doi:10.1111/ncn3.

12092

ORIGINAL ARTICLE

Pelvic alignment in standing, and its relationship with trunk

control and motor recovery of lower limb after stroke
Suruliraj Karthikbabu,1 Mahabala Chakrapani,2 Sailakshmi Ganesan3 and Ratnavalli Ellajosyla4
Departments of 1Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal Hospital, Bangalore, 2Medicine, 3Physiotherapy,
Kasturba Medical College, Manipal University, Mangalore, and 4Neurology, Manipal Hospital, Bangalore, India

Key words Abstract

motor recovery, pelvic tilt, postural control,
stroke, trunk control.
Accepted for publication 31 July 2016.
Correspondence
S Karthikbabu
Department of Physiotherapy, School of Allied
Health Sciences (SOAHS), A Constituent
College of Manipal University, Manipal
Hospital, Old Airport Road, Bangalore 560017,
India. Emails: karthik.babu@manipal.edu;
karthikbabu78@gmail.com
Background: The pelvis is not stable after stroke, and poor trunk recovery might
be the foremost contributor to altered pelvic alignment in sitting, standing and
during walking.
Aim: To analyze the relationship between pelvic alignment in standing and trunk
control after stroke, and also test how these correlations are related to Brunn-
stroms lower limb motor recovery.
Methods: In the present cross-sectional study, 116 ambulant patients after stroke
were assessed for their pelvic tilt angles in standing and trunk control using a pal-
pation meter (PALM device) and the Trunk Impairment Scale (TIS), respectively.
The pelvic tilt values were correlated to TIS scores by the Pearsons correlation
coefficient.
Results: The mean age, post-stroke duration, and Brunnstroms lower limb motor
recovery of study participants were 55 (13) years, 14.2 (11.3) months and 3.75
(0.79), respectively. The present study reported more lateral pelvic tilt of 2.47
(1.78) towards the most affected side and an anterior pelvic tilt of 4.4 (1.8)
bilaterally. The mean score of TIS was 10.4 (3). Pelvic tilt angles had a moderately
inverse correlation with the total TIS score and coordination subscale of TIS (r-
value from 0.44 to 0.54), but a low inverse relationship to the dynamic sitting
balance subscale of TIS (0.36 to 0.45). Also, the pelvic tilt had a high negative
correlation with trunk control (r-value from 0.68 to 0.84) in lower limb motor
recovery stage 5.
Conclusion: Pelvic alignment when standing is not normal after stroke, and this is
influenced by poor trunk control and impairment of the lower extremities. Assess-
ment of the pelvis provides further insight into planning the appropriate rehabilita-
tion strategies in stroke.

the pelvic movement, and this transverse thoraxpelvis coor-

Introduction
Lower trunk and hip muscular coactivity provides stability
to the pelvis, and serves the function of postural stability
and transferring the load to the lower extremities in stand-
ing.1,2 The altered recruitment of hip abductors and exten-
sors on the most affected leg influences the pelvic stability,
thus resulting in more lateral and anterior pelvic tilt in the
frontal and sagittal plane, respectively.3 There is a gross
impairment of gluteus medius muscle activity during pertur-
bations in standing, and this is compensated by increased
activity of the contralateral hip muscles after stroke.4 People
post-stroke have a more forward-leaning posture with an
anteriorly tilted pelvis in standing, and their altered postural
alignment is related to worse trunk control and balance abil-
ity.5 On observing the intersegmental trunk coordination
during gait, the thoracic range of movement is more than
dination is related to poor gait and balance capacities in
people post-stroke.6
After stroke, there is a reduced anterior displacement of
the body mass with an unequal weight bearing on both feet
during forward reaches in the sitting position. Most of the
flexion movement is accomplished by the upper trunk, with
minimum anterior tilt of the pelvis indicating poor postural
stability of lower trunk.7 In a cross-sectional study, an
increased lateral pelvic towards of the most affected side
was observed using a PALM device, and was related to
poor trunk control and lower limb recovery after stroke.8
Brunnstroms motor recovery grading is widely used by
physical therapists to assess the prognosis of lower limb
motor recovery in people with stroke.9 The involvement of
trunk control after stroke is related to balance, gait and
function, but how impaired trunk control influences the

Neurology and Clinical Neuroscience (2016) 17 1

2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
Pelvic alignment and trunk control after stroke
pelvic position in standing posture is less known.10 The aim
of the present study was to test the relationship between pel-
vic alignment in standing and trunk control after stroke,
and also to find how these correlations are related to differ-
ent stages of lower limb motor recovery.
Methods
The present cross-sectional study received the approval from
the institutional research committee of Manipal University,
India. People after stroke were contacted, and an explana-
tion was given about the purpose, benefits and brief
methodology of the study. All the volunteers signed an
informed consent form before their participation in the
study. After screening for study eligibility, people after
stroke with an ambulatory capacity were recruited from ter-
tiary care rehabilitation centres, community settings, and
outpatient physiotherapy departments of speciality hospitals
between June 2011 and May 2015. People with first ever
ischemic or hemorrhagic stroke, both sexes aged between 30
and 70 years, walk ability with/without walking aids, medi-
cal stability, no brainstem and/or cerebellar stroke, absence
of visual field defects, and Brunnstroms recovery stage of
3 were included in the study. People with the following
impairments were excluded from the study: any peripheral
vestibular dysfunction, severe sensory loss on the soles of
the feet affecting standing balance, any perceptual dysfunc-
tion that might limit their understanding to verbal instruc-
tions, any diagnosed fracture and/or surgeries of lower
extremities in the recent 4-month period, severe chronic
back and/or knee pain that affected their standing posture,
and contracture of hip flexors and ankle plantar flexors lim-
iting the passive range of movement to neutral hip extension
and dorsiflexion, respectively.
After obtaining the demographic profile from patients with
stroke, they were evaluated for their pelvic alignment in
standing and trunk control in sitting by a palpation meter
(PALM device, Performance Attainment Associates, St.
Paul, MN, USA)8,11,12 and Trunk Impairment Scale,13,14
respectively. The order of each test administration was deter-
mined using the coin-toss method for each patient. Rest time
of 5 min was given between the tests to overcome practice
effects. The palpation meter (PALM device) is a pelvic level-
ing device that combines the features of a caliper and an
inclinometer, and this device was tested for its intrarater and
interrater reliability in measuring pelvic obliquity.11,12 Earlier
in our settings, we carried out a testretest reliability of the
palpation device in 64 individuals post-stroke. We
observed an excellent intrarater reliability for measuring
pelvic tilt that ranged from 0.76 to 0.91, and good interrater
reliability of 0.500.92. The Trunk Impairment Scale (TIS), a
valid and reliable tool, has been widely used to assess the
trunk control after stroke. The dynamic sitting balance and
coordination subscales of the TIS scale with a maximum
score of 16 points evaluate the dynamic stability of the
lower trunk upon moving the upper trunk in the sagittal and -
coronal plane, and vice versa.14 These clinical measures were
collected by four qualified physical therapists, and they
were well trained to administer the TIS and PALM device.
2 Neurology and Clinical Neuroscience (2016) 17
S Karthikbabu et al.
The data were analyzed using SPSS software (version 16.0;
SPSS, Chicago, IL, USA), and the demographic characteris-
tics were reported with descriptive statistics. Pearsons corre-
lation coefficient (r) was used to test the relationship
between pelvic alignment (lateral pelvic tilt on most affected
side, anterior pelvic tilt bilaterally) and trunk control (total
TIS score, dynamic sitting balance and coordination sub-
scales of TIS). Furthermore, we grouped the population into
three strata based on their lower limb recovery stage ranging
from 3 to 5, and then analyzed the correlation between the
pelvic alignment and trunk control for each strata. The
interpretation of either positive or negative values of corre-
lation coefficient (r-value) is classified as follows: r < 0.20,
very low; 0.200.39, low; 0.400.59, moderate; 0.600.79,
high; and 0.801.00, very high. A P-value <0.05 was consid-
ered as statistically significant, and a P-value of <0.001 as
highly statistically significant. The scores of clinical measures
were plotted in a scattergram to allow a visual interpretation
of how strong the relationship was between the variables.15
Results
Among 116 patients included in the study, 72 were men and
44 were women, with a mean (SD) age of 55 years
(13 years) and post-stroke duration of 14 months
(11 months). A total of 70 patients (60%) had ischemic
stroke lesion, and 46 (40%) had hemorrhagic stroke lesion.
Right-sided stroke was present in 75 patients (65%),
whereas 41 patients (35%) had left-sided stroke. The mean
(SD) Brunnstroms lower limb motor recovery stage was 3.8
(0.8), and the number of people from third, fourth, and fifth
stage motor recovery was 43, 54 and 19 individuals, respec-
tively. A total of 74 patients were independently ambulant,
whereas 42 were using walking aids, such as a cane, tripod
and so on (Table 1). When standing, the pelvic alignment
was not normal in both the frontal and sagittal planes show-
ing more lateral pelvic tilt of 2.47 (1.78) towards the most
affected side, and an anterior pelvic tilt of 4.4 (1.8) bilater-
ally. The mean (SD) score of total TIS (out of 16 maximum
points), dynamic sitting balance (10), and coordination (6)
subscales of TIS in people after stroke was found to be 10.4
(3), 6.9 (2) and 3.6 (1.5). We measured the pelvic obliquity
in the sagittal and coronal planes in 48 age-matched healthy
individuals who had a weight-bearing asymmetry of 1.83%
(2.82%). We observed that their pelvis was tilted 0.87
(1.28) laterally towards the dominant side (95 % CI 2 to
30). Also, the pelvis was tilted 2.33 (1.13) and 2.67
(1.27) anteriorly on the dominant and on the non-dominant
sides, respectively (95% CI 15) in healthy people.
There was a moderate inverse correlation between total
TIS scores and lateral pelvic tilt (r-value 0.54), and also
for two subscales of TIS and lateral pelvic tilt (r-value
0.45 to 0.53). As for anterior pelvic tilt, the correlation
was moderate with total TIS score and coordination sub-
scale of TIS (r-value 0.46 to 0.48; Table 2). On correlat-
ing the pelvic tilt to trunk control in different Brunnstroms
lower limb motor recovery, the lateral pelvic tilt was moder-
ately inversely correlated with total TIS and the coordina-
tion subscale of TIS in motor recovery stage 3 and 4
2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
S Karthikbabu et al. Pelvic alignment and trunk control after stroke

Table 1 Demographic characteristics of people with stroke we further stratified them into three groups (aged 30
Demographic variables (n = 116) 45 years in the first strata; 4659 years in the second strata
Mean age, years (SD) 54.83 (12.97) and 60 years in the third strata). The pelvic tilt angles were
Sex (male/female) 72 (62%)/44 (38%) highly negatively correlated to the trunk impairment scale
Type of lesion (ischemic/ 70 (60%)/46 (40%) for people who were categorized into the first and second
hemorrhagic) strata, and the corresponding P-value was statistically signif-
Side of hemiplegia (right/left) 41 (35%)/75 (65%) icant (P < 0.05). The correlation coefficient (r) of lateral pel-
Mean post-stroke duration, 14.16 (11.31) vic tilt, most affected and least affected side anterior pelvic
months (SD) tilt to trunk performance in the first strata was 0.42,
Mean Brunnstrom recovery 3.75 (0.79) 0.46 and 0.64, respectively. The correlation coefficient (r)
stage 16 (SD) in second strata was 0.61, 0.40 and 0.47, respectively.
Recovery stage 3, 4 and 5 43 (37%)/54 (47%)/19 (16%) Conversely, the correlation of trunk performance to most
Walk ability (independent/ 74 (64%)/42 (36%) affected side anterior pelvic tilt was highly positive (r-value
walking Aid) 0.32), and there was a moderate positive correlation with
Mean height, cm (SD) 167.4 (9.04) lateral pelvic tilt (0.32) and least affected side anterior pelvic
Mean weight, kg (SD) 69.66 (9.89)
tilt (0.38).
Mean BMI, kg/m2 (SD) 24.96 (3.05)

BMI, body mass index.

(r-value 0.48 to 0.55). In recovery stage 3 and 4, the
dynamic sitting balance subscale of TIS showed a similar
low negative relationship with lateral pelvic tilt (r-value 0.39
to 0.44). Whereas the correlation of bilateral anterior pel-
vic tilt with total TIS score and its subscales was low (r-
value 0.25 to 0.39) in motor recovery stage 3 and 4
(Tables 3 and 4). Interestingly, the correlation of lateral and
anterior pelvic tilt degrees with trunk control ranged
between high and very high (r-value from 0.68 to 0.84)
in people with lower limb motor recovery stage 5 (Table 5;
Figs. 13). According to the age of participants with stroke,
Discussion
The aim of the present study was to test the relationship
between pelvic tilt in standing and trunk control after
stroke, and also to find how these correlations are related to
different stages of lower limb motor recovery. The study
findings showed that there was an excessive anterior pelvic
tilt bilaterally and a lateral pelvic tilt towards the most
affected side, and these pelvic deviations were moderately
correlated to trunk control as measured by the TIS and the
coordination subscale of TIS, but the correlation of anterior
pelvic tilt was low with the dynamic sitting balance subscale
of the TIS.

Table 2 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke

TIS-16 DSB-TIS Coord-TIS

10.41 (3.15) 6.88 (2.02) 3.55 (1.45)
n = 116 Mean (SD)
Pelvic tilt Degree r P r P r P

LPT 2.47 (1.78) 0.541 <0.001 0.448 <0.001 0.529 <0.001

APTMAS 4.43 (1.8) 0.431 <0.001 0.364 <0.001 0.457 <0.001
APTLAS 4.32 (1.8) 0.444 <0.001 0.364 <0.001 0.475 <0.001

P < 0.05 is significant. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS, coordination
subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r, correlation
coefficient; TIS-16, Trunk Impairment Scale-16.

Table 3 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke with Brunnstroms recovery stage 3

TIS-16 DSB-TIS Coord-TIS

9.35 (2.77) 6.19 (1.92) 3.17 (1.28)
n = 43 Mean (SD)
Pelvic tilt Mean (SD) r P r P r P

LPT 2.7 (1.99) 0.501 0.001 0.386 0.007 0.545 0.001

APTMAS 4.33 (1.81) 0.293 0.050 0.248 0.100 0.297 0.048
APTLAS 4.31 (1.83) 0.358 0.016 0.293 0.051 0.373 0.012

P < 0.05 is significant.

Tilt values are expressed in degrees. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS,
coordination subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r,
correlation coefficient; TIS-16, Trunk Impairment Scale-16.

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Pelvic alignment and trunk control after stroke S Karthikbabu et al.

Table 4 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke with Brunnstroms recovery stage 4

TIS-16 DSB-TIS Coord-TIS

10.36 (3.06) 6.86 (1.94) 3.50 (1.43)
n = 54 Mean (SD)
Pelvic tilt Mean (SD) r P r P r P

LPT 2.45 (1.66) 0.499 0.001 0.442 0.001 0.481 0.001

APTMAS 4.58 (1.84) 0.388 0.004 0.349 0.010 0.357 0.009
APTLAS 4.45 (1.95) 0.369 0.007 0.302 0.028 0.373 0.006

P < 0.05 is significant.

Tilt values are expressed in degrees. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS,
coordination subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r,
correlation coefficient; TIS-16, Trunk Impairment Scale-16.

Table 5 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke with Brunnstroms recovery stage 5

TIS-16 DSB-TIS Coord-TIS

12.68 (3.09) 8.29 (1.77) 4.47 (1.47)
n = 19 Mean (SD)
Pelvic tilt Mean (SD) r P r P r P

LPT 1.64 (1.12) 0.841 0.001 0.722 0.012 0.733 0.010

APTMAS 4.09 (1.70) 0.748 0.008 0.802 0.003 0.758 0.007
APTLAS 3.73 (1.27) 0.677 0.022 0.736 0.010 0.675 0.023

P < 0.05 is significant.

Tilt values are expressed in degrees. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS,
coordination subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r,
correlation coefficient; TIS-16, Trunk Impairment Scale-16.

12 12 Brunnstrom's recovery stage -3

Brunnstrom's recovery stage (35)
10 10
Lateral pelvic tilt
Lateral pelvic tilt

8 8

6 6

4 4

2 2

0 0
0 5 10 15 20 0 2 4 6 8 10 12 14 16
Trunk impairment scale -16 Trunk impairment scale -16

9 Brunnstrom's recovery stage -4 3.5 Brunnstrom's recovery stage -5

8 3 3
3
7
Lateral pelvic tilt

Lateral pelvic tilt

6 2.5
5 2
2
4
1.5
3
2 2
2 1
1 0.5
0 2 3
0
0 5 10 15 20 0 5 10 15 20
Trunk impairment scale -16 Trunk impairment scale -16

Figure 1 Scattergram showing the relationship between lateral pelvic tilt and trunk control in different Brunnstroms motor recovery of the lower
extremities.

An increased bilateral forward tilted pelvis and lateral pel-
vic tilt towards the most affected side in standing post-
stroke patients, and also their moderate correlation to trunk
control might be explained by the following facts. The trunk
is activated bilaterally in postural control by extrapyramidal
supra-spinal inputs.16 The bilateral involvement of the trunk
after stroke has been widely studied.17 Also, apart from the
rectus abdominal muscle, the rest of the muscles of the
abdominal wall are attached to the linea alba by more than
half through central aponeurosis fascial expansions bilater-
ally. After stroke, poor abdominal muscle activity of the
most and least affected sides, and excessive trunk extensor
activity together contribute to forward tilting of the anterior
superior iliac spines towards the femur, allowing more hip
flexion in standing. Our findings are in agreement with Ver-
heyden et al.,5 who showed an excessive forward tilted pelvis

4 Neurology and Clinical Neuroscience (2016) 17

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S Karthikbabu et al. Pelvic alignment and trunk control after stroke

Anterior pelvic tilt -most affected side

Brunnstrom's recovery stage (3-5)

Anterior pelvic tilt -most affected side

Brunnstrom's recovery stage -3
12 10
9
10 8
7
8
6
6 5
4
4 3
2
2
1
0 0
0 5 10 15 20 0 2 4 6 8 10 12 14 16
Trunk impairment scale -16 Trunk impairment scale -16
Anterior pelvic tilt -most affected side

Anterior pelvic tilt -most affected side

Brunnstrom's recovery stage -4 9 Brunnstrom's recovery stage -5
12
8
10 7
3
8 6
2 2
5
6
4
2 3 4
4 3
2
2
1
0 0
0 5 10 15 20 0 5 10 15 20
Trunk impairment scale -16 Trunk impairment scale -16

Figure 2 Scattergram showing the relationship between anterior pelvic tilt on the most affected side and trunk control in different Brunnstroms
motor recovery of the lower extremities.
Anterior pelvic tilt-least affected side

12 Brunnstrom's recovery stage (35) Anterior pelvic tilt-least affected side 10 Brunnstrom's recovery stage-3
9
10 8
8 7
6
6 5
4
4 3
2 2
1
0 0
0 5 10 15 20 0 2 4 6 8 10 12 14 16
Trunk impairment scale -16 Trunk impairment scale -16
Anterior pelvic tilt-most affected side
Anterior pelvic tilt-least affected side

12 Brunnstrom's recovery stage-4 8 Brunnstrom's recovery stage-5

10 7
6
8 3
5
6 2 2
4
2 3 4
4 3
2
2
1
0 0
0 5 10 15 20 0 5 10 15 20
Trunk impairment scale -16 Trunk impairment scale -16

Figure 3 Scattergram showing the relationship between anterior pelvic tilt on the least affected side and trunk control in different Brunnstroms
motor recovery of the lower extremities.

in standing, and was correlated to poor trunk control and It is well-known from the published literature that the
balance ability in people with chronic stroke. It is believed contribution of hip muscles to the pelvic stability during
that muscular balance between flexors and extensors of the standing and walking is different from sitting. Movement
trunk is required for active elongation of the trunk lateral analysis of trunkpelvis dissociation during forward reach-
flexors; that is, quadratus lumborum of the most affected outs in sitting post-stroke showed that the trunk movement
side in standing after stroke. With impaired muscular con- was largely executed from the upper trunk with pelvis tilt
trol of the lower trunk, the pelvis is tilted excessively for- posteriorly.7 Impaired co-activity between the gluteus max-
ward bilaterally and laterally on the most affected side, so imus and lower trunk abdominal muscles in sitting early
as to orient the pelvis towards the least affected leg with after stroke might be responsible for restricted posterior pel-
asymmetrical weight distribution between the feet. After vis tilt. As motor recovery proceeds, the gluteus maximus of
stroke, any trunk-initiated weight transfer in standing allows the paretic leg could assist the trunk muscles during forward
excessive lateral pelvic shift towards the least affected side movement of trunk in sitting, but the gluteus medius muscle
with a forward tilted pelvis.18 The gluteus medius muscle does not contribute to the lateral movement of the trunk,
inactivity during perturbations in standing is much more which is otherwise controlled only by trunk muscles. Van
evident during stroke recovery, and is compensated by more Nes et al.20 in their study confirmed the above statement.
activity of the contralateral muscles.19 As the dynamic sitting balance subscale of the TIS evaluates

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Pelvic alignment and trunk control after stroke
the lateral stability of upper and lower trunk movements in
the coronal plane for people with stroke, its low correlation
to anterior pelvic tilt bilaterally, particularly in recovery
stage 3, was justifiable.
The movement sequence of the head, trunk and pelvis
during lateral reach post-stroke was analyzed using the
CODA motion system in a recent study.21 Although reach-
ing to the least affected side, people with stroke moved their
pelvis first, followed by the trunk and the head. This is in
contrast to the movement of healthy controls who initiated
from the head, and then moved their trunk and pelvis. Poor
dynamic stability of the lower trunk after stroke might allow
the pelvis to move first while reaching for a target initiated
from the upper body. Postural deviation of the pelvis in sit-
ting, as measured through photogrammetry, showed a direct
correlation to poor seated postural control in people with
acute and subacute stroke.22 A recent study by Pathak
et al.8 supports our views. An increased lateral pelvic tilt
measured using the PALM device in sitting was found to be
related to poor trunk control after stroke.9
We found a stronger relationship between pelvic tilt
degrees in standing and trunk control in lower limb motor
recovery stage 5 than recovery stage 3 and 4. The present
study findings also show that people with Brunnstroms
lower limb motor recovery displayed an improved pelvic
alignment and trunk control. The better muscular recruit-
ment of hip abductors and extensors of the paretic leg, as
seen in lower extremity motor recovery stage 5, could possi-
bly keep the pelvis tilted posteriorly and iliac crests at the
same level during balanced standing. The volitional move-
ment control tests of recovery stage 5, such as balancing on
the most affected leg while abducting the least affected hip
and knee flexion with hip extension of the most affected leg
while standing on the least affected leg, would indicate
improved trunk and lower extremity recovery. This explains
the fact that the typical alignment of the pelvis during
dynamic standing is maintained by improved hip muscles
control; that is, good recovery of the gluteus maximus, med-
ius and trunk muscles. The lower trunk abdominal and hip
muscles provide dynamic postural pelvic stability, which is
an ability of the human body to maintain stablility up
against gravity yet still remain active, so that other parts of
the body can move freely to carry out goal-directed func-
tional tasks, such as in walking.23
The literature supports that poor trunk control post-stroke
is related to balance dysfunction,24 gait abnormalities and
daily functional difficulties.10 Studies also showed that poor
hip abductor activity of the most affected leg was responsible
for poor pelvic stability and asymmetric weight shifting dur-
ing gait.25,26 On analyzing the trunk kinematics during gait, a
large lateral displacement of the pelvis on the least affected
side and vertical displacement of the pelvis on the most
affected side were observed as a result of poor hip abductors
and extensors control, respectively.3 Hence, it is evident that
impaired trunk control and poor motor recovery of the lower
limbs play a postural role of atypical pelvic alignment in peo-
ple post-stroke. In previous trials, pelvis stability strategies of
proprioceptive neuromuscular facilitation were shown to be
beneficial in improving trunk control, balance and walk
6 Neurology and Clinical Neuroscience (2016) 17
S Karthikbabu et al.
ability after stroke.27,28 Posterior rotation of the pelvis on the
most affected side is the commonest observational finding
seen in stroke, and it was not reported in the present study
because of the methodological limitations.
We concluded that lateral pelvic tilt in standing after
stroke is moderately correlated with trunk control in lower
extremity motor recovery stages 3 and 4. The correlation of
bilateral anterior pelvic tilt degrees to trunk control was low
in similar recovery stages. In recovery stage 5, the relation-
ship of pelvic tilt with trunk control ranged from high to
very high. The findings of the present study stress the
importance of measuring pelvic tilt in standing, and would
also help physical therapists to plan suitable pelvic control
treatment strategies for people post-stroke.
Acknowledgments
We are grateful to all the study participants. This study
received no funding support from any governmental or non-
governmental organization. We all authors state that there
is no conflict of interest.
References
1 Dalstra M, Huiskes R. Load transfer across the pelvic bone. J.
Biomech. 1995; 28: 71524.
2 Grimaldi A. Assessing the lateral stability of the hip and pelvis.
Man. Ther. 2011; 16: 2632.
3 Tyson SF. Trunk kinematics in hemiplegia gait and the effect of
walking aids. Clin. Rehabil. 1999; 13: 295300.
4 Kirker SG, Jenner JR, Simpson DS, Wing AM. Changing
patterns of postural hip muscle activity during recovery from
stroke. Clin. Rehabil. 2000; 14: 61826.
5 Verhyden G, Reusen C, Gorrison M et al. Postural alignment is
altered in people with chronic stroke and related to motor and
functional performance. J. Neurol. Phys. Ther. 2014; 38: 23945.
6 Hacmon RR, Krasovsky T, Lamontagne A, Levin MF. Deficits
in intersegmental trunk coordination during walking are related
to clinical balance and gait function in chronic stroke. J. Neurol.
Phys. Ther. 2012; 36: 17381.
7 Messier S, Bourbonnais D, Desrosiers J, Roy Y. Dynamic
analysis of trunk flexion after stroke. Arch. Phys. Med. Rehabil.
2004; 85: 161924.
8 Pathak S, Vijayakumar K, Nayak A, Kedambadi RC. The
relationship between pelvic alignment and trunk control in
stroke subjects: a cross-sectional study. Int. J. Res. Med. Sci.
2015; 2: 14837.
9 Sawner KA, LaVigne JM. Brunnstroms Movement Therapy in
Hemiplegia: A Neurophysiologic Approach, 2nd edn.
Philadelphia, United States: Lippincott Williams & Wilkins,
1992.
10 Verheyden G, Vereeck L, Truijen S et al. Trunk performance
after stroke and the relationship with balance, gait and
functional ability. Clin. Rehabil. 2006; 20(5): 4518.
11 Hagins M, Brown M, Cook C et al. Intratester and intertester
reliability of the palpation meter (PALM) in measuring pelvic
position. J. Man. Manip. Ther. 1998; 6: 1306.
12 Petrone M, Guinn J, Reddin A, Sutlive T, Flynn T, Garber M.
The accuracy of the palpation meter (palm) for measuring pelvic
crest height difference and leg length discrepancy. J. Orthop.
Sports Phys. Ther. 2003; 33: 31925.
2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
S Karthikbabu et al.
13 Gjelsvik BEB, Breivik K, Verheyden G, Smedal T, Hofstad H,
Strand LI. The Trunk Impairment Scale- modified to original
scales in the Norwgian verson. Disabil. Rehabil. 2012; 34: 1385
95.
14 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: 212737.
15 Malgady RG, Krebs DE. Understanding correlation coefficients
and regression. Phys. Ther. 1986; 66: 11020.
16 Carr LJ, Harrison LM, Stephens JA. Evidence for bilateral
innervation of certain homologus motoneurone pools in man. J.
Physiol. 1994; 475: 21727.
17 Karthikbabu S, Chakrapani M, Ganeshan S, Rakshith KC,
Nafeez S, Prem V. A review on assessment and treatment of the
trunk in stroke: a need or luxury. Neural. Regen. Res. 2012; 7:
19747.
18 Lennon S. Gait re-education based on the Bobath concept in
two patients with hemiplegia following stroke. Phys. Ther. 2001;
81: 92435.
19 Kirker SG, Simpson DS, Jenner JR, Wing AM. Stepping before
standing: hip muscle function in stepping and standing balance
after stroke. J. Neurol. Neurosurg. Psychiatry 2000; 68: 45864.
20 Van Nes IJW, Nienhuis B, Latour H, Geurts ACH.
Posturographic assessment of sitting balance recovery in the
subacute phase of stroke. Gait Posture. 2008; 28: 50712.
Neurology and Clinical Neuroscience (2016) 17
2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
Pelvic alignment and trunk control after stroke
21 Verheyden G, van Duijnhoven HJR, Burnett M et al. Kinematic
analysis of head, trunk, and pelvis movement when people early
after stroke reach sideways. Neurorehab. Neural. Rep. 2011; 25:
65663.
22 Iyengar YR, Vijayakumar K, Abraham JM, Misri ZK, Suresh
BV, Unnikrishnan B. Relationship between postural alignment
in sitting by photogrammetry and seated postural control in
post-stroke subjects. NeuroRehabil. 2014; 35: 18190.
23 Mohr JD. Management of the trunk in adult hemiplegia: the
Bobath concept. Top. Neurol. 1990; 1(1): 112.
24 Jijimol G, Fayaz RK, Vijesh PV. Correlation of trunk
impairment with balance in patients with chronic stroke.
NeuroRehabil. 2013; 32: 3235.
25 Patterson KK, Parafianowicz I, Danells CJ et al. Gait
asymmetry in community-ambulating stroke survivors. Arch.
Phys. Med. Rehabil. 2008; 89: 30410.
26 Petrofsky J. The use of electromyogram biofeedback to
reduce trendelenburg gait. Eur. J. App. Physiol. 2001; 85(5):
4915.
27 Khanal D, Singaravelan R, Khatri S. Effectiveness of pelvic
proprioceptive neuromuscular facilitation technique on
facilitation of trunk movement in hemiparetic stroke patients. J.
Dent. Med. Sci. 2013; 3: 2937.
28 Trueblood PR, Walker JM, Perry J, Gronley JK. Pelvic exercise
and gait in hemiplegia. Phys. Ther. 1989; 69: 1826.
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