Effects of lumbar joint mobilization on trunk function,postural balance,and gait in patients with chronic stroke: A randomized pilot study

Abstract

BACKGROUND:

Patients with stroke have hypomobility in the facet joint of affected side. Lumbar joint mobilization could be used to maintain function and mobility of the joints.

OBJECTIVE:

This study aimed to investigate the effects of lumbar joint mobilization on trunk function, postural balance, and gait in patients with stroke.

METHODS:

Thirty patients with stroke were randomly assigned to two groups. Lumbar joint mobilization was provided for 15 min, 5 times a week for 6 weeks to patients who were allocated into the experimental group. Patients who were allocated into the control group received a sham intervention. Trunk function (trunk impairment scale), postural balance (weight distribution, Berg balance scale, and timed up and go test), and walking (10 m walk test, functional gait assessment, step length, and stride length) were evaluated before and after the experiment for all the patients.

RESULTS:

Lumbar joint mobilization significantly improved trunk function, postural balance, and gait compared with pre-test values in the experimental group ( $P<$ 0.05). Significant differences were seen in trunk function, postural balance, and walking between the two groups ( $P<$ 0.05).

CONCLUSION:

Lumbar joint mobilization might be an effective intervention for trunk function, postural balance, and walking in patients with stroke.

Keywords

Lumbar mobilization trunk postural balance gait

1. Introduction

Stroke causes a variety of physical, psychological, and social disabilities, and about 40% of patients with stroke suffer from physical disability depending on the brain area impaired due to the stroke event [1, 2]. Patients with hemiplegia may experience physical disabilities due to muscle weakness and sensory changes, including decreased trunk control, increased postural sway, decreased walking ability, and limited daily living functions [3]. Especially, postural sway increases due to a decrease in the strength of the trunk muscles that are essential for maintaining stability of the trunk and postural balance. Owing to a decrease in endurance due to muscle weakness, it becomes difficult to maintain a static posture upon bearing weight [4]. Trunk muscles are required to maintain an upright posture and control balance against gravity [5]. The lower trunk is particularly important in functional activities and is the basis or motive force for every limb movement [6].

Hemiplegia after a stroke causes imbalance of the trunk and asymmetrical posture. Further, it reduces the ability of the trunk to maintain the center of mass on its base of support and the equilibrium response to maintain symmetrical static balance. Therefore, stroke patients move their center of mass to the less affected side to ensure stability [6], and load most of their body weight onto the trunk on the less affected side to compensate for the decreased stability, which results in a decrease in balance and walking ability [7].

Joint mobilization is mainly used for patients with motion restriction, hypomobility, acute joint locking, and joint fixation [8]. It is used for patients with musculoskeletal injury as well as for those with severe damage to the central nervous system, such as in stroke patients, when they suffer from degenerative joint disease or when tissues around joints require relaxation [9]. Joint mobilization performed on the corresponding joint of stroke patients with hypomobility of the spine is expected to increase the range of joint movement and decrease pain, and muscle re-education [9, 10, 11]. Previous studies reported that joint mobilization can increase the mobility of connective tissues around joints, such as articular capsules, and optimize the movement of joints by retaining the length of muscles around the joints [12, 13]. Moreover, a previous study reported that muscle thickness increased after joint mobilization on the lumbar spine, as observed with ultrasound images of the multifidus muscle [14].

Until now, studies on joint mobilization were mainly conducted with subjects without neurological disorders and only a few studies have addressed joint mobilization as an intervention to improve the trunk function of stroke patients. Therefore, the purpose of this study was to investigate the effects of joint mobilization on trunk function, postural balance, and gait in patients with stroke.

2. Methods

2.1 Subjects

This study was designed as a randomized pilot trial. We included stroke patients who were admitted to a rehabilitation hospital between April to June 2015. To recruit patients for the study, advertisements were placed in the physical therapy office which described the purpose of the study, and that participants would be able to withdraw from the study at any time. Consent was obtained from all the subjects willing to participate and the study was approved by the research ethics committee of Sahmyook University (SYUIRB2015-075). The inclusion criteria were as follows: patients with chronic stroke for more than 6 months, who were able to walk independently for more than 10 m, and who had no cognitive impairments such as dementia. Exclusion criteria included: patients with a medical history of musculoskeletal disease such as fractures or bone deformities, those with vision or auditory disorders, those with dysphasia, those with vestibular dysfunctions, and those with other neurological disorders such as Parkinson’s disease.

2.2 Experimental procedure

In total, 42 individuals participated in the study and 12 were excluded because five of them had a duration of less than 6 months, one had a femur fracture, two had other neurological disorders, and four had dysphasia. The participants were evaluated before and after the present study for trunk function, postural balance, and walking. Subsequently, they were randomly divided into an experimental group ( $n=$ 15) and a control group ( $n=$ 15). The experimental group received 15 minutes of joint mobilization for 5 days a week for 6 weeks, while the control group was required to hold the same posture but received no joint mobilization. The joint mobilization was performed by physical therapists with at least 5 years of experience, and the intensity of the joint mobilization was applied according to the grade level of the mobilization technique and lumbar joint mobility of the participants. For the control group, a sham stimulus was given on the lumbar spine by physical therapists. Both the experimental and control groups received the same conventional physical therapy for 60 minutes for 5 days a week for 6 weeks (Fig. 1).

Figure 1.

Flowchart of total experimental procedure.

2.3 Intervention

2.3.1 Lumbar joint mobilization

The Gape technique was used for lumbar joint mobilization [15], wherein the subjects were required to lie on their side and the hip joints were flexed until the second lumbar vertebra moved. Following this, the position was fixed to hold the lower vertebrae. A rolled towel was placed under the lumbar spine to facilitate joint mobilization. The therapist used one hand to fix the spinous process of the second lumbar vertebra and the other hand to fix the spinous process of the first lumbar vertebra. The therapist pressed their elbow against the patient to induce extension, lateral flexion, and ipsilateral rotation. During the treatment, the patient was required to continuously look at the therapist to indicate an increase in the degree of rotation. Patients with hypermobility were administered grade I and II joint mobilization, and those with hypomobility were administered grade III mobilization. Lumbar joint mobilization was performed on the first to fifth lumbar vertebrae, with 2 $\sim$ 5 minutes for each segment.

2.3.2 Sham therapy

The posture was the same as the actual lumbar joint mobilization, but the spinous process of the lumbar vertebra was not fixed, and no force was applied.

2.3.3 Conventional physical therapy

Convention physical therapy, which consisted of range of motion exercises, stretching, strengthening, functional approaches, and Bobath treatment was administered in the hospital. Functional approaches included bed exercise, come-to-sit, sit-to-stand, and gait [16]. Conventional physical therapy was performed by a physical therapist who did not apply the lumbar joint mobilization.

2.4 Outcome measurements

2.4.1 Trunk function

In this study, trunk function was measured using the Trunk Impairment Scale (TIS). This is a popular tool to measure motor impairment of the trunk after stroke that evaluates static sitting balance, dynamic sitting balance, and coordination of the trunk. A higher score indicates better trunk control. The test-retest reliability and inter-rater reliability for the TIS total score were high, 0.87–0.96 and 0.85, respectively [17].

Table 1
General characteristics of subjects

	Experimental group ( $n=$ 15)	Control group ( $n=$ 15)	$P$ value
Sex (male/female)	9/6	11/4	0.439
Affected side (right/left)	4/11	5/10	0.690
Stroke type (infarction/hemorrhage)	11/4	12/3	0.666
Age (year)	60.80 $\pm$ 6.72	60.87 $\pm$ 6.64	0.978
Body weight (kg)	64.77 $\pm$ 7.88	65.79 $\pm$ 7.32	0.718
Height (cm)	166.25 $\pm$ 5.78	166.87 $\pm$ 5.18	0.758
Onset of stroke (month)	16.60 $\pm$ 2.53	17.13 $\pm$ 2.44	0.562

Values are presented as mean $\pm$ SD.

2.4.2 Postural balance

Postural balance was measured using body weight disturbance, the Berg balance scale (BBS), and the timed up and go test (TUG). The body weight distribution was measured with the balance analyzer (Bio-Rescue, RM INGENERIE, France, 2014). When a subject stood on the force plate of the balance analyzer, the distribution of weight between the affected and less affected side was evaluated. For consistency of measurement, the distance between the heels was maintained at 3 cm and the subjects were required to stand up at an angle of 30 ${}^{\circ}$ on the long axis of the foot. The distribution of weight was expressed as a percentage, and the average of the three trials was used. BBS, which was used to measure the balance of older adults or patients with neurological impairments, consisted of 14 items that examined the ability to maintain and control posture, and react to postural sway. The test-retest reliability and inter-rater reliability BBS scores were high at 0.99 and 0.98, respectively [18]. TUG was used to assess the time taken by the participants to rise from a chair, walk 3 m, turn around, walk back to the chair, and sit down. The average of three trials was used. The test-retest reliability and inter-rater reliability scores for TUG were high, with values of 0.99 and 0.98, respectively [19].

2.4.3 Walking

The ability to walk was measured in terms of temporal, spatial, and functional variables, using the 10 m walk test (10MWT), the gait analyzer, and the functional gait assessment (FGA). The 10MWT assessed the time that a participant took to walk 10 m, and had a high reliability ( $r=$ 0.89–1.00) [20]. The subjects were asked to walk for 14 m for the 10MWT, considering the possible acceleration and deceleration during walking that could vary the effective walking time. The time to walk the middle 10 m was measured. The test was performed three times and the average was used. The gait analyzer (OptoGait, Microgate S.r.l, Italy, 2010) was constructed with a 3 m infrared transmitter and matching receiver and two web cameras (Logitech Webcam Pro 9000, Logitech International S.A., Switzerland, 2010) and was used to distinguish which foot the participant took the first step with. The infrared sensors were installed at 1 cm intervals and transmitted data at 1000 Hz. Infrared transmitters and receivers were installed on both sides at a distance of 3 m, and the subjects were asked to walk between them. Considering the acceleration and deceleration during walking, the walking distance was set to 7 m. The measurement was taken three times and the average of the data was used. The gait analyzer is a highly reliable measurement tool, with a reliability of 0.99 [21]. The FGA is a four-point scale consisting of 10 evaluation items. A higher score corresponds to better walking ability. It is a highly reliable tool used to evaluate the functional walking ability of older adults ( $r=$ 0.93) [22].

2.5 Statistical analysis

In this study, SPSS version 19.0 (IBM Corp., Armonk, NY, USA) was used to analyze the data. All parameters were presented with the mean and standard deviation, and the Shapiro-Wilk test was used for normality. To evaluate the homogeneity of the participants, chi-square test and independent $t$ -test were conducted. Two-way repeated ANOVA was performed to determine the effects of the intervention on trunk function, postural balance, and gait. The significance level was set to 0.05.

3. Results

In this study, a total of 30 subjects participated and were randomly assigned to two groups. There were no differences between the two groups at the baseline ( $P>$ 0.05). The general characteristics of the subjects are described in Table 1.

Table 2
Change of trunk impairment scale in the subjects

TIS	Experimental group ( $n=$ 15)		Control group ( $n=$ 15)		Group $\times$ Time
	Pre-test	Pos-test	Pre-test	Post-test	F(P)
Static (points)	6.13 $\pm$ 1.55	6.53 $\pm$ 1.25 ${}^{\ast}$	6.07 $\pm$ 1.03	6.47 $\pm$ 0.83 ${}^{\ast}$	0.000 (1.000)
Dynamic (points)	5.53 $\pm$ 2.56	6.47 $\pm$ 2.50 ${}^{\ast}$	5.20 $\pm$ 2.54	5.73 $\pm$ 2.81	1.361 (0.253)
Coordination (points)	2.60 $\pm$ 0.83	3.47 $\pm$ 1.36 ${}^{\ast}$	2.93 $\pm$ 1.03	3.07 $\pm$ 1.03	7.30 (0.012)
Total (points)	14.27 $\pm$ 4.34	16.47 $\pm$ 4.36 ${}^{\ast}$	14.20 $\pm$ 3.36	15.27 $\pm$ 3.63 ${}^{\ast}$	6.859 (0.014)

Values are presented as mean $\pm$ SD and * presented significant time effects between the pre-test and post-test ( $P<$ 0.05) TIS: trunk impairment scale.

Table 3

Change of postural balance in the subjects

Postural balance	Experimental group ( $n=$ 15)		Control group ( $n=$ 15)		Group $\times$ Time
	Pre-test	Pos-test	Pre-test	Post-test	F(P)
BWD (%)	73.50 $\pm$ 16.02	78.24 $\pm$ 15.03 ${}^{\ast}$	73.06 $\pm$ 10.92	74.63 $\pm$ 11.04 ${}^{\ast}$	16.418 ( $<$ 0.001)
BBS (points)	43.40 $\pm$ 5.44	45.33 $\pm$ 5.51 ${}^{\ast}$	44.13 $\pm$ 8.21	45.07 $\pm$ 8.08 ${}^{\ast}$	5.546 (0.026)
TUG (s)	24.77 $\pm$ 9.43	21.28 $\pm$ 9.79 ${}^{\ast}$	23.96 $\pm$ 8.18	21.79 $\pm$ 8.22	10.439 (0.03)

Values are presented as mean $\pm$ SD and * presented significant time effects between the pre-test and post-test ( $P<$ 0.05) BWD: body weight disturbance; BBS: Berg balance scale; TUG: timed up & go test.

Table 4

Change of gait in the subjects

Walking	Experimental group ( $n=$ 15)		Control group ( $n=$ 15)		Group $\times$ Time
	Pre-test	Post-test	Pre-test	Post-test	F(P)
10MWT (s)	21.04 $\pm$ 7.50	17.74 $\pm$ 7.36 ${}^{\ast}$	19.96 $\pm$ 7.71	17.86 $\pm$ 7.38 ${}^{\ast}$	5.152 (0.031)
FGA (points)	17.33 $\pm$ 6.59	18.60 $\pm$ 5.95 ${}^{\ast}$	18.60 $\pm$ 6.94	19.20 $\pm$ 6.90 ${}^{\ast}$	2.869 (0.101)
Step (cm)	52.40 $\pm$ 9.80	58.87 $\pm$ 11.24 ${}^{\ast}$	51.33 $\pm$ 8.21	55.20 $\pm$ 8.68 ${}^{\ast}$	7.263 (0.012)
Stride (cm)	99.93 $\pm$ 20.99	112.67 $\pm$ 20.65 ${}^{\ast}$	100.07 $\pm$ 23.99	105.53 $\pm$ 25.67	11.992 (0.002)

Values are presented as mean $\pm$ SD and * presented significant times effects between the pre-test and post-test ( $P<$ 0.05). 10MWT: 10 m walk test; FGA: functional gait assessment.

The TIS scores are shown in Table 2, and the scores for static, dynamic, co-ordination, and total score are presented. There was a significant time effect in the experimental group overall ( $P<$ 0.05), but the static balance and total score showed significant time effects in the control group ( $P<$ 0.05). Group by time interaction effect was significantly different for co-ordination and total score between the two groups ( $P<$ 0.05).

Body weight distribution, BBS, and TUG showed a significant time effect in the experimental group, but the control group had a time effect on body weight distribution and BBS ( $P<$ 0.05). There were significant differences in group by time interaction effect on body weight distribution, BBS, and TUG between the two groups ( $P<$ 0.05) (Table 3).

The 10MWT, FGA, step, and stride showed a significant time effect in the experimental group, but the control group had a time effect on the 10MWT, FGA, and step ( $P<$ 0.05). There were significant differences in group by time interaction effect on the 10MWT, step, and stride between the two groups ( $P<$ 0.05) (Table 4).

4. Discussion

This study investigated the effect of lumbar joint mobilization on trunk function, postural balance, and walking in patients with stroke. Patients with stroke are likely to have asymmetric postures, wherein the trunk is deflected to the less affected side, which results in decreased static and dynamic postural balance due to muscle imbalance while controlling the trunk, difficulty in performing various daily tasks, excessive energy consumption, and muscle fatigue [23]. Based on results of previous studies which showed that trunk movement could affect both postural balance and walking, this study was designed to evaluate the effect of lumbar joint mobilization in stroke patients with asymmetric spinal alignment and limited mobility. The present study revealed that there was a significant increase in trunk function, postural balance, and walking in the experimental group after the intervention, compared to the control group.

The lumbar spine segment is closest to the center of the body and is the segment where a compensating effect is often shown when the deep muscle of the trunk becomes weak, even in healthy adults [24, 25, 26]. In particular, patients with hemiplegia have various compensatory mechanisms to maintain their posture [26, 27]. For most patients with stroke, trunk muscles on the affected side are not used. Hence, it is rather common to observe locking in the affected lumbar segments, which results in asymmetric alignment of the trunk and weakening of the trunk functions [28]. TIS was used to measure the ability of the patients to control their trunk. The significant improvement in static sitting balance and coordination for the experimental group as compared to the control group, may be attributable to the mobility and symmetry of the trunk, which improved due to lumbar joint mobilization and promoted the activation of muscles on the affected side. In the previous study, patients with stroke performed upper extremity task training with symmetric abdominal muscle contraction, resulting in a significant improvement on the TIS, and reported that the trunk stability affected their postural balance, which was evaluated using the limit of stability [29].

The benefits of lumbar joint mobilization include increased spinal extensor muscles activation and improved joint position sense in lumbar flexion, extension, and lateral flexion [30, 31]. Further, joint mobilization contributed to an increase in the activity of intrinsic muscles, such as the multifidus, leading to an increase stability of the spine [32]. The improvement in trunk alignment may induce the center of mass of the body to move towards the centre line of the body, which can cause a significant increase in the weight bearing ability of a patient with stroke on the affected side. The facet joints of the lumbar spine biomechanically share the axial compression and shear loads along the spine with the intervertebral disc and transverse ligaments and limit axial rotation of the lumbar segment [33]. Small axial rotation of the lumbar joint should be considered to increase mobility, since it is generated by high congruency between the superior and inferior joint surfaces [4]. The lumbar joint mobilization used in this study emphasized the motion of the lumbar spine joint by using the Gape technique and consequently, it provided stability and mobility of the spine on the affected side and enhanced the spine alignment. Trunk malalignment in patients with stroke could influence postural control and lumbar spine curvature [34], and pelvic movements were clearly related to coordination in sub-items of the TIS and the BBS [35]. In this study, the experimental group showed a significant improvement in coordination of the TIS and the BBS, so it is reasonable to assume that the mobility of both the pelvis and lumbar spine increased. In a study by Hyung and Ha, joint mobilization was performed for patients with chronic low back pain, who had a structural limitation of the lumbar joint, and there was a significant improvement in postural balance as measured by the star excursion balance test ( $P<$ 0.05). Therefore, the improvement of somatosensory input could be attributed to lumbar joint mobilization, which increased lumbar mobility and muscle activity, thereby, enhancing the dynamic balance [36, 37].

Walking is a movement that requires coordination of each segment of the body, which continually controls the postural sway. The trunk muscles are essential for posture control and are activated while walking [38]. Since independent walking is an important factor in daily life, improvement in walking is a crucial goal in rehabilitation. Walking speed can be a useful indicator to determine the overall function and whether the patients can be discharged [1, 20]. In a previous study in which patients with chronic stroke performed body weight supported training for 3 weeks, the 10MWT showed a significant decrease from 44.0 s to 35.9 s ( $P<$ 0.05) [39]. Additionally, in a study in which three-dimensional spine stabilization exercise was performed for 7 weeks, the 10MWT showed a significant decrease from 11.96 s to 9.66 s in patients with stroke ( $p<$ 0.05) [40]. Lumbar joint mobilization was shown to improve weight bearing on the affected side and improved trunk alignment increased stability, which had a positive influence on the walking speed [41]. For both the groups, the FGA increased significantly ( $P<$ 0.05), but there was no significant difference between the two groups. This might have been due to the sub-items of the FGA which are highly associated with vestibular or visual information, such as walking while rotating the head left to right, walking while nodding the head up and down, and walking with eyes closed.

Schmidt and Lee reported that proprioception relays movement-related information to the central nervous system when the body segments are properly aligned, generating an optimum movement [42]. Manual therapy, such as joint mobilization, is a conventional treatment to correct spine alignment. It could be a useful intervention to improve trunk alignment and improve the postural balance and walking in patients with stroke [9]. In addition, lumbar joint mobilization in patients with central nervous system impairment could improve the postural balance and walking as well as aid neuroplasticity by stimulating proprioception.

However, this study had several limitations. First, the scope of generalization of the results is limited since only a small number of patients participated in the study. Further, the change in the range of motion due to lumbar joint mobilization was not evaluated. In addition, TIS was assessed in the sitting position, so it is difficult to directly describe the postural control of stroke patients in a standing position. Although it was possible to assess the compensation of the trunk, it was not possible to quantify the degree of the compensation; hence, the qualitative improvement of lumbar joint mobilization could not be demonstrated in this study. There are only a few studies on manual treatments for patients with stroke, and since lumbar joint mobilization is generally performed in patients suffering from low back pain, it would be necessary to address various effects of lumbar joint mobilization in patients with central nervous system impairment in the future studies.

5. Conclusion

This study suggests that lumbar joint mobilization could be effective in improving trunk function, postural balance, and gait in patients with stroke. Lumbar joint mobilization can be used as a new approach to improve postural balance and gait for patients with stroke who have an asymmetric alignment of the trunk or compensative posture. The development of a therapeutic program, combined with manual therapy according to the limitation of lumbar segments, could qualitatively improve the rehabilitation of patients with stroke.

Footnotes

Acknowledgments

This work was supported by Sahmyook University.

Conflict of interest

The authors declare no conflicts of interest.

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Effects of lumbar joint mobilization on trunk function,postural balance,and gait in patients with chronic stroke: A randomized pilot study

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Subjects

2.2 Experimental procedure

2.3.1 Lumbar joint mobilization

2.3.2 Sham therapy

2.3.3 Conventional physical therapy

2.4 Outcome measurements

2.4.1 Trunk function

Table 1 General characteristics of subjects

2.4.3 Walking

2.5 Statistical analysis

3. Results

Table 2 Change of trunk impairment scale in the subjects

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
General characteristics of subjects

Table 2
Change of trunk impairment scale in the subjects