Shapiro-Wilk test to evaluate normal data distribution.
Parametric statistics were used to analyze normally distrib-
uted data, while non-parametric comparisons were applied
for variables that did not display normal distributions. To
examine the effect of our randomization procedure, differ-
ences between all variables for the experimental and control
groups were evaluated using an independent t test or the χ2
test for continuous or dichotomous data, respectively.
To analyze the results, a general repeated-measures
model was used. Pre- and posttreatment results were entered
as the within-subjects variable “time,” and the experimental
and control groups were included as the between-subjects
factor “condition.” Probability values for the variable time
would indicate whether a significant change occurred
between pre- and posttreatment assessments. A significant
interaction of “time × condition” would mean that the
change between pre- and posttreatment evaluation differs
significantly between groups. Probability values for the TIS
and its subscales were Bonferroni corrected. The signifi-
cance level was set at P < .013 for the primary outcome
measures. Secondary outcome measures were not corrected
for multiple testing, with a significance level of P < .05. A
post hoc power calculation was performed together with
determination of the effect size and numbers needed to treat
based on the assumption of a 10% improvement. SPSS ver-
sion 22.0-J (IBM, Tokyo, Japan) and G*Power version 3.153
were used for statistical analyses.
Results
A total of 16 patients from the experimental group (conven-
tional rehabilitation program including 400 minutes of core
stability training over a 4-week period) and 16 patients from
the control group (only conventional rehabilitation pro-
gram) were included in the analysis. In the control group,
one patient could not be analyzed because he had changed
hospital due to recurrence of stroke during the study, while
another patient who had been discharged after completing
13 of the 20 training sessions was still included in the analy-
sis. Figure 1 shows the flow diagram for the study. No
adverse events associated with either intervention were
encountered.
Characteristics of both groups are presented in Table 1.
No significant differences were found between the 2 groups
in terms of outcome measures. Both groups showed signifi-
cant improvements in all outcome measures during the 4
weeks between pre- and posttreatment assessment, with the
exception of the static sitting balance subscale of the TIS.
The “time × condition” effect was significant for total score
(P < .001) and the dynamic sitting balance subscale
(P = .002) of the TIS as primary outcome measures, and
pelvic AROM (P < .001), the Brief-BESTest (P < .001),
TUG (P = .008), and FAC (P = .022). These results are
summarized in Table 2.
244 Neurorehabilitation and Neural Repair 31(3)
Figure 1.  Flow diagram for subject assignment in the study. A
total 16 patients were included in the experimental group and
16 patients in the control group.
The significant “time × condition” effect showed a
strong effect size (>0.80) and power greater than 0.80
(Table 3). The numbers needed to treat were small, ranging
from 1.60 to 4.00, for all outcome measures with a signifi-
cant “time × condition” effect.
Discussion
The present study showed that core stability training (ie,
stepwise core stability training using selective pelvic exer-
cises) improved balance and mobility, in addition to trunk
function, more than the conventional physical therapy pro-
gram in stroke patients. We found that a total of about 6.5
hours (20 min/d for 20 days) of exercises to improve core
stability increased trunk performance, particularly in terms
of dynamic sitting balance. In addition, the results showed
that improved trunk function increased standing balance
and mobility. These results offer evidence that interventions
aimed at trunk muscle activation based on the core stability
theory result in positive effects for patients with stroke.
Core stability training achieved similar results to the
trunk training that has been previously reported, particu-
larly for improvement of dynamic sitting balance.18 The TIS
as a primary outcome showed a significant change in total
score and suggested improvements in comprehensive trunk
function. Among the subscales, the lack of a difference in
static sitting balance was not surprising. The static balance
subscale has been pointed out to readily show a ceiling
effect21,22 and low internal validity.54 The coordination sub-
scale showed no significant difference in treatment effect
between groups in this study. Results for coordination have
been inconsistent in previous research; Saeys et al22 reported
benefits for coordination, whereas Verheyden et al21 found
no improvements. Although the kinds of exercise performed
in those reports were relatively similar, training time was
much greater in the study by Saeys et al than in that by
Verheyden et al. The amount of training in our study might
have been insufficient to improve coordination. In addition,
one report suggests that the subscales of the TIS are
hierarchical.55 That report stated that static sitting balance
appeared easier to improve than dynamic sitting balance,
which in turn was easier to improve than coordination. Such
a hierarchy may explain why our study did not demonstrate
beneficial effects for the experimental group compared to
the control group for coordination.
In our results, core stability training also improved
standing balance and mobility. Van Nes et al56 reported that
lateral trunk control might be a primary target for rehabilita-
tion, since lateral balance was more affected by stroke than
balance in the anteroposterior direction, and showed the
strongest association with the Berg Balance Scale.
Improvement of the dynamic sitting balance subscale was
seen to reflect lateral trunk control in this study, resulting in
improved balance and mobility despite not performing a
specific exercise. Improvement of mobility, which is
described in the TUG, was confirmed in our study.
Furthermore, differences in the level of improvement of
functional ambulation level were seen between groups,
demonstrating the effect of improvements in trunk function
on gait ability. However, the tendency toward a difference
in TUG scores at the baseline evaluation between groups
may warrant consideration, although no significant differ-
ence was present. Participants in this study showed slow
TUG times compared with some previous reports.57,58
Because participants in this study had been admitted for
rehabilitation in the subacute phase, a relatively high pro-
portion may have shown severe gait disorder. Although
greater improvement was shown in the experimental group,
the effect of core stability training for mobility should only
be generalized with caution.
We also found improvements in pelvic AROM angle.
Core stability training, including pelvic control exercises
enhanced the voluntary range of motion of the pelvis in the
sagittal plane, and improved lumbo-pelvic flexibility was
suggested. In a report by O’Sullivan et al,59 upright posture
of the pelvis was considered to result in greater activation of
local muscles in healthy individuals. Because core stability
training likewise activates local core muscles, pelvic
Haruyama et al 245

Table 1.  Characteristics of the 2 Groups.a

Variable Scoring Range Experimental group (n = 16) Control group (n = 16) P

Age (years) 67.56 (10.11) 65.63 (11.97) .624b
Sex (women/men) 3/13 4/12 .669c
Time since stroke onset (days) 66 (49.25. 91.5) 72 (48.25, 93.5) .970d
Type of stroke (ischemia/hemorrhage) 7/9 7/9 >.999c
Paretic side (left/right) 9/7 8/8 .723c
Physical therapy (minutes) 1440.00 (129.40) 1301.25 (281.75) .084b
Occupational therapy (minutes) 1432.50 (156.27) 1316.25 (209.15) .085b
Primary outcome measures  
  Trunk Impairment Scale (score) 0-23 15.50 (3.33) 15.50 (3.44) >.999b
   Static sitting balance 0-7 7 (6.25, 7) 7 (7, 7) .657d
   Dynamic sitting balance 0-10 7 (5.25, 9.75) 7 (6, 9.75) .969d
  Coordination 0-6 1 (1, 3) 2 (0, 3) .985d
Secondary outcome measures  
  Pelvic active range of motion (degrees) 26.38 (9.78) 21.38 (9.76) .158b
  Brief-BESTest (score) 0-18 4.25 (3.13, 4.25) 9.25 (3, 12.38) .257d
  Functional Reach (cm) 26.72 (4.25) 26.25 (7.35) .827b
  Timed Up-and-Go (s) 47.13 (31.61) 33.89 (31.45) .252b
  Functional Ambulation Categories (score) 0-5 2.5 (2, 3) 3 (2, 4) .112d

Abbreviation: Brief-BESTest, the Balance Evaluation Systems Test-brief version.

a
Pretreatment differences between both groups for descriptive variables and outcome measures, where applicable mean scores (SD) or median scores
(lower quartile, upper quartile) were provided. Primary outcome measures were Bonferroni corrected with a significance level of P < .013.
b
Evaluated by means of independent t test or Welch’s t test.
c
Evaluated by means of chi-square test.
d
Evaluated by means of Mann-Whitney U test.

Table 2.  Outcome Measures in the Experimental and Control Groups.a

Pretreatment Posttreatment P

Time ×
Outcome Measures Experimental Control Experimental Control Time Condition
Primary outcome measures
  Trunk Impairment Scale (range 0-23) 15.50 (3.33) 15.50 (3.44) 19.63 (2.45) 16.69 (3.72) <.001 <.001
   Static sitting balance (range 0-7) 6.38 (1.41) 6.56 (1.26) 7.00 (0.00) 6.63 (1.26) .064 .126
   Dynamic sitting balance (range 0-10) 7.38 (2.03) 7.25 (2.44) 9.44 (0.81) 7.81 (2.10) <.001 .002
   Coordination (range 0-6) 1.75 (1.29) 1.69 (1.35) 3.19 (1.94) 2.25 (1.61) <.001 .085
Secondary outcome measures
  Pelvic active range of motion (degrees) 26.38 (9.78) 21.38 (9.76) 36.31 (8.22) 22.56 (10.76) <.001 <.001
  Brief-BESTest (score) 5.43 (3.47) 8.25 (5.45) 8.22 (4.67) 8.31 (5.70) <.001 <.001
  Functional reach (cm) 26.72 (4.25) 26.25 (7.35) 30.09 (6.25) 28.53 (8.97) .003 .534
  Timed Up-and-Go (seconds) 47.13 (31.61) 33.89 (31.45) 33.46 (26.81) 32.56 (33.42) .002 .008
  Functional Ambulation Categories (score) 2.44 (1.03) 3.13 (1.15) 2.94 (1.06) 3.25 (1.24) <.001 .022

Abbreviation: Brief-BESTest, the Balance Evaluation Systems Test-brief version.

a
Values are presented as mean (SD). P values are the result of the general linear repeated-measures model. Primary outcome measures were
Bonferroni corrected, with a significance level of P < .013. Secondary outcome measures were not corrected for multiple testing and used a
significance level of P < .05.

exercises with core stabilization might prove more effective
than either form in isolation.
Improvement of the TIS seen in this study is not surpris-
ing given the results of previous studies.18 We think it is
important that balance and mobility as secondary outcomes
were improved in addition to trunk function. This shows
similar results to Saeys et al22 with comprehensive trunk
exercise and their larger intervention in terms of the amount
of training. In addition, Cabanas-Valdés et al20 also showed
a positive effect of comprehensive trunk exercises in raising
stepwise difficulty from a stable surface to an unstable sur-
face using a comparable intervention time to the present
study. Compared with their comprehensive trunk exercise
intervention, the training protocol in the present study was
246 Neurorehabilitation and Neural Repair 31(3)
Table 3.  Post Hoc Calculations.a
Outcome Measures Power Effect Size
Primary outcome measures
  Trunk Impairment Scale (range 0-23) 1.00 1.53
   Static sitting balance (range 0-7) 0.68 0.56
   Dynamic sitting balance (range 0-10) 0.99 1.18
   Coordination (range 0-6) 0.82 0.64
Secondary outcome measures
  Pelvic active range of motion (degrees) 1.00 1.42
  Brief-BESTest (score) 1.00 1.58
  Functional Reach (cm) 0.22 0.22
  Timed Up-and-Go (s) 0.99 1.02
  Functional Ambulation Categories (score) 0.99 0.84
Abbreviations: CI, confidence interval; Brief-BESTest, the Balance Evaluation Systems Test-brief version.
a
Effect size is between-group differences in pre-post training differences.
focused on core stability exercises to clarify the effect of
trunk exercise. The training protocol in this study used only
localized exercises and their combinations, mainly based on
activation of deep trunk muscle. Features of our training
protocol were as follows: (1) a progressive program, (2) use
of an upright sitting position, and (3) integration of core
local muscles and global muscles. Given the results show-
ing positive effects of a definite protocol, clinicians might
be able to easily plan trunk exercises for stroke patients.
Activities of the deep abdominal muscles (ie, TrA and
obliquus internus muscles) remain intact in stroke
hemiplegia.38 Stroke patients can thus achieve co-contraction
of the global muscles of the trunk while the core is activated.
As for the intervention in this study, we set the program based
on the basic strategy of improving core stability through the
activation of local core muscles. Consequently, we found that
the trunk stabilization achieved through core stability train-
ing improved balance and mobility. This result was consis-
tent with the report on the intervention effect of core stability
improvement by Cabanas-Valdés et al.20 However, their core
stability training comprised selective trunk or pelvic move-
ment exercises, bridge exercises, and reaching exercises, and
exercises of the local core muscles were not emphasized in
contrast to our protocol. Although they confirmed an inter-
vention effect using core stability training as additional train-
ing, our protocol based on the activation of the local muscles
of the core showed positive effects without additional train-
ing. We thus emphasize that activation of core muscles is
essential in trunk exercises for stroke rehabilitation.
Recent research has observed the effect of progressive
programs,60 and has shown their utility in core stability exer-
cises.20 We therefore made an original progressive protocol
for core stability exercises. As for the content of the protocol,
we selected a few particular types of training because we
wanted to make a more focused protocol than previous
studies.20-22 Additionally, most training was carried out in an
Number Needed to Treat
Mean Difference (95% CI) (>10% Improvement)
2.94 (1.55, 4.32) 1.60
0.56 (−0.17, 1.29) 5.33
1.50 (0.58, 2.42) 4.00
0.88 (−0.13, 1.88) 3.20
8.75 (4.31, 13.19) 2.67
2.72 (1.48, 3.96) 1.60
1.09 (−2.46, 4.64) 16.00
12.35 (3.48, 21.21) 2.02
0.38 (0.06, 0.69) 2.67
upright sitting position. Core stability training in an upright,
anti-gravity position is more effective than that in a lying
position61,62 and was safe and easy to implement in a clinical
setting. Furthermore, we emphasized the integration of local
core muscles and global muscles as a process of core stability
training (see Table 1, selective pelvic exercises with
ADIM).29,36 In healthy subjects, a combination of ADIM and
exercise of global muscles has shown increased activation of
the TrA.63 Pelvic exercises result in the increased recruitment
of global muscles as the movement system.31,64-66 We there-
fore combined ADIM exercise and selective pelvic control
exercises. The training protocol in this study started from
ADIM in supine and antigravity positions, pelvic control
exercises, and synchronization of both exercises in a step-by-
step manner. As efficacy was achieved in less intervention
time than applied in other studies, the effectiveness of our
protocol is suggested.
Some limitations warrant caution when interpreting the
results of our study. This investigation involved a relatively
small number of subjects from a single center. The findings
of this study must therefore be generalized with caution.
Additionally, the lack of quantitative assessment of the suc-
cess of core stability training and nonblinding of the patient
and therapist were less than ideal. Outcomes of the present
study were determined from impairment/function level, and
the effects of core stability training on ADL and quality of
life remain unclear. Furthermore, no follow-up assessments
were performed. As future research, comparison between
groups with the same amount of core stability training and
general trunk exercise is needed to examine the effective-
ness of core stability theory more precisely.
Conclusions
Our findings provide support for introducing core stability
training to address trunk dysfunction in stroke patients.
Haruyama et al 247
Core stability training based on a graded protocol was found
to be beneficial to balance and mobility measures, as well as
trunk performance. Future research is needed to clarify the
effects on functional activities once training has proceeded
to advanced strategies for achieving stability.
Acknowledgments
We wish to thank Takaharu Kondo, Toru Tanaka, and Katsumi
Shimizu for their assistance with this study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
References
1. Karatas M, Cetin N, Bayramoglu M, Dilek A. Trunk mus-
cle strength in relation to balance and functional disability
in unihemispheric stroke patients. Am J Phys Med Rehabil.
2004;83:81-87.
2. Dickstein R, Shefi S, Marcovitz E, Villa Y. Electromyographic
activity of voluntarily activated trunk flexor and extensor mus-
cles in post-stroke hemiparetic subjects. Clin Neurophysiol.
2004;115:790-796.
3. Tanaka S, Hachisuka K, Ogata H. Muscle strength of trunk
flexion-extension in post-stroke hemiplegic patients. Am J
Phys Med Rehabil. 1998;77:288-290.
4. Bohannon RW, Cassidy D, Walsh S. Trunk muscle strength
is impaired multidirectionally after stroke. Clin Rehabil Res.
1995;9:47-51.
5. Ryerson S, Byl NN, Brown DA, Wong RA, Hidler JM.
Altered trunk position sense and its relation to balance func-
tions in people post-stroke. J Neurol Phys Ther. 2008;32:
14-20.
6. Perlmutter S, Lin F, Makhsous M. Quantitative analy-
sis of static sitting posture in chronic stroke. Gait Posture.
2010;32:53-56.
7. Chern JS, Lo CY, Wu CY, Chen CL, Yang S, Tang FT.
Dynamic postural control during trunk bending and reaching
in healthy adults and stroke patients. Am J Phys Med Rehabil.
2010;89:186-197.
8. Verheyden G, Nieuwboer A, Feys H, Thijs V, Vaes K, De
Weerdt W. Discriminant ability of the Trunk Impairment
Scale: a comparison between stroke patients and healthy indi-
viduals. Disabil Rehabil. 2005;27:1023-1028.
9. Tyson SF. Trunk kinematics in hemiplegic gait and the effect
of walking aids. Clin Rehabil. 1999;13:295-300.
10. Jijimol G, Fayaz RK, Vijesh PV. Correlation of trunk
impairment with balance in patients with chronic stroke.
NeuroRehabilitation. 2013;32:323-325.
11. Verheyden G, Vereeck L, Truijen S, et al. Trunk performance
after stroke and the relationship with balance, gait and func-
tional ability. Clin Rehabil. 2006;20:451-458.
12. Duarte E, Morales A, Pou M, Aguirrezábal A, Aguilar JJ,
Escalada F. Trunk control test: early predictor of gait bal-
ance and capacity at 6 months of the stroke. Neurologia.
2009;24:297-303.
13. Wang CH, Hsueh IP, Sheu CF, Hsieh CL. Discriminative,
predictive, and evaluative properties of a trunk control mea-
sure in patients with stroke. Phys Ther. 2005;85:887-894.
14. Di Monaco M, Trucco M, Di Monaco R, Tappero R, Cavanna
A. The relationship between initial trunk control or postural
balance and inpatient rehabilitation outcome after stroke:
a prospective comparative study. Clin Rehabil. 2010;24:
543-554.
15. Franchignoni FP, Tesio L, Ricupero C, Martino MT. Trunk
control test as an early predictor of stroke rehabilitation out-
come. Stroke. 1997;28:1382-1385.
16. Hsieh CL, Sheu CF, Hsueh IP, Wang CH. Trunk control as
an early predictor of comprehensive activities of daily living
function in stroke patients. Stroke. 2002;33:2626-2630.
17. Verheyden G, Nieuwboer A, De Wit L, et al. Trunk perfor-
mance after stroke: an eye catching predictor of functional
outcome. J Neurol Neurosurg Psychiatry. 2007;78:694-698.
18. Cabanas-Valdés R, Cuchi GU, Bagur-Calafat C. Trunk train-
ing exercises approaches for improving trunk performance
and functional sitting balance in patients with stroke: a sys-
tematic review. NeuroRehabilitation. 2013;33:575-592.
19. Sorinola IO, Powis I, White CM. Does additional exercise
improve trunk function recovery in stroke patient? A meta-
analysis. NeuroRehabilitation. 2014;35:205-213.
20. Cabanas-Valdés R, Bagur-Calafat C, Girabent-Farrés M,
Caballero-Gómez FM, Hernández-Valiño M, Urrútia Cuchí
G. The effect of additional core stability exercises on improv-
ing dynamic sitting balance and trunk control for subacute
stroke patients: a randomized controlled trial. Clin Rehabil.
2015;29:1-10.
21. Verheyden G, Vereeck L, Truijen S, et al. Additional exer-
cises improve trunk performance after stroke: a pilot random-
ized controlled trial. Neurorehabil Neural Repair. 2009;23:
281-286.
22. Saeys W, Vereeck L, Truijen S, Lafosse C, Wuyts FP, Heyning
PV. Randomized controlled trial of truncal exercises early
after stroke to improve balance and mobility. Neurorehabil
Neural Repair. 2012;26:231-238.
23. Karthikbabu S, Rao BK, Manikandan N, Solomon JM,
Chakrapani M, Nayak A. Role of trunk rehabilitation on trunk
control, balance and gait in patients with chronic stroke. A
pre-post design. Neurosci Med. 2011;2:61-67.
24. Kisner C, Thorp JN. The spine: management guidelines. In:
Kisner C, Colby LA, eds. Therapeutic Exercise: Foundations
and Techniques. 5th ed. Philadelphia, PA: F.A. Davis;
2007:439-480.
25. Hibbs AE, Thompson KG, French D, Wrigley A, Spears I.
Optimizing performance by improving core stability and core
strength. Sports Med. 2008;38:995-1008.
26. Bergamrk A. Stability of the lumbar spine: a study in mechan-
ical engineering. Acta Orthop Scand. 1989;230:20-24.
27. Faries MD, Greenwood M. Core training: stabilizing the con-
fusion. Strength Cond J. 2007;29:10-25.
28. Key J. ‘The core’: understanding it, and retraining its dys-
function. J Bodyw Mov Ther. 2013;17:541-559.
248 Neurorehabilitation and Neural Repair 31(3)
29. Hides J, Richardson C, Hodges P. Local segmental control. In:
Therapeutic Exercise for Lumbopelvic Stabilization: A Motor
Control Approach for the Treatment and Prevention of Low
Back Pain. 2nd ed. London, England: Churchill Livingstone;
2004:185-219.
30. Hides J, Wilson S, Stanton W, et al. An MRI investigation
into the function of the transversus abdominis muscle during
“drawing-in” of the abdominal wall. Spine (Phila Pa 1976).
2006;31:E175-E178.
31. Urquhart DM, Hodges PW, Allen TJ, Story IH. Abdominal
muscle recruitment during a range of voluntary exercises.
Man Ther. 2005;10:144-153.
32. Teyhen DS, Rieger JL, Westrick RB, Miller AC, Molloy JM,
Childs JD. Changes in deep abdominal muscle thickness dur-
ing common trunk-strengthening exercises using ultrasound
imaging. J Orthop Sports Phys Ther. 2008;38:596-605.
33. Cresswell AG, Grundström H, Thorstensson A. Observations
on intra-abdominal pressure and patterns of abdominal intra-
muscular activity in man. Acta Physiol Scand. 1992;144:
409-418.
34. Hodges PW, Jull GA. Spinal segmental stabilization train-
ing. In: Liebenson C, ed. Rehabilitation of the Spine: A
Practitioner’s Manual. 2nd ed. Baltimore, MD: Lippincott
Williams & Wilkins; 2006:585-611.
35. Comerford MJ, Mottram SL. Functional stability re-training:
principles and strategies for managing mechanical dysfunc-
tion. Man Ther. 2001;6:3-14.
36. Freeman JA, Gear M, Pauli A, et al. The effect of core stabil-
ity training on balance and mobility in ambulant individuals
with multiple sclerosis: a multi-centre series of single case
studies. Mult Scler. 2010;16:1377-1384.
37. Carr LJ, Harrison LM, Stephens JA. Evidence for bilateral
innervation of certain homologous motoneurone pools in
man. J Physiol. 1994;475:217-227.
38. Marsden JF, Hough A, Shum G, Shaw S, Freeman JA. Deep
abdominal muscle activity following supratentorial stroke. J
Electromyogr Kinesiol. 2013;23:985-990.
39. Verheyden G, Nieuwboer A, Mertin J, Preger R, Kiekens C,
De Weerdt W. The trunk impairment scale: a new tool to mea-
sure motor impairment of the trunk after stroke. Clin Rehabil.
2004;18:326-334.
40. Moher D, Schulz KF, Altman DG. The CONSORT state-
ment: revised recommendations for improving the quality of
reports of parallel-group randomised trials. Lancet. 2001;357:
1191-1194.
41. Schulz KF, Altman DG, Moher D; CONSORT Group.
CONSORT 2010 statement: updated guidelines for report-
ing parallel group randomised trials. Ann Int Med. 2010;152:
726-732.
42. Padgett PK, Jacobs JV, Kasser SL. Is the BESTest at its best?
A suggested brief version based on interrater reliability, valid-
ity, internal consistency, and theoretical construct. Phys Ther.
2012;92:1197-1207.
43. Horak FB, Wrisley DM, Frank J. The Balance Evaluation
Systems Test (BESTest) to differentiate balance deficits. Phys
Ther. 2009;89:484-498.
44. Duncan RP, Leddy AL, Cavanaugh JT, et al. Comparative
utility of the BESTest, mini-BESTest, and brief-BESTest for
predicting falls in individuals with Parkinson disease: a cohort
study. Phys Ther. 2013;93:542-550.
45. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional
reach: a new clinical measure of balance. J Gerontol.
1990;45:M192-M197.
46. Weiner DK, Duncan PW, Chandler J, Studenski SA.
Functional reach: a marker of physical frailty. J Am Geriatr
Soc. 1992;40:203-207.
47. Mathias S, Nayak US, Isaacs B. Balance in elderly patients:
the “get-up and go” test. Arch Phys Med Rehabil. 1986;67:
387-389.
48. Podsiadlo D, Richardson S. The timed “Up & Go”: a test
of basic functional mobility for frail elderly persons. J Am
Geriatr Soc. 1991;39:142-148.
49. Hafsteinsdóttir TB, Rensink M, Schuurmans M. Clinimetric
properties of the Timed Up and Go Test for patients with
stroke: a systematic review. Top Stroke Rehabil. 2014;21:
197-210.
50. Holden MK, Gill KM, Magliozzi MR, Nathan J, Piehl-
Baker L. Clinical gait assessment in the neurologically
impaired. Reliability and meaningfulness. Phys Ther.
1984;64:35-40.
51. Collen FM, Wade DT, Bradshaw CM. Mobility after stroke:
reliability of measures of impairment and disability. Int
Disabil Stud. 1990;12:6-9.
52. Stevenson TJ. Using impairment inventory scores to deter-
mine ambulation status in individuals with stroke. Physiother
Can. 1999;51:168-174.
53. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical
power analyses using G*Power 3.1: tests for correlation
and regression analyses. Behav Res Methods. 2009;41:
1149-1160.
54. Verheyden G, Kersten P. Investigating the internal validity of
the Trunk Impairment Scale (TIS) using Rasch analysis: the
TIS 2.0. Disabil Rehabil. 2010;32:2127-2137.
55. Verheyden G, Nieuwboer A, Feys H, Thijs V, Vaes K, De
Weerdt W. Discriminant ability of the trunk impairment scale:
a comparison between stroke patients and healthy individuals.
Disabil Rehabil. 2005;27:1023-1028.
56. van Nes IJ, Nienhuis B, Latour H, Geurts AC. Posturographic
assessment of sitting balance recovery in the subacute phase
of stroke. Gait Posture. 2008;28:507-512.
57. Persson CU, Danielsson A, Sunnerhagen KS, Grimby-Ekman
A, Hansson PO. Timed Up & Go as a measure for longitudi-
nal change in mobility after stroke—Postural Stroke Study in
Gothenburg (POSTGOT). J Neuroeng Rehabil. 2014;11:83.
doi:10.1186/1743-0003-11-83.
58. Hafsteinsdóttir TB, Rensink M, Schuurmans M. Clinimetric
properties of the Timed Up and Go Test for patients with
stroke: a systematic review. Top Stroke Rehabil. 2014;21:
197-210.
59. O’Sullivan PB, Dankaerts W, Burnett AF, et al. Effect of
different upright sitting postures on spinal-pelvic curvature
and trunk muscle activation in a pain-free population. Spine
(Phila Pa 1976). 2006;31:E707-E712.
60. Rose D, Paris T, Crews E, et al. Feasibility and effectiveness
of circuit training in acute stroke rehabilitation. Neurorehabil
Neural Repair. 2011;25:140-148.
Haruyama et al 249
61. Reeve A, Dilley A. Effects of posture on the thickness of transver-
sus abdominis in pain-free subjects. Man Ther. 2009;14:679-684.
62. McCook DT, Vicenzino B, Hodges PW. Activity of deep
abdominal muscles increases during submaximal flexion
and extension efforts but antagonist co-contraction remains
unchanged. J Electromyogr Kinesiol. 2009;19:754-762.
63. Bjerkefors A, Ekblom MM, Josefsson K, Thorstensson A.
Deep and superficial abdominal muscle activation during
trunk stabilization exercises with and without instruction to
hollow. Man Ther. 2010;15:502-507.
64. Vezina MJ, Hubley-Kozey CL. Muscle activation in thera-
peutic exercises to improve trunk stability. Arch Phys Med
Rehabil. 2000;81:1370-1379.
65. Workman JC, Docherty D, Parfrey KC, Behm DG. Influence
of pelvis position on the activation of abdominal and hip
flexor muscles. J Strength Cond Res. 2008;22:1563-1569.
66. Buchtelová E, Tichý M, Vaníková K. Influence of muscular
imbalances on pelvic position and lumbar lordosis: a theo-
retical basis. J Nurs Soc Stud Public Health Rehabil. 2013;
1-2:25-36.