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Effect of Taping of Thoracic and Abdominal Muscles on Pelvic Alignment and Forward Reach Distance Among Stroke Subjects: A Randomized Controlled Trial

Effect of Taping of Thoracic and Abdominal Muscles on Pelvic Alignment and Forward Reach Distance... Introduction: The objective of this study was to find the immediate as well as short-term effect on pelvic alignment and forward arm reach distance in sitting among stroke patients following thoracic spine and abdominal muscles taping along with conventional therapy. Methods: Thirty subjects with stroke attending the physiotherapy programme at Department of Physiotherapy at a tertiary care hospital underwent this randomized controlled experimental study. Subjects in the experimental group received taping, along with conventional physiotherapy treatment, for restricting thoracic kyphosis and facilitating abdominal muscles. Subjects in the control group received only conventional physiotherapy treatment. To assess the change in pelvic alignment and TM TM forward arm reach distance while sitting, Palpation Meter (PALM ) and sit and reach test were used, respectively. Results: In the experimental group, pelvic obliquity was corrected (4.1 ± 0.94) and anterior pelvic tilt revealed improvement (4.9 ± 2.1, p value < 0.001). In the control group, no improvement in pelvic alignment was recorded. Improvement in forward arm reach distance was similar in both groups (p value = 0.804). Conclusion: Taping as an adjunctive treatment method to physiotherapy can cause immediate as well as short-term improvement of pelvic alignment in sitting, following stroke. It also, immediately improves the sit and reach distance in the same population. Keywords Stroke, taping, pelvic alignment, trunk muscles the ability to independently perform reach-out activities. Introduction 10–12 TM Earlier literatures have used Palpation Meter (PALM ) and sit and reach test (SRT) to objectively assess the pelvic Stroke, one of the major causes of disability, results in sensory asymmetry and forward reaching distance, respectively. and motor impairment which influences postural control, 1,2 balance and postural symmetry. Stroke survivors often adapt compensatory strategies to maintain balance which 1 College of Physiotherapy, Sumandeep Vidyapeeth an Institution Deemed to 3,4 leads to poor sitting ability. Sitting, being a skill that is be University, Piparia, Gujarat, India. Department of Physiotherapy, Kasturba Medical College, Mangalore; critical to independent living, is one of the useful prognostic Manipal Academy of Higher Education, Manipal, India. indicators of functional outcome for stroke population. Re- Department of Physiotherapy, Manipal College of Health Professions, Manipal establishment of control in sitting for function is an important Hospital, Bangalore; Manipal Academy of Higher Education, Manipal, India. early goal in stroke rehabilitation. 4 Department of Neurology, Kasturba Medical College, Mangalore; Manipal In sitting, postural control depends on trunk alignment, Academy of Higher Education, Manipal, India. 7,8 5 Department of Community Medicine, Kasturba Medical College, Mangalore, particularly the position of pelvis. Due to disturbed postural Manipal Academy of Higher Education, Manipal, India. symmetry, stroke subjects sit with flexed thoracic spine and often show lateropulsion, characterized by elevation of pelvis Corresponding author: on the unaffected side, lateropulsion probably results from Abraham M. Joshua, Department of Physiotherapy Kasturba Medical College, compensation of weak bilateral trunk lateral flexors and Mangalore 575001, Manipal Academy of Higher Education, Manipal, India. 7,9 E-mail: abraham.joshua@manipal.edu rotators. Postural asymmetry following stroke may limit Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Mehta et al. 11 Considerable amount of work has been done in training the Inclusion criteria postural symmetry for stroke subjects, in standing and gait using 1. First episode of unilateral supratentorial stroke treatment techniques including Bobath’s, motor learning, task- diagnosed by the neurologist 3,4,14 related training and feedback approach. Among chronic stroke 2. Sitting unsupported on a stable surface for more subjects, during ambulation, for immediate correction of postural than 1 minute asymmetry, taping has been used. Hypoallergic sports tape helps 3. MMSE score of ≥23. to align the joint and enhance muscle retraining by balancing the tissue length–tension relationship, thus assisting neuromuscular Exclusion criteria control and postural re-education. Taping may also improve joint 1. Any known disease other than stroke that could proprioception and effective loading of the affected extremity influence the sitting balance and may minimize thoracic kyphosis and facilitate abdominal 2. Pusher syndrome or other perceptual deficits 15–17 muscles. Studies related to immediate and short-term effect 3. Loss of skin integrity or hypersensitive skin in the of taping on pelvic alignment and forward arm reach distance part where taping needs to be applied. among stroke subjects are limited. The purpose of this study was to find the immediate and the short-term (three-day) effect of Both the principle investigator and the independent blinded taping thoracic spine and abdominal muscles to improve pelvic observer were qualified physiotherapists of the Department alignment and forward arm reach distance in sitting. of Physiotherapy. Methods Intervention Both groups received conventional physiotherapy focussing Design on the length of muscle, normalization of tone, motor control improvement, strengthening for hemiplegic side extremities Following approval from the Institutional Ethics Committee and trunk, and balance training. Each treatment session lasted (IEC), Kasturba Medical College, Mangalore, Karnataka, India, for approximately an hour. The distribution of time spent a pilot study was performed on five stroke subjects to calculate and the number of repetitions given for each component of the sample size, feasibility and flaws in the methodology. conventional therapy was uniform for all the participants. During the study period (March 2011–February 2012), The experimental group received taping along with informed consent was obtained from each subject referred by conventional physiotherapy. The skin area where taping was the neurologists. A total of 41 interested stroke participants applied was cleaned with medical spirit. Prior to the application (excluding the five stroke subjects who participated for the pilot of the tape, to remove skin hair, the area was shaved. For study) were screened for the inclusion and exclusion criteria providing and maintaining proper alignment, first Fixomull and 30 subjects who met the inclusion criteria were enrolled for (BSN Medical, Hamburg, Deutschland) stretch tape, which is this study. Eligible subjects were assigned to the study groups an underwrap to avoid skin damage, was applied prior to the by block randomization. Block size of 6 was used in the trial application of a 2 inch width rigid Leukotape (BSN Medical, to allocate the participants to two study groups; each block 17,18 Hamburg, Deutschland). Based on the previous literature, consisted of three experimental and three control interventions. to restrict and correct the thoracic kyphosis, each participant The allocation concealment was done using sealed opaque was made to sit with erect spine with or without assistance envelopes which were sequentially arranged. Post allocation of and tapes were applied diagonally across the upper back subjects into experimental (n = 15) and control (n = 15) groups, starting from the anterior aspect of shoulder towards inferio- baseline data and demographic data of the eligible participants medial aspect of the scapula. Similarly, to facilitate the were taken. Both the groups received three days of conventional oblique muscles on either side, each of the participants was physiotherapy and the experimental group received taping as an adjunct. The outcomes were assessed by a blinded independent positioned supine with hips flexed to approximately 45° assessor at three levels. Level 1 (baseline data) was one day to place the pelvis in neutral position and shoulders flexed before the commencement of the treatment session, level 2 was over head to elongate the trunk musculature. The length of immediately after the first treatment session and level 3 was the tapes were measured from participants’ anterior superior immediately at the end of the third treatment session. iliac spine (ASIS) to the opposite 10th rib, following which the tapes were anchored at the ASIS and applied towards the participants’ 10th rib stretching across the umbilicus. Figures Participants, Therapists, Centres 1 and 2 depict the post-application appearance of tapes for restricting thoracic kyphosis and facilitation of abdominal The study was conducted at the Department of Physiotherapy, muscles, respectively. All the participants were able to in the study institute. Following screening for the inclusion tolerate the taping protocol until it was removed on the third and exclusion criteria, 24 hours before the commencement day following the completion of the trial. The flowchart of the of the study, patch tests were performed to check whether study is given in Figure 3. eligible participants were allergic to tape. 12 Annals of Neurosciences 26(3–4) TM PALM placed on the ASIS and posterior superior iliac spine (PSIS) of the hemiparetic side (Figure 5). Three test trials of pelvic obliquity and anterior pelvic tilt were performed, and the mean reading was used for analysis. Standard procedure was used for measuring the forward arm reach distance using SRT. Data Analysis The collected data were analysed using IBM SPSS for Windows, Version 25.0 (IBM Corp, Armonk, NY). Normality of the outcome measures was statistically verified using the Kolmogorov–Smirnov Z test. For between group comparison, Student’s t test was used. For within group comparison, paired t test was used. Chi square test was used for descriptive statistics. A p value of less than 0.05 was considered as statistically significant. Result Figure 1. Taping for Restricting Thoracic Kyphosis Source: The authors. Baseline characteristics of experimental and control groups are depicted in Table 1. Except the duration since stroke (p = 0.02), all the variables were similar between the groups. In order to find the immediate effect of taping, level 1 and level 2 data within the experimental group were compared and to find the short-term effect, level 1 and level 3 data for either group were compared. Figure 2. Taping for Facilitating Abdominal Muscles Source: The authors. Outcome Measures To evaluate the pelvic alignment and forward arm reach TM distance, the PALM and SRT were used respectively. For pelvic alignment, each participant was made to sit on a plinth with no back support, with thighs fully supported on plinth, hips, knees and ankles at 90° of flexion, and feet positioned flat on the floor in the same line with the knees. Commands like ‘sit as tall as possible’ or ‘sit tall’ were given after positioning. Pelvic obliquity was measured in the frontal plane and the anterior pelvic tilt was measured in the sagittal plane. Pelvic obliquity was measured in degrees, with the lever arms of the TM PALM placed on the left and right ASIS (Figure 4). The direction of obliquity (i.e., the left or right side lower) was Figure 3. Flowchart of Participant Enrollment and Analysis noted based on the earlier literature. Anterior pelvic tilt on Source: Consolidated Standards of Reporting Trials (CONSORT) diagram the hemiparetic side was measured with the lever arms of the adapted to the current study. Mehta et al. 13 Pelvic Alignment Taping had shown statistically significant improvement in pelvic obliquity and anterior pelvic tilt in the experimental group. As shown in Table 2, pelvic obliquity improved and reached closer towards neutral and anterior pelvic tilt improved by 4.5°. There was significant short-term improvement in the pelvic alignment within the experimental group. Pelvic obliquity improved towards neutral and anterior pelvic tilt improved by 4.9°. On the contrary, within the control group, pelvic obliquity remained the same and anterior pelvic tilt increased marginally to 0.07° which was statistically not significant (Table 3). Forward Arm Reach Distance Forward arm reach distance improved immediately in the experimental group by 3 cm with a p value of 0.016 (Table TM Figure 4. Assessing Pelvic Obliquity with Palpation Meter (PALM ) 2). With respect to the short-term effects of taping, both the Source: The authors. groups showed significant improvement in forward arm reach distance. However, visual inspection of the data reveals that the experimental group had a better improvement when compared to the control group (Table 4). Table 2. Immediate Effect of Taping on Pelvic Alignment and For- ward Arm Reach Distance in the Experimental Group Baseline IET Variables Mean (SD) Mean (SD) P Value Pelvic 4.4° (0.75) 0.27° (0.80) < 0.001* obliquity Anterior 2.3° (2.4) 6.8° (1.64) < 0.001* pelvic tilt Forward 32 (7.8) 35 (4.9) 0.016* arm reach distance Figure 5. Assessing Anterior Pelvic Tilt on the Hemiplegic Side with (cm) TM Palpation Meter (PALM ) Source: The authors. Source: The authors. Abbreviations: IET, immediate effect of taping; SD, standard deviation; cm, centimetres. Note: * significant. Table 1. Demographic Data Experi- Table 3. Short-term Effect of Taping on Pelvic Alignment in Exper- mental Controls imental and Control Group Group Group (n = P Val- Pelvic Obliquity Anterior Pelvic Tilt Demographic Data (n = 15) 15) ue Base- Base- Age mean (SD) years 60 (8.6) 62 (5.6) 0.57 line SET line SET Gender Male, n (%) 10 (67) 11 (73) 0.69 Mean Mean Mean Mean P Val- Female, n 5 (33) 4 (27) Group (SD) (SD) P Value (SD) (SD) ue (%) Exper- 4.4° 0.27° <0.001* 2.3° 7.2° <0.001* imen- (0.75) (0.79) (2.4) (1.9) Duration since stroke 47 (58) 16 (2.9) 0.02* tal (n mean (SD) days = 15) Affected side Right, 10 (67) 8 (53) 0.36 Con- 3.5° 3.5° 0.334 2.2° 2.2° 0.334 Left, n (%) n (%) trol (n (1.1) (1.1) (1.7) (1.8) 5 (33) 7 (47) = 15) Source: The authors. Source: The authors. Abbreviation: SET, short-term effect. Abbreviation: SD, standard deviation. * Notes: * significant; n, number of participants. Notes: significant; n, number of participants. 14 Annals of Neurosciences 26(3–4) Table 4. Short-term Effect of Taping on Forward Arm Reach Dis- In addition to the above, the participants also exhibited tance in Experimental and Control Group increased anterior pelvic tilt. Furthermore, this improvement was maintained for three days. Present study findings reveal Forward Arm Reach Distance (cm) that the improvement in pelvic alignment could be the result Baseline SET of taping, as conventional treatment was common for both the Group Mean (SD) Mean (SD) P Value experimental and the control groups. Experimental 32 (7.8) 37 (6.2) 0.009* Efficient stabilization of spine required for the static (n = 15) and dynamic normal posture is produced by the passive Control (n = 27 (4.8) 31 (4.4) 0.006* osteoligamentous system, active musculotendinous system 15) and neural control system. In stroke, impairment of the Source: The authors. latter two systems leads to altered alignment and disturbed Abbreviations: cm, centimetre; SD, standard deviation; SET, short-term postural symmetry. The results of this study suggest that effect of taping. Notes: *, significant; n, number of participants. taping may have improved the active musculotendinous and the neural control component of the stabilizing system of the spine leading to improvement in the pelvic alignment, that is, Table 5. Change Scores of Pelvic Alignment and Forward Arm taping prevented thoracic kyphosis by positioning the pelvis Reach Distance in Experimental and Control Group in neutral, thus, promoting better recruitment of obliques. The Experimen- Controls current findings are reinforced by earlier works of Maguire et Change Scores tal (n = 15) (n = 15) P Value 15,16 al and Kilbreath et al. Pelvic obliquity 4.1° (0.94) 0.00 <0.001* Hemiparesis results in pronounced weakness of the mean (SD) affected side trunk muscles, with more weight bearing on the Anterior pelvic 0.06° unaffected side, elevation of pelvis on the affected side and 4.9° (2.1) <0.001* tilt mean (SD) (0.26) 9,22 with impaired sitting balance. Though the forward reach in Forward arm sitting improved in either group, visual inspection of change reach distance 4.5 (5.4) 4.0 (4.8) 0.804 scores (4.5 cm for experimental group and 4.0 cm for control (cm) mean (SD) group) reveals a better result for the experimental group, Source: The authors. indicating that the improvement could have been the result Abbreviations: SD, standard deviation; cm, centimetre. of improved postural symmetry and enhanced recruitment of Notes: *, significant; n, number of participants. trunk muscles. Repeated practice might have improved perceptual Table 5 depicts the change scores (pre to post intervention processes involved in coordinated movement and execution difference) of pelvic alignments and forward arm reach of task and the same would have been responsible for distance across the experimental and the control groups. improvement in the forward reach for either group. Besides, Except for the forward arm reach distance, the experimental subjects in both the groups had relatively normal balance at group showed statistically significant improvement in the beginning of the study as represented by their baseline postural alignment when compared to the control group. value for forward arm reach distance, resulting in an almost parallel improvement in sitting balance. Discussion The current study had paid attention to check the immediate and short-term effect of taping on postural control, To the best of our knowledge, this is a preliminary study to and not the carry-over or long-term effect of taping. Care examine the immediate and the short-term effect of taping is to be taken while generalizing the effect as the current as an adjunct to conventional physiotherapy in improvising study used a smaller sample size. Future studies are required sitting postural control. In this study, we assumed that taping to see the effect of taping on other functional activities. of the thoracic spine and abdominal muscles may improve the Incorporation of objective outcome measures for quantitative pelvic alignment and forward reach among stroke patients. analysis of the improvement, such as kinematic analysis of Descriptive statistics of demographic data revealed reaching and forced platform analysis of postural symmetry significant difference in post-stroke duration in experimental in sitting, may provide additional information including true and control groups (Table 1). Inclusion of three participants motor improvement and the plausible compensations. with post-stroke duration of more than three months under the experimental group made the post-stroke data skewed; Conclusion otherwise, all the rest of the parameters were comparable between the groups. The result of this study indicates that taping as a treatment Thirteen out of fifteen participants in the experimental adjunct can result in immediate as well as short-term group were able to achieve neutral horizontal alignment. improvement of pelvic alignment while sitting. It may also Remaining two subjects achieved near-neutral alignment. Mehta et al. 15 result in immediate improvement of sitting balance among 5. Dean CM, Channon EF and Hall JM. Sitting training early after stroke patients and may prevent adverse effect of postural stroke improves sitting ability and quality and carries over to asymmetry in sitting following stroke. standing up but not to Walking: A randomised controlled trial. Aus J Physiother 2007; 53: 97–102. Acknowledgements 6. Genthon N, Vuillerme N, Monnet JP, et al. Biomechanical We would like to thank Manipal Academy of Higher Education, assessment of the sitting posture maintenance in patients with Manipal, India, and all the participants of the study for all the stroke. Clin Biomech 2007; 22: 1024–1029. support. 7. Zakaria Y, Rashad U and Mohammed R. Assessment of malalignment of trunk and pelvis in stroke patients. Egypt J Author Contributions Neurol Psychiat Neurosurg 2010; 47: 599–604. Megha Mehta was the principal investigator for this study. 8. Nichols DS, Miller L, Colby LA, et al. Sitting balance: Its Conceptualization of the study was by Abraham M. Joshua. relation to function in individual with hemiparesis. Arch Phys Supervision of the trial and data collection was done by Suruliraj Med Rehabil 1996; 77: 865–869. Karthikbabu. The study was designed and the data analysis was executed by Bhaskaran Unnikrishnan and Prasanna Mithra. Zulkifli 9. Karthikbabu S, Chakrapani M, Ganesan S, et al. Relationship K Misri and Akshatha Nayak provided critical inputs and aided with between pelvic alignment and weight-bearing asymmetry in data management. Authors of this study had equally contributed in community-dwelling chronic stroke survivors. J Neurosci preparation and editing of this manuscript. Rural Prac 2016; 7: S37–S40. 10. Axelson P, Axelson DY, Hayes A, et al. Hip grip pelvic Ethical Statement stabilization device for wheelchair users phase II final report. The Institutional Ethical Committee (IEC), Kasturba Medical Minden, NV: Beneficial Designs Inc, 2004. College, Mangalore, Karnataka, India, approved this study. All participants gave written informed consent before data collection 11. Petrone MR, Guinn J, Reddin A, et al. The accuracy of the began. palpation meter (PALM) for measuring pelvic crest height difference and leg length discrepancy. J Orthop Sports Phys Declaration of Conflicting Interests Ther 2003; 33(6): 319–325. The authors declared no potential conflicts of interest with respect to 12. Naval D, Syed N and Karthikbabu S. Intra-rater and inter-rater the research, authorship and/or publication of this article. reliability of measuring pelvic tilt using the palpation meter TM (PALM ) device in stroke. Int J Med Health Sci 2016; 5(4): Funding 276–280. The authors disclosed receipt of the following financial support for 13. Tsang YL and Mak MK. Sit-and-reach test can predict mobility the research, authorship and/or publication of this article: The study of patients recovering from acute stroke. Arch Phys Med was partially funded by, Kasturba Medical College, Mangalore, Rehabil 2004; 85: 94–98. Manipal Academy of Higher Education, Manipal, India. 14. Vasileva D, Lubenova D and Mihova M. Postural control and balance reactions in patients with ischemic stroke in the References chronic period. Sport, Stress, Adaptation—Scientific Journal 1. Chern J, Lo C, Wu C, et al. Dynamic postural control during 2014; Extra issue: 648–652. trunk bending and reaching in healthy adults and stroke 15. Maguire C, Sieben JM, Frank M, et al. Hip abductor control in patients. Am J Phys Med Rehabil 2010; 89: 186–197. walking following stroke-the immediate effect of canes, taping 2. Karatas M, Cetin N, Bayramoglu M, et al. Trunk muscle and theratogs on gait. Clin Rehabil 2010; 24: 37–45. strength in relation to balance and functional disability in 16. Kilbreath SL, Perkins S, Crosbie J, et al. Gluteal taping improves unihemispheric stroke patients. Am J Phys Med Rehabil 2004; hip extension during stance phase of walking following stroke. 83: 81–87. Aus J Physiother 2006; 52: 53–56. 3. Mudie MH, Winzeler-Mercay U, Radwan S, et al. Training symmetry of weight distribution after stroke: A randomized 17. Cepeda JP, Fishweicher A, Gleeson M, et al. Does Kinesio taping controlled pilot study comparing task-related reach, Bobath and of the abdominal muscles improve the supine-to-sit transition feedback training approaches. Clin Rehabil 2002; 16: 582–592. in children with hypotonia? http://www.kinesiotaping.com (8 December 2010). 4. Pellegrino L, Giannoni P, Marinelli L, et al. Effects of continuous visual feedback during sitting balance training in chronic stroke 18. Boyling JD and Jull GA, eds. Grieve’s modern manual therapy survivors. J Neuroeng Rehabil 2017; 14: 107–120. the vertebral column. Edinburgh: Churchil Livingstone, 2004. 16 Annals of Neurosciences 26(3–4) 19. Biely S, Smith SS and Silfies SP. Clinical instability of the 22. Sharma V and Kaur J. Effect of core strengthening with pelvic lumbar spine: Diagnosis and intervention. Ortho Phys Ther proprioceptive neuromuscular facilitation on trunk, balance, gait, Pract 2006; 8(3): 11–18. and function in chronic stroke. J Exerc Rehabil 2017; 13: 200–205. 20. Tasseel-Ponche S, Yelnik AP and Bonan IV. Motor strategies 23. Muratori LM, Lamberg EM, Quinn L, et al. Applying principles of postural control after hemispheric stroke. Neurophysiol Clin of motor learning and control to upper extremity rehabilitation. 2015; 45(4–5): 327–333. J Hand Ther 2013; 26: 94–103. 21. Bohannon R. Recovery and correlates of trunk muscle strength after stroke. Int J Rehabil Res 1995; 18: 162–167. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Neurosciences SAGE

Effect of Taping of Thoracic and Abdominal Muscles on Pelvic Alignment and Forward Reach Distance Among Stroke Subjects: A Randomized Controlled Trial

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Abstract

Introduction: The objective of this study was to find the immediate as well as short-term effect on pelvic alignment and forward arm reach distance in sitting among stroke patients following thoracic spine and abdominal muscles taping along with conventional therapy. Methods: Thirty subjects with stroke attending the physiotherapy programme at Department of Physiotherapy at a tertiary care hospital underwent this randomized controlled experimental study. Subjects in the experimental group received taping, along with conventional physiotherapy treatment, for restricting thoracic kyphosis and facilitating abdominal muscles. Subjects in the control group received only conventional physiotherapy treatment. To assess the change in pelvic alignment and TM TM forward arm reach distance while sitting, Palpation Meter (PALM ) and sit and reach test were used, respectively. Results: In the experimental group, pelvic obliquity was corrected (4.1 ± 0.94) and anterior pelvic tilt revealed improvement (4.9 ± 2.1, p value < 0.001). In the control group, no improvement in pelvic alignment was recorded. Improvement in forward arm reach distance was similar in both groups (p value = 0.804). Conclusion: Taping as an adjunctive treatment method to physiotherapy can cause immediate as well as short-term improvement of pelvic alignment in sitting, following stroke. It also, immediately improves the sit and reach distance in the same population. Keywords Stroke, taping, pelvic alignment, trunk muscles the ability to independently perform reach-out activities. Introduction 10–12 TM Earlier literatures have used Palpation Meter (PALM ) and sit and reach test (SRT) to objectively assess the pelvic Stroke, one of the major causes of disability, results in sensory asymmetry and forward reaching distance, respectively. and motor impairment which influences postural control, 1,2 balance and postural symmetry. Stroke survivors often adapt compensatory strategies to maintain balance which 1 College of Physiotherapy, Sumandeep Vidyapeeth an Institution Deemed to 3,4 leads to poor sitting ability. Sitting, being a skill that is be University, Piparia, Gujarat, India. Department of Physiotherapy, Kasturba Medical College, Mangalore; critical to independent living, is one of the useful prognostic Manipal Academy of Higher Education, Manipal, India. indicators of functional outcome for stroke population. Re- Department of Physiotherapy, Manipal College of Health Professions, Manipal establishment of control in sitting for function is an important Hospital, Bangalore; Manipal Academy of Higher Education, Manipal, India. early goal in stroke rehabilitation. 4 Department of Neurology, Kasturba Medical College, Mangalore; Manipal In sitting, postural control depends on trunk alignment, Academy of Higher Education, Manipal, India. 7,8 5 Department of Community Medicine, Kasturba Medical College, Mangalore, particularly the position of pelvis. Due to disturbed postural Manipal Academy of Higher Education, Manipal, India. symmetry, stroke subjects sit with flexed thoracic spine and often show lateropulsion, characterized by elevation of pelvis Corresponding author: on the unaffected side, lateropulsion probably results from Abraham M. Joshua, Department of Physiotherapy Kasturba Medical College, compensation of weak bilateral trunk lateral flexors and Mangalore 575001, Manipal Academy of Higher Education, Manipal, India. 7,9 E-mail: abraham.joshua@manipal.edu rotators. Postural asymmetry following stroke may limit Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Mehta et al. 11 Considerable amount of work has been done in training the Inclusion criteria postural symmetry for stroke subjects, in standing and gait using 1. First episode of unilateral supratentorial stroke treatment techniques including Bobath’s, motor learning, task- diagnosed by the neurologist 3,4,14 related training and feedback approach. Among chronic stroke 2. Sitting unsupported on a stable surface for more subjects, during ambulation, for immediate correction of postural than 1 minute asymmetry, taping has been used. Hypoallergic sports tape helps 3. MMSE score of ≥23. to align the joint and enhance muscle retraining by balancing the tissue length–tension relationship, thus assisting neuromuscular Exclusion criteria control and postural re-education. Taping may also improve joint 1. Any known disease other than stroke that could proprioception and effective loading of the affected extremity influence the sitting balance and may minimize thoracic kyphosis and facilitate abdominal 2. Pusher syndrome or other perceptual deficits 15–17 muscles. Studies related to immediate and short-term effect 3. Loss of skin integrity or hypersensitive skin in the of taping on pelvic alignment and forward arm reach distance part where taping needs to be applied. among stroke subjects are limited. The purpose of this study was to find the immediate and the short-term (three-day) effect of Both the principle investigator and the independent blinded taping thoracic spine and abdominal muscles to improve pelvic observer were qualified physiotherapists of the Department alignment and forward arm reach distance in sitting. of Physiotherapy. Methods Intervention Both groups received conventional physiotherapy focussing Design on the length of muscle, normalization of tone, motor control improvement, strengthening for hemiplegic side extremities Following approval from the Institutional Ethics Committee and trunk, and balance training. Each treatment session lasted (IEC), Kasturba Medical College, Mangalore, Karnataka, India, for approximately an hour. The distribution of time spent a pilot study was performed on five stroke subjects to calculate and the number of repetitions given for each component of the sample size, feasibility and flaws in the methodology. conventional therapy was uniform for all the participants. During the study period (March 2011–February 2012), The experimental group received taping along with informed consent was obtained from each subject referred by conventional physiotherapy. The skin area where taping was the neurologists. A total of 41 interested stroke participants applied was cleaned with medical spirit. Prior to the application (excluding the five stroke subjects who participated for the pilot of the tape, to remove skin hair, the area was shaved. For study) were screened for the inclusion and exclusion criteria providing and maintaining proper alignment, first Fixomull and 30 subjects who met the inclusion criteria were enrolled for (BSN Medical, Hamburg, Deutschland) stretch tape, which is this study. Eligible subjects were assigned to the study groups an underwrap to avoid skin damage, was applied prior to the by block randomization. Block size of 6 was used in the trial application of a 2 inch width rigid Leukotape (BSN Medical, to allocate the participants to two study groups; each block 17,18 Hamburg, Deutschland). Based on the previous literature, consisted of three experimental and three control interventions. to restrict and correct the thoracic kyphosis, each participant The allocation concealment was done using sealed opaque was made to sit with erect spine with or without assistance envelopes which were sequentially arranged. Post allocation of and tapes were applied diagonally across the upper back subjects into experimental (n = 15) and control (n = 15) groups, starting from the anterior aspect of shoulder towards inferio- baseline data and demographic data of the eligible participants medial aspect of the scapula. Similarly, to facilitate the were taken. Both the groups received three days of conventional oblique muscles on either side, each of the participants was physiotherapy and the experimental group received taping as an adjunct. The outcomes were assessed by a blinded independent positioned supine with hips flexed to approximately 45° assessor at three levels. Level 1 (baseline data) was one day to place the pelvis in neutral position and shoulders flexed before the commencement of the treatment session, level 2 was over head to elongate the trunk musculature. The length of immediately after the first treatment session and level 3 was the tapes were measured from participants’ anterior superior immediately at the end of the third treatment session. iliac spine (ASIS) to the opposite 10th rib, following which the tapes were anchored at the ASIS and applied towards the participants’ 10th rib stretching across the umbilicus. Figures Participants, Therapists, Centres 1 and 2 depict the post-application appearance of tapes for restricting thoracic kyphosis and facilitation of abdominal The study was conducted at the Department of Physiotherapy, muscles, respectively. All the participants were able to in the study institute. Following screening for the inclusion tolerate the taping protocol until it was removed on the third and exclusion criteria, 24 hours before the commencement day following the completion of the trial. The flowchart of the of the study, patch tests were performed to check whether study is given in Figure 3. eligible participants were allergic to tape. 12 Annals of Neurosciences 26(3–4) TM PALM placed on the ASIS and posterior superior iliac spine (PSIS) of the hemiparetic side (Figure 5). Three test trials of pelvic obliquity and anterior pelvic tilt were performed, and the mean reading was used for analysis. Standard procedure was used for measuring the forward arm reach distance using SRT. Data Analysis The collected data were analysed using IBM SPSS for Windows, Version 25.0 (IBM Corp, Armonk, NY). Normality of the outcome measures was statistically verified using the Kolmogorov–Smirnov Z test. For between group comparison, Student’s t test was used. For within group comparison, paired t test was used. Chi square test was used for descriptive statistics. A p value of less than 0.05 was considered as statistically significant. Result Figure 1. Taping for Restricting Thoracic Kyphosis Source: The authors. Baseline characteristics of experimental and control groups are depicted in Table 1. Except the duration since stroke (p = 0.02), all the variables were similar between the groups. In order to find the immediate effect of taping, level 1 and level 2 data within the experimental group were compared and to find the short-term effect, level 1 and level 3 data for either group were compared. Figure 2. Taping for Facilitating Abdominal Muscles Source: The authors. Outcome Measures To evaluate the pelvic alignment and forward arm reach TM distance, the PALM and SRT were used respectively. For pelvic alignment, each participant was made to sit on a plinth with no back support, with thighs fully supported on plinth, hips, knees and ankles at 90° of flexion, and feet positioned flat on the floor in the same line with the knees. Commands like ‘sit as tall as possible’ or ‘sit tall’ were given after positioning. Pelvic obliquity was measured in the frontal plane and the anterior pelvic tilt was measured in the sagittal plane. Pelvic obliquity was measured in degrees, with the lever arms of the TM PALM placed on the left and right ASIS (Figure 4). The direction of obliquity (i.e., the left or right side lower) was Figure 3. Flowchart of Participant Enrollment and Analysis noted based on the earlier literature. Anterior pelvic tilt on Source: Consolidated Standards of Reporting Trials (CONSORT) diagram the hemiparetic side was measured with the lever arms of the adapted to the current study. Mehta et al. 13 Pelvic Alignment Taping had shown statistically significant improvement in pelvic obliquity and anterior pelvic tilt in the experimental group. As shown in Table 2, pelvic obliquity improved and reached closer towards neutral and anterior pelvic tilt improved by 4.5°. There was significant short-term improvement in the pelvic alignment within the experimental group. Pelvic obliquity improved towards neutral and anterior pelvic tilt improved by 4.9°. On the contrary, within the control group, pelvic obliquity remained the same and anterior pelvic tilt increased marginally to 0.07° which was statistically not significant (Table 3). Forward Arm Reach Distance Forward arm reach distance improved immediately in the experimental group by 3 cm with a p value of 0.016 (Table TM Figure 4. Assessing Pelvic Obliquity with Palpation Meter (PALM ) 2). With respect to the short-term effects of taping, both the Source: The authors. groups showed significant improvement in forward arm reach distance. However, visual inspection of the data reveals that the experimental group had a better improvement when compared to the control group (Table 4). Table 2. Immediate Effect of Taping on Pelvic Alignment and For- ward Arm Reach Distance in the Experimental Group Baseline IET Variables Mean (SD) Mean (SD) P Value Pelvic 4.4° (0.75) 0.27° (0.80) < 0.001* obliquity Anterior 2.3° (2.4) 6.8° (1.64) < 0.001* pelvic tilt Forward 32 (7.8) 35 (4.9) 0.016* arm reach distance Figure 5. Assessing Anterior Pelvic Tilt on the Hemiplegic Side with (cm) TM Palpation Meter (PALM ) Source: The authors. Source: The authors. Abbreviations: IET, immediate effect of taping; SD, standard deviation; cm, centimetres. Note: * significant. Table 1. Demographic Data Experi- Table 3. Short-term Effect of Taping on Pelvic Alignment in Exper- mental Controls imental and Control Group Group Group (n = P Val- Pelvic Obliquity Anterior Pelvic Tilt Demographic Data (n = 15) 15) ue Base- Base- Age mean (SD) years 60 (8.6) 62 (5.6) 0.57 line SET line SET Gender Male, n (%) 10 (67) 11 (73) 0.69 Mean Mean Mean Mean P Val- Female, n 5 (33) 4 (27) Group (SD) (SD) P Value (SD) (SD) ue (%) Exper- 4.4° 0.27° <0.001* 2.3° 7.2° <0.001* imen- (0.75) (0.79) (2.4) (1.9) Duration since stroke 47 (58) 16 (2.9) 0.02* tal (n mean (SD) days = 15) Affected side Right, 10 (67) 8 (53) 0.36 Con- 3.5° 3.5° 0.334 2.2° 2.2° 0.334 Left, n (%) n (%) trol (n (1.1) (1.1) (1.7) (1.8) 5 (33) 7 (47) = 15) Source: The authors. Source: The authors. Abbreviation: SET, short-term effect. Abbreviation: SD, standard deviation. * Notes: * significant; n, number of participants. Notes: significant; n, number of participants. 14 Annals of Neurosciences 26(3–4) Table 4. Short-term Effect of Taping on Forward Arm Reach Dis- In addition to the above, the participants also exhibited tance in Experimental and Control Group increased anterior pelvic tilt. Furthermore, this improvement was maintained for three days. Present study findings reveal Forward Arm Reach Distance (cm) that the improvement in pelvic alignment could be the result Baseline SET of taping, as conventional treatment was common for both the Group Mean (SD) Mean (SD) P Value experimental and the control groups. Experimental 32 (7.8) 37 (6.2) 0.009* Efficient stabilization of spine required for the static (n = 15) and dynamic normal posture is produced by the passive Control (n = 27 (4.8) 31 (4.4) 0.006* osteoligamentous system, active musculotendinous system 15) and neural control system. In stroke, impairment of the Source: The authors. latter two systems leads to altered alignment and disturbed Abbreviations: cm, centimetre; SD, standard deviation; SET, short-term postural symmetry. The results of this study suggest that effect of taping. Notes: *, significant; n, number of participants. taping may have improved the active musculotendinous and the neural control component of the stabilizing system of the spine leading to improvement in the pelvic alignment, that is, Table 5. Change Scores of Pelvic Alignment and Forward Arm taping prevented thoracic kyphosis by positioning the pelvis Reach Distance in Experimental and Control Group in neutral, thus, promoting better recruitment of obliques. The Experimen- Controls current findings are reinforced by earlier works of Maguire et Change Scores tal (n = 15) (n = 15) P Value 15,16 al and Kilbreath et al. Pelvic obliquity 4.1° (0.94) 0.00 <0.001* Hemiparesis results in pronounced weakness of the mean (SD) affected side trunk muscles, with more weight bearing on the Anterior pelvic 0.06° unaffected side, elevation of pelvis on the affected side and 4.9° (2.1) <0.001* tilt mean (SD) (0.26) 9,22 with impaired sitting balance. Though the forward reach in Forward arm sitting improved in either group, visual inspection of change reach distance 4.5 (5.4) 4.0 (4.8) 0.804 scores (4.5 cm for experimental group and 4.0 cm for control (cm) mean (SD) group) reveals a better result for the experimental group, Source: The authors. indicating that the improvement could have been the result Abbreviations: SD, standard deviation; cm, centimetre. of improved postural symmetry and enhanced recruitment of Notes: *, significant; n, number of participants. trunk muscles. Repeated practice might have improved perceptual Table 5 depicts the change scores (pre to post intervention processes involved in coordinated movement and execution difference) of pelvic alignments and forward arm reach of task and the same would have been responsible for distance across the experimental and the control groups. improvement in the forward reach for either group. Besides, Except for the forward arm reach distance, the experimental subjects in both the groups had relatively normal balance at group showed statistically significant improvement in the beginning of the study as represented by their baseline postural alignment when compared to the control group. value for forward arm reach distance, resulting in an almost parallel improvement in sitting balance. Discussion The current study had paid attention to check the immediate and short-term effect of taping on postural control, To the best of our knowledge, this is a preliminary study to and not the carry-over or long-term effect of taping. Care examine the immediate and the short-term effect of taping is to be taken while generalizing the effect as the current as an adjunct to conventional physiotherapy in improvising study used a smaller sample size. Future studies are required sitting postural control. In this study, we assumed that taping to see the effect of taping on other functional activities. of the thoracic spine and abdominal muscles may improve the Incorporation of objective outcome measures for quantitative pelvic alignment and forward reach among stroke patients. analysis of the improvement, such as kinematic analysis of Descriptive statistics of demographic data revealed reaching and forced platform analysis of postural symmetry significant difference in post-stroke duration in experimental in sitting, may provide additional information including true and control groups (Table 1). Inclusion of three participants motor improvement and the plausible compensations. with post-stroke duration of more than three months under the experimental group made the post-stroke data skewed; Conclusion otherwise, all the rest of the parameters were comparable between the groups. The result of this study indicates that taping as a treatment Thirteen out of fifteen participants in the experimental adjunct can result in immediate as well as short-term group were able to achieve neutral horizontal alignment. improvement of pelvic alignment while sitting. It may also Remaining two subjects achieved near-neutral alignment. Mehta et al. 15 result in immediate improvement of sitting balance among 5. Dean CM, Channon EF and Hall JM. Sitting training early after stroke patients and may prevent adverse effect of postural stroke improves sitting ability and quality and carries over to asymmetry in sitting following stroke. standing up but not to Walking: A randomised controlled trial. Aus J Physiother 2007; 53: 97–102. Acknowledgements 6. Genthon N, Vuillerme N, Monnet JP, et al. Biomechanical We would like to thank Manipal Academy of Higher Education, assessment of the sitting posture maintenance in patients with Manipal, India, and all the participants of the study for all the stroke. Clin Biomech 2007; 22: 1024–1029. support. 7. Zakaria Y, Rashad U and Mohammed R. Assessment of malalignment of trunk and pelvis in stroke patients. Egypt J Author Contributions Neurol Psychiat Neurosurg 2010; 47: 599–604. Megha Mehta was the principal investigator for this study. 8. Nichols DS, Miller L, Colby LA, et al. Sitting balance: Its Conceptualization of the study was by Abraham M. Joshua. relation to function in individual with hemiparesis. Arch Phys Supervision of the trial and data collection was done by Suruliraj Med Rehabil 1996; 77: 865–869. Karthikbabu. The study was designed and the data analysis was executed by Bhaskaran Unnikrishnan and Prasanna Mithra. Zulkifli 9. Karthikbabu S, Chakrapani M, Ganesan S, et al. Relationship K Misri and Akshatha Nayak provided critical inputs and aided with between pelvic alignment and weight-bearing asymmetry in data management. Authors of this study had equally contributed in community-dwelling chronic stroke survivors. J Neurosci preparation and editing of this manuscript. Rural Prac 2016; 7: S37–S40. 10. Axelson P, Axelson DY, Hayes A, et al. Hip grip pelvic Ethical Statement stabilization device for wheelchair users phase II final report. The Institutional Ethical Committee (IEC), Kasturba Medical Minden, NV: Beneficial Designs Inc, 2004. College, Mangalore, Karnataka, India, approved this study. All participants gave written informed consent before data collection 11. Petrone MR, Guinn J, Reddin A, et al. The accuracy of the began. palpation meter (PALM) for measuring pelvic crest height difference and leg length discrepancy. J Orthop Sports Phys Declaration of Conflicting Interests Ther 2003; 33(6): 319–325. The authors declared no potential conflicts of interest with respect to 12. Naval D, Syed N and Karthikbabu S. Intra-rater and inter-rater the research, authorship and/or publication of this article. reliability of measuring pelvic tilt using the palpation meter TM (PALM ) device in stroke. Int J Med Health Sci 2016; 5(4): Funding 276–280. The authors disclosed receipt of the following financial support for 13. Tsang YL and Mak MK. Sit-and-reach test can predict mobility the research, authorship and/or publication of this article: The study of patients recovering from acute stroke. Arch Phys Med was partially funded by, Kasturba Medical College, Mangalore, Rehabil 2004; 85: 94–98. Manipal Academy of Higher Education, Manipal, India. 14. Vasileva D, Lubenova D and Mihova M. Postural control and balance reactions in patients with ischemic stroke in the References chronic period. Sport, Stress, Adaptation—Scientific Journal 1. Chern J, Lo C, Wu C, et al. 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Journal

Annals of NeurosciencesSAGE

Published: Jul 1, 2019

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