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387
https://doi.org/10.1590/0004-282X20190048
ARTICLE
Relationship between pulmonary function,
functional independence, and trunk control in
patients with stroke
Relação entre função pumonar, independência functional e controle de tronco em
pacientes após acidente vascular cerebral
Rafaela Sant’anna dos SANTOS1, Sara Carolina Fontoura DALL’ALBA1, Soraia Genebra Ibrahim
FORGIARINI2, Daniele ROSSATO3, Alexandre Simões DIAS3,4, Luiz Alberto FORGIARINI JUNIOR5
1Centro Universitário Metodista, Porto Alegre, RS, Brasil;
2Centro Universitário Metodista, Curso de Fisioterapia, Porto Alegre, RS, Brasil;
3Hospital de Clínicas de Porto Alegre, Serviço de Fisioterapia, Porto Alegre, RS, Brasil;
4Universidade Federal do Rio Grande do Sul, Programas de Pós-graduação em Ciências Pneumológicas e Ciências do Movimento Humano , Porto Alegre, RS, Brasil.
5Universidade La Salle, Curso de Fisioterapia e Programa de Pós-graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brasil.
Rafaela Sant’anna dos Santos https://orcid.org/0000-0001-9238-7836; Sara Carolina Fontoura Dall’Alba https://orcid.org/0000-0002-4995-3086;
Soraia Genebra Ibrahim Forgiarini https://orcid.org/0000-0002-8688-4999; Daniele Rossato https://orcid.org/0000-0001-8245-5903; Luiz Alberto
Forgiarini Junior https://orcid.org/0000-0002-6706-2703; Alexandre Simões Dias https://orcid.org/0000-0002-0609-4779
Correspondence: Luiz Alberto Forgiarini Junior; Av. Vítor Barreto, 2288 - Canoas - RS, 92010-000 RS, Brasil; E-mail: forgiarini.luiz@gmail.com
Conflict of interest: There is no conflict of interest to declare.
Received 03 September 2018; Received in final form 12 December 2018; Accepted 21 January 2019.
ABSTRACT
Stroke often leads to abnormalities in muscle tone, posture, and motor control that may compromise voluntary motor function, thus affecting
the motor control required for maintaining the synergy of both peripheral and respiratory muscles. Objective: To evaluate respiratory muscle
strength, pulmonary function, trunk control, and functional independence in patients with stroke and to correlate trunk control with the
other variables. Methods: This was a cross-sectional study of patients diagnosed with stroke. We assessed respiratory muscle strength,
trunk control as assessed by the Trunk Impairment Scale, spirometric variables, and the Functional Independence Measure. Results:
Forty-four patients were included. Pulmonary function and respiratory muscle strength were significantly lower than predicted for the
study population, and the mean Trunk Impairment Scale score was 14.3 points. The following significant correlations were found between
the variables: trunk control vs. maximal inspiratory pressure (r = 0.26, p < 0.05); trunk control vs. forced vital capacity (r = 0.28, p < 0.05);
trunk control vs. forced expiratory volume in one second (r = 0.29, p < 0.05), and trunk control vs. the Functional Independence Measure
(r = 0.77, p < 0.05). Conclusion: The present study showed that respiratory muscle strength, pulmonary function, functional independence,
and trunk control are reduced in patients diagnosed with stroke.
Keywords: Spirometry; manometry; stroke; Physical therapy specialty.
RESUMO
Acidente vascular cerebral (AVC) frequentemente leva a anormalidades no tônus muscular, postura e controle motor que podem comprometer
a função motora voluntária, afetando o controle motor necessário para manter a sinergia dos músculos periféricos e respiratórios. Objetivo:
Avaliar a força muscular respiratória, a função pulmonar, o controle do tronco e a independência funcional em pacientes com AVC e
correlacionar o controle do tronco com as demais variáveis. Métodos: Este foi um estudo transversal, incluindo pacientes diagnosticados
com AVC. Avaliamos a força muscular respiratória, o controle do tronco avaliado pela escala de comprometimento de tronco, as variáveis
espirométricas e a medida de independência funcional. Resultados: Quarenta e quatro pacientes foram incluídos. A função pulmonar e a
força muscular respiratória foram significativamente menores do que o previsto para a população estudada, e o escore médio do escala
de comprometimento de tronco foi de 14,3 pontos. As seguintes correlações significativas foram encontradas entre as variáveis: controle
do tronco vs. pressão inspiratória máxima (r = 0,26, p <0,05); controle do tronco vs capacidade vital forçada (r = 0,28, p <0,05); controle do
tronco versus volume expiratório forçado no primeiro segundo (r = 0,29, p <0,05) e controle do tronco vs. medida de independência funcional
(r = 0,77, p <0,05). Conclusão: O presente estudo demonstrou que a força muscular respiratória, a função pulmonar, a independência
funcional e o controle do tronco estão diminuídos em pacientes diagnosticados com AVC.
Palavra-chave: Espirometria; manovacuometria; acidente vascular cerebral; fisioterapia.
388 Arq Neuropsiquiatr 2019;77(6):387-392
Stroke is one of the most common causes of long-
term disability worldwide and a major public health prob-
lem1. Each year, nearly 11 million people worldwide have a
stroke, of whom ve million remain functionally limited2,3.
According to the World Health Organization, stroke is a
rapidly-progressing syndrome characterized by clinical
signs of focal or global brain function impairment of pos-
sible vascular origin and lasting for at least 24 hours4. Nearly
50% to 70% of aected patients recover functional indepen-
dence and, within six months, nearly 50% still present with
hemiparesis/hemiplegia2.
Stroke often leads to abnormalities in muscle tone, pos-
ture, and motor control that may compromise voluntary
motor function, thus aecting the motor control required for
maintaining the synergy of both peripheral and respiratory
muscles1,5. Pulmonary infections are the most prevalent com-
plications, causing the death of 30% of patients before hospi-
tal discharge6,7. Nevertheless, the lack of strength in muscles
of the trunk could impact in respiratory function.
e eect of stroke on the respiratory system depends on
the injured structures, and maintenance of normal ventila-
tion requires functional components of the neuromuscular
system to be intact. Ventilatory disorders occur when the
disease aects the nervous system, muscle paths and/or rib
cage movements8,9. erefore, we hypothesized that stroke
patients present with several sequelae usually leading to def-
icits in functional capacity and pulmonary function. Hence,
the objectives of this study were to assess respiratory muscle
strength, pulmonary function, trunk control, and functional
independence in patients with stroke, and to correlate trunk
control with the other variables.
METHODS
is was a cross-sectional study conducted at the
Department of Neurology of Hospital de Clínicas de Porto
Alegre from November 2014 to May 2015. e research proj-
ect was approved by the Research Ethics Committee of
Hospital de Clínicas de Porto Alegre (process no. 14-0582).
Patients who met the inclusion criteria and agreed to partici-
pate in the study provided written informed consent prior to
their participation.
is study included male and female patients, over
18 years of age, clinically diagnosed with stroke by the neu-
rology team. Exclusion criteria were an inability to per-
form study-related procedures, presence of respiratory tract
metastases, hemodynamic instability, and altered cognitive
status compromising the patient’s ability to perform the tests.
Patients with pulmonary complications such as broncho-
aspiration and pneumonia during hospitalization were not
included. After inclusion in the study, all patients were simul-
taneously assessed for functional independence, trunk con-
trol, respiratory muscle strength, and pulmonary function.
Data on age, weight, height, body mass index, length of hos-
pital stay, time elapsed after stroke, type of stroke, and num-
ber of previous strokes were collected directly from medi-
cal records. e patients eligible to participate in the study
were evaluated by the clinical team and underwent physio-
therapy treatment. All patients were hemodynamically sta-
ble, with controlled blood pressure, no syncope, and absence
of tumors or clinical diseases that could interfere with the
evaluation process.
Physical functioning was assessed using the Functional
Independence Measure scale, an instrument designed to
quantitatively assess the burden of care required for someone
to perform a series of everyday motor and cognitive activi-
ties, such as self-care, transfer, locomotion, sphincter con-
trol, communication, and social cognition, including mem-
ory, social interaction, and problem solving. Each category is
given a score from 1 (total dependence) to 7 (complete inde-
pendence). is yields a total score ranging from 18 to 12610.
e trunk control was assessed using the Trunk
Impairment Scale, an instrument comprising seven main
domains scored from 0 (minimum) to 21 (maximum) points.
ese domains assessed the perception and impairment of
trunk verticality, abdominal muscle strength, trunk rota-
tion muscle strength, and righting reex, all of which were
assessed bilaterally. e Trunk Impairment Scale was admin-
istered by the same examiner, providing a score that indi-
cated the patient’s status at the time of assessment11.
e respiratory muscle strength was assessed using an
analog manometer (Marshall Town, MVM 120, USA) to mea-
sure maximal inspiratory pressure (MIP) and maximal expi-
ratory pressure (MEP). Measures were assessed with patients
in the sitting position using a nose clip and a mouthpiece
positioned rmly between their lips. e MIP was acquired at
residual volume, and the MEP at total lung capacity. In both
cases, measures were taken in triplicate or more, the high-
est of which was considered for analysis, and dierences
between measures could not be greater than 10%2,4,12,13.
For pulmonary function analysis, forced expiratory vol-
ume in one second (FEV1), forced vital capacity (FVC), and
the Tieneau index (TIFF) (FEV1/FVC) were measured
through spirometry (One Flow micro spirometer, Clement
Clarke International, Edinburgh, Scotland)14. eir predicted
values were also calculated based on the equation proposed
by Derumond et al.15, to assess levels of pulmonary function
in a healthy population. is equation was compared with
two other equations in a previous study that found no signi-
cantly relevant dierences between equations16.
Sample size was calculated based on a previous study
conducted by our group17, resulting in a sample size of at least
38 patients for an alpha of 5% and a power of 80. Continuous
data were expressed as mean ± standard deviation, and cat-
egorical variables as absolute and percentage values. e
Shapiro-Wilk test was used to assess the normality of data
distribution. Pulmonary function and maximal respiratory
389
Santos RS et al. Trunk control in patients with stroke
pressures were compared using the Student’s t test, and the
correlation between trunk control and the other variables
was assessed using Pearson’s correlation. e level of signi-
cance was set at 5%.
RESULTS
Fifty-four patients participated in the study from
November 2014 to May 2015. ere was a predominance of
females (65.7%), the mean patient age was 59.4 ± 12.2 years,
and ischemic stroke was the most prevalent type (92.1%).
e demographic characteristics of the population are
shown in Table 1. Results for pulmonary function, respiratory
muscle strength, and trunk control are presented in Table 2,
and functional independence as assessed by the Functional
Independence Measure is described in Table 3.
We also assessed the correlation of trunk control with pul-
monary function, respiratory muscle strength, and functional
independence. Trunk control was found to be signicantly
correlated with MIP (r = 0.26, p < 0.05), FVC (r = 0.28, p < 0.05),
FEV1 (r = 0.29, p < 0.05), and the Functional Independence
Measure (r = 0.77, p < 0.05) (Figure).
DISCUSSION
Trunk control has a primary function in pulmonary
mechanics—when diaphragmatic function is compro-
mised in individuals after stroke, it is perceived that mus-
cular paresis leads to unilateral hypoventilation and con-
sequent decrease of pulmonary complacency, with greater
elastic and nonelastic resistance of the lung, which fails to
maintain lung volumes and decreases ventilation and per-
fusion capacity. In the present study, most of participants
showed restrictive ventilatory disorder (81.6%), character-
ized by impairment of total lung capacity and vital capac-
ity, demonstrating that respiratory biomechanics is altered
in patients with stroke, as well as thoracic and pulmonary
compliance. is data corroborates the nding between the
Trunk Impairment Scale and spirometric data, conrming
the ndings in the literature, which demonstrate the rela-
tionship between a decrease in pulmonary capacity and
hemiparesis presented by individuals, and this may occur
because the trunk exor and extensor muscles directly inter-
fere in respiratory mechanics and trunk stabilization18,19.
Regarding sociodemographic data and risk factors for
cerebrovascular injury, the mean age of our patients was
59.4 years, corresponding to the age group at the highest
risk of stroke in Brazil, which includes individuals older than
55 years of age12. e incidence of stroke increases the risk,
showing a two-fold increase for every 10 years of age beyond
557. Additionally, most patients were classied as overweight
according to their body mass index and were female, both of
which are important risk factors for stroke13. Together with
these factors, other modiable risk factors for cerebrovascu-
lar diseases in this population have been reported in the lit-
erature, such as high levels of blood cholesterol, high blood
pressure, diabetes, and smoking14,15.
e mean length of hospital stay, for our patients, was
14.6 days, similar to that reported in a study conducted in a
Table 1. Demographic characteristics of the study population.
Variables n = 44
Sex, female 25 (65.7)
Age, years 59.4 ± 12.2
Weight, kg 73.9 ± 15.1
Height, m 1.6 ± 0.1
Body Mass Index, kg/m² 27.8 ± 5.3
Length of stay, days 14.6 ± 7.1
Stroke, n (%)
Ischemic 52 (92.1)
Hemorrhagic 3 (7.9)
Stroke time, days 14.9 ± 26.3
Values expressed as mean ± standard deviation or number (percentage).
Table 2. Evaluation of pulmonary function, respiratory
muscular strength and trunk control.
Variable Value
obtained
Predicted
value p-value
FEV1 1.9 ± 0.9 3.3 ± 0.6
FVC 2.5 ± 0.9 3.8 ± 0.7
Tiffeneau Index 88.9 ± 12.5
Expiratory flow
peak 227.2 ± 121.3
MIP, cmH2O 47.4 ± 29.1 91.1 ± 13.9 0.001
MEP, cmH2O 36.1 ± 18.6 93.3 ± 18.8 0.001
Trunk Impairment
Scale 14.4 ± 5.8
Data expressed as mean ± standard deviation. FEV1: forced expiratory volume
in the first second; FVC: forced vital capacity; Tiffeneau Index - relationship
between FEV1/FVC; MIP: maximum inspiratory pressure; MEP: maximum
expiratory pressure/ cmH2O: centimeter of water.
Table 3. Evaluation of functionality through the Functional
Independence Measure.
Variables n = 44
Self Care 29.0 ± 11.4
Sphincter Control 12.2 ± 3.3
Transfers 13.0 ± 7.1
Locomotion 6.4 ± 4.0
Communication 6.4 ± 4.0
Social Cognition 12.1 ± 2.8
Total 91.2 ± 26.4
390 Arq Neuropsiquiatr 2019;77(6):387-392
neurology ward (16.8 days)17. In the present study, 92% of the
patients were diagnosed with ischemic stroke. is percent-
age was higher than that in previous Brazilian studies (53 to
85%)16,17, which may be related to our treatment regimen for
patients with hemorrhagic stroke, who remain in the inten-
sive care unit for a longer time.
e mean MIP and MEP were lower than predicted for
our patients, thus corroborating ndings from the literature,
such as those by Meneghetti et al.12, who also found mean
MIP and MEP lower than predicted for the Brazilian popula-
tion (62.7 cmH2O and 69.8 cmH2O, respectively). ese results
suggest that the patients showed reduced respiratory muscle
strength (diaphragmatic and abdominal dysfunction) and,
therefore, their rehabilitation program should include respi-
ratory muscle training12.
Similarly, pulmonary function measures were lower
than predicted for our sample, which is in agreement with
previous studies showing that pulmonary function was
reduced in stroke patients assessed by spirometry16,17,20.
Some studies also found that impaired respiratory muscles
and pulmonary function may have a direct impact on the
cough mechanism, as the compression phase of this mech-
anism involves the activation of the diaphragm, chest and
abdominal wall muscles21,22.
e mean Trunk Impairment Scale score in our patients
(14.3 points) may be considered a fairly good result, consid-
ering that this score ranges from 0 to 21 points, with 0 being
the worst result and 21 the best. We also observed that trunk
control was weakly correlated with the FVC and FEV1 (r =
0.28 and r = 0.29, respectively), which indicated that muscu-
loskeletal changes experienced by hemiplegic or hemiparetic
patients aected pulmonary biomechanics23. is was espe-
cially so if these changes involved the exor and extensor
muscles of the trunk, as they have a key role in chest expan-
sion, diaphragm excursion, and cough eciency24,25.
e correlation of trunk control and MIP, although
weak (r = 0.34; p < 0.05), provided evidence of the relation-
ship between muscular postures and respiratory muscle
Figure. Correlation between the Trunk Impairment Scale (TIS) and forced vital capacity (FVC) (A - r = 0.28; p < 0.05); forced
expiratory volume in the first second (FEV1) (B - r = 0.29, p < 0.05); maximal inspiratory pressure (MIP) (C - r = 0.34, p < 0.05) and
the Functional Independence Measure (FIM) (D - r = 0.77, p < 0.05).
0
5
10
15
20
25
0
0
5
10
15
20
25
0
TIS
TIS
FIM
0
5
10
15
20
25
0
TIS
FVC (ml) FEV1 (ml)
0
5
10
15
20
25
0
TIS
MIP (cm H
2
0)
3.
5
32.521.510.5654321
100
80
60
4020 140120100806040
20
A B
C D
391
Santos RS et al. Trunk control in patients with stroke
strength26. Previous studies evaluating the latter in hemipa-
retic patients have demonstrated that respiratory muscle
strength may compromise trunk control and directly inter-
fere with respiratory biomechanics.
Yoon et al.22 found reduced spirometric values in stroke
patients and a correlation between these values and activi-
ties of daily living. is resulted from weakened intercostal
muscles and increased chest wall rigidity, which decreased
movements of the rib and lowered the distending pressure
that expands the lungs, ultimately leading to reduced pul-
monary capacity22. ese changes could be explained by
impairments in total pulmonary capacity and vital capacity,
indicating that respiratory biomechanics were decient in
these patients, as well as chest and lung compliance23. is
deciency eventually limited pulmonary ventilation and
conrmed that ventilatory disorders could occur in neuro-
logical diseases aecting the neuromuscular path or the rib
cage even if there was no specic pulmonary involvement
or lesion7.
e functionality evaluated by the Functional
Independence Measure showed that the patients had reduced
capacity to perform activities of daily living with complete
independence. A systematic review aiming to assess the dis-
ease severity and functional capacity using the Functional
Independence Measure in stroke patients revealed that,
based on the studies included in the review, this condition
aected patient’s lives by causing limitations and disability,
both in acute and chronic phases, often leading to moderate
or severe dependence and increasing the complexity of the
rehabilitation process27.
Additionally, we observed an association between trunk
control and functional independence, as patients with
greater postural control gained the stability required to
reproduce functional movements. is was because axial
muscles supported anti-gravitational postures and stabi-
lized the body for limb mobilization28. A study conducted
by Karatas et al.29 found a correlation of muscle weakness
in trunk exion and extension with locomotion and transfer
domains of the Functional Independence Measure, showing
the importance of axial stability movements for the develop-
ment of limb functionality29.Other studies have observed that
trunk control is important for balance, gait, and functional
independence as assessed by the Functional Independence
Measure30,31,32.Future studies should prospectively evaluate
patients to assess trunk control and functionality and further
establish the causal relationship between the variables.
In conclusion, stroke patients showed reduced pulmo-
nary function, respiratory muscle strength, and functional
independence, and there was a strong correlation between
trunk control and physical functioning.
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