Trunk Exercises in Stroke Patients

Why Trunk Training Matters

Trunk Exercise Program - By Position and Level

SUPINE EXERCISES (Early Stage / Low Ability)

A. Bridging (Gluteal/Core Activation)

• Targets: Gluteus maximus, hamstrings, lumbar extensors, transversus abdominis
• Modification: Use a foam roller under the knees or a therapist can support the affected leg

B. Bridging with Arm Raise

C. Single-Leg Bridging

D. Supine Knee Rolling (Trunk Rotation)

• Targets: Obliques, lumbar rotators

Clinical Photo - Supine and Standing Trunk Control Exercise Program

• (A) Bridging - pelvis lifted, supine
• (B) Bridging with bilateral arm raise overhead
• (C) Single-leg bridging / advanced bridge with unstable support
• (D) Supine trunk rotation with foam roller
• (E-G) Standing balance progressions - bilateral stance, tandem stance, single-leg stance on step

SEATED EXERCISES (Mid Stage / Most Common in Clinical Practice)

1. Back Extensor Isometric Hold

• Targets: Lumbar extensors, thoracic erectors

2. Trunk Rotation (Seated Twists)

• Targets: Obliques, thoracic rotators
• Clinical note: Particularly useful for stroke patients with truncal asymmetry leaning toward the affected side

3. Lateral Trunk Flexion (Oblique Side Dip)

• Targets: Obliques, quadratus lumborum

4. Seated Trunk Extension (Hip Hinge Forward)

5. Trunk Circles

• Targets: Global trunk stabilizers, weight-shifting ability

Clinical Photo - Seated Trunk Training / Therapist-Assisted

ADVANCED EXERCISES (Late Stage / Regained Motor Control)

10. Bridges (see supine section above)

11. Crossbody Leg Lift (Dead Bug)

• Targets: Transversus abdominis, rectus abdominis, hip flexors

12. Modified Plank / Four-Point Kneeling

13. Unstable Surface Training (Gym Ball / Balance Board)

• Evidence: A systematic review (PMID: 24018373) found trunk training on unstable surfaces produces additional improvement in trunk performance beyond stable surface training alone.

Assessment Tools for Trunk Function

Key Clinical Evidence

• Trunk training (stable + unstable surfaces) improves trunk performance and functional sitting balance - systematic review of 12 RCTs (Karthikbabu et al., 2013)
• Core stabilization exercises added to conventional therapy significantly improve trunk impairment scale scores, ambulation, and quality of life vs. conventional therapy alone - RCT in BMC Sports Science (2022)
• Sitting balance physiotherapy in early sub-acute stroke improves outcomes - meta-analysis by Rayner et al. 2026 (PMID: 41275723)
• Dynamic balance is best improved by task-specific training and balance training programs - meta-analysis by Han et al. 2024 (PMID: 38598557)

Practical Tips for Clinicians

1. Start position matters - begin in the position the patient can safely control (supine → sitting → standing)
2. Affected side activation - cue the patient to activate muscles on the hemiplegic side consciously; tactile cues on the affected trunk help
3. Feedback - use a mirror or verbal feedback to correct truncal asymmetry (the classic post-stroke lean)
4. Progression - stable surface → unstable surface → dual-task (e.g., talk while doing seated trunk rotation)
5. Frequency - most protocols use 30-60 min sessions, 5 days/week during inpatient rehab

Note: Always screen for spinal instability, osteoporosis, or orthostatic hypotension before initiating trunk exercises. Exercises should be supervised by a physiotherapist, especially in the early post-stroke phase. The exercises described here are for educational purposes and should be adapted to the individual patient's abilities and goals.

Physiotherapy Management Plan

Patient: 60-year-old, Left Hemiplegia, Cardiac Pacemaker

Step 1: Understanding the MMT Grades (Clinical Picture)

Step 2: Pacemaker - Critical Precautions FIRST

Absolute Contraindications (DO NOT USE):

• Shortwave diathermy (SWD) - absolute contraindication; must stay >3 meters from any pacemaker patient
• Microwave diathermy - absolute contraindication
• NMES / FES (neuromuscular electrical stimulation / functional electrical stimulation) over the chest or upper trunk - contraindicated
• Interferential therapy (IFT) over the chest, shoulder, or upper back - avoid
• TENS near the chest/cardiac region - contraindicated

Conditional / Caution:

• TENS to the affected upper limb (arm only, well away from chest) - may be used cautiously with ECG monitoring and cardiologist clearance; low-intensity sensory-level stimulation
• NMES to the lower extremity - generally considered safe
• Ultrasound to the limb - generally safe, do not apply over the pacemaker device implant site (usually left infraclavicular area)

Safe Electrotherapy Options:

• Infrared / heat to affected limb (not chest)
• Paraffin wax to hand/wrist
• Laser therapy to limb (low level)

Exercise Precautions:

• Monitor heart rate and SpO2 during all sessions
• Know the pacemaker's lower/upper rate limits (consult cardiology notes)
• Stop exercise if: palpitations, dizziness, syncope, chest pain, disproportionate dyspnea
• Avoid Valsalva maneuver (straining/breath-holding during exercises)
• Rate of perceived exertion (RPE) should stay at 11-13/20 (light to somewhat hard)

Step 3: Physiotherapy Goals (Short & Long Term)

Short-Term (0-4 weeks)

1. Prevent shoulder subluxation and pain on the hemiplegic side
2. Maintain full passive range of motion (PROM) at all upper limb joints
3. Prevent contracture and spasticity
4. Stimulate early voluntary motor activation (grades 1-2)
5. Prevent deep vein thrombosis, pressure injuries, and chest complications

Long-Term (4-12 weeks)

1. Progress from passive to active-assisted to active ROM
2. Facilitate motor recovery toward grade 3+ (anti-gravity movement)
3. Improve functional use of the affected limb in ADLs
4. Trunk control and postural alignment

Step 4: Exercise Protocol - By Priority

A. POSITIONING (Always the First Intervention)

• Supine: Affected arm supported on a pillow in slight abduction and external rotation; elbow slightly flexed, wrist neutral, fingers loosely extended
• Side-lying on affected side: Shoulder protracted, elbow extended, forearm supinated, wrist neutral
• Side-lying on unaffected side: Affected arm resting on a pillow in front of the body, shoulder forward-flexed ~90°
• Sitting: Arm supported on a lapboard or armrest; never allow the arm to hang unsupported (causes subluxation)
• Shoulder sling: Use during ambulation/transfers only (not for prolonged use as it promotes flexor synergy)

B. PASSIVE RANGE OF MOTION (PROM)

C. ACTIVE-ASSISTED ROM (AAROM)

Elbow Flexion/Extension (Grade 2+/2)

• Position: Patient lying on side (affected arm uppermost), or arm supported on a smooth surface (powder board or smooth table)
• Exercise: Slide the arm on the table to flex and extend the elbow through full range. Patient initiates, therapist assists completion.
• Reps: 10-15, 3 sets

Forearm Pronation/Supination (Grade 2)

• Position: Seated or supine, elbow at 90°, forearm supported
• Exercise: Patient attempts to rotate forearm; therapist assists as needed
• Reps: 10-15, 3 sets

Self-AAROM Using Unaffected Hand (VERY IMPORTANT)

• Bilateral arm raise (prayer position): Patient clasps hands together with unaffected hand supporting the affected one, raises both arms overhead slowly. Maintains shoulder ROM and stimulates bilateral neural activation.
• Elbow clasp exercise: Hands clasped, elbows flex and extend together
• Perform: 15-20 reps, 3-4 times/day independently

D. FACILITATION TECHNIQUES (To Stimulate Grade 1 Muscles)

1. Proprioceptive Neuromuscular Facilitation (PNF) - D1 and D2 Patterns (Passive)

• Apply resistance on the UNAFFECTED side while verbally cueing the affected side to "try to move"
• Use tapping, quick stretch, and vibration over the muscle belly of the target muscle to facilitate

2. Tapping / Vibration

• Tap briskly over the deltoid (anterior/middle fibers) to facilitate shoulder flexion/abduction
• Vibrate over the wrist extensors (extensor carpi radialis) to encourage wrist extension

3. Biofeedback (EMG)

• Surface EMG biofeedback on deltoid or wrist extensors helps patient visualize and amplify trace muscle activity (grades 1-1+)
• Safe with pacemaker when placed on the arm (well away from chest)

4. Mirror Therapy

• Position a mirror sagittally between the two arms. Patient watches the unaffected arm move while attempting to mirror the movement with the affected arm. This creates a visual illusion of the affected arm moving and facilitates cortical reorganization.
• Safe with pacemaker - no electrotherapy involved
• Strong evidence for grade 1-2 upper limb weakness in stroke

5. Mental Practice / Motor Imagery

• Patient imagines performing shoulder flexion, wrist extension etc. before attempting movement
• Activates the same motor cortex areas as actual movement
• Safe, no contraindications

E. SHOULDER SUBLUXATION PREVENTION

• Proper positioning at ALL times (described above)
• Strapping / taping of the shoulder (kinesio tape or rigid strapping)
• Shoulder support in sitting and standing
• Educate all caregivers: never pull the patient by the affected arm

F. SPASTICITY MANAGEMENT (Anticipatory)

• Shoulder: adduction + internal rotation
• Elbow: flexion
• Wrist/fingers: flexion

• PROM in the OPPOSITE direction of anticipated spasticity (shoulder ER, elbow extension, wrist/finger extension)
• Positioning to avoid reinforcing flexor synergy
• Splinting: resting hand splint at night (wrist neutral, fingers extended)
• Avoid any tight clothing or restraints on the affected arm

G. SENSORY STIMULATION

• Brushing over the skin of the affected shoulder and arm (quick brushing = facilitatory)
• Proprioceptive loading: Gentle compression through the shoulder joint in correct alignment
• Temperature: Alternating warm/cool towels on the arm to heighten sensory awareness
• Textured object handling: Place objects of different textures in the affected hand even if grip is absent - provides afferent input

H. FUNCTIONAL ELECTRICAL STIMULATION (FES) - MODIFIED APPROACH

• FES to the wrist extensors or shoulder muscles is a proven adjunct for grade 1-2 weakness in stroke
• Only permissible with cardiologist clearance, and only to the affected upper limb (arm), away from the chest
• ECG monitoring during first application is mandatory
• If not cleared, skip FES and rely on mirror therapy + EMG biofeedback instead

Step 5: Additional Interventions

Step 6: Suggested Daily Session Structure (45-60 minutes)

Key Outcome Measures to Track Progress

• Fugl-Meyer Assessment - Upper Extremity (FMA-UE) - gold standard for motor recovery in stroke
• Manual Muscle Test (MMT) - track weekly changes in grades
• Trunk Impairment Scale (TIS) - trunk postural control
• Modified Ashworth Scale (MAS) - monitor for emerging spasticity
• Visual Analogue Scale (VAS) - shoulder pain

Important note: This patient requires close coordination between physiotherapy and cardiology. Before initiating any electrotherapy (even to the arm), obtain written cardiologist clearance specifying the pacemaker model, rate limits, and approved modalities. Monitor vital signs at every session. Stop immediately if any cardiac symptoms develop.

Recent evidence (Rayner et al. 2026, PMID 41275723) supports early and intensive physiotherapy for post-stroke patients; the pacemaker does not limit exercise-based rehabilitation, only electrotherapy selection.