stroke is the most common cerebrovascular disease and the most frequent cause of death as a 
 single disease despite advancements in modern medical technology and increased awareness . 

activities of daily living are limited by the disability in sensory , motor , and cognitive 
 and emotional control functions seen following a stroke1 . due to muscular stiffness and weakness ,
stroke patients have 
 difficulties in supporting their weight on the lower extremity on the affected side , thereby 
 causing disabilities in balance control while standing , which affects quality of life 
 negatively2 .
in addition , significant 
 reductions in the function of the upper extremity on the affected side are experienced by 
 stroke , resulting in significant difficulties in independent movements and performing the 
 activities of daily living3 . during arm stretching movements by stroke patients ,
muscle activity is reduced more in the 
 affected side than in the unaffected side , leading to problems with postural adjustment due 
 to the weakness of trunk muscles4 .
as 
 static and dynamic balance abilities that can maintain the body s center of gravity within 
 the basal plane in the standing position are reduced , asymmetrical posture of the trunk is 
 revealed in order to compensate for the instability .
the trunk muscles are involved with trunk movements and 
 spinal stability5 and extend in a wide 
 area in both vertical and horizontal directions .
they also adjust trunk motions in various 
 spatial directions6 and are involved with 
 postural control by maintaining balance through maintaining a normal lumbar curvature7 .
upper extremity training in the standing position 
 improves postural control while maintaining the body s center of gravity8 .
trainings of the maintenance of a standing 
 position and upper extremity are more beneficial to the performances of activites of daily 
 living if they are conducted simultaneously rather than independently9 .
task training in the standing position can improve postural 
 control thereby helping stroke patients to pay more attention to their safety in complex 
 environments as well as maintaining safety while improveing their ability to perform various 
 activites of daily living10 .
functional and dynamic 
 balance training is important to improve the gait and functional balance of stroke 
 patients11 .
trunk alignment is affected by weakness in trunk muscles and abnormal postures following a 
 stroke .
therefore , this study aimed to identify the effect of upper extremity training in a standing 
 position on trunk alignment and provide a scientific foundations for upper extremity 
 training in a standing position , which is frequently used clinically .
this study conducted experiments with 12 stroke patients who were admitted to 
 rehabilitation hospital in incheon gyeonggi - do in korea .
the sitting group had four males and two females 
 patients , while the standing group had three males and three females patienta .
the mean was 
 62  years for the sitting group and 60  years for the standing group .
the mean duration of 
 disease was 13 months for sitting group and 15 months for standing group .
the numbers of 
 subjects with right and left hemiplegia were seven and five respectively . signed consent was 
 given voluntarily by the subjects involved in the study .
the selection criteria for subjects : were 
 hemiplegic patients , moderate severity according to the fugl - meyer upper extremity test , and 
 being able to maintain a standing position without assistance for five  min or longer .
this 
 study was conducted from march 31 , 2015 to may 30 , 2015 .
upper extremity training in either 
 a sitting or a standing positions was given for 30  min per day , five times a week , for six 
 weeks .
upper extremity training involved the following : grabbing a cone on the table and 
 moveing it to a specified place , moveing a cone on a table to a shelf , stretching an upper 
 extremity to grab a ball to put it into a basket , and stretching an upper extremity to grab 
 a ring and put it onto bar .
this study evaluated postural alignment before and after the upper extremity training 
 between sitting control group and standing experimental group .
postural alignment evaluation 
 was performed using the formetric 4d system ( diers , international gmbh , schlangenbad , 
 germany , 2010 ) , which provides an alternative to radiographic examination for the analysis 
 of spinal alignment .
the formetric 4d system provides a high reproducibility rate and 
 objective data , as well as accurate analysis on spinal curvature .
it can analyze the ear 
 surface of the trunk in three dimensions and examine spinal shapes rapidly using surface 
 contour lines without the need for radiation exposure .
the measurement principle is as 
 follows : the surface of the back is reconstructed via raster lines , followed by camera 
 capture thereby locating the estimated spinous process , in order to measure the curvature 
 through anatomical markers and the spinous processes .
the normal distribution of data was 
 demonstrated using the kolmogorov - smirnov test . to compare changes in measured variables 
 before and after the upper extremity training in both groups ,
the independent t - test was used to compare changes in outcome measures between the two 
 groups .
no significant changes in lordosis or kyphosis were seen in the results of the sitting 
 group , before and after the upper extremity training ( p>0.05 ) . in the standing group , no 
 significant changes in lumbar lordosis was found ( p>0.05 ) but significant change in 
 thoracic kyphosis was found ( p<0.05 ) ( table 
 1table 1.comparison of change in lordosis and kyphosis within and between groupssitting group ( n=6)standing group ( n=6)prepostpost - preprepostpost - prelordosis ( )30.9  9.530.7  7.90.2  2.129.8  10.830.2  8.50.3  2.9kyphosis ( )47.0  6.247.9  7.2 0.9  1.356.6  5.352.2  4.94.4
 2.4values are mean  standard deviation ( sd ) , p<0.05 : paired t - test , 
 p<0.05 : independent t - test ) .
no significant difference in the change before and after the upper extremity 
 training in lumbar lordosis was found between the two groups ( p<0 .
05 ) but a significant 
 difference in the change in thoracic kyphosis after training was found between the two 
 groups ( p<0.05 ) ( table 1 ) .
values are mean  standard deviation ( sd ) , p<0.05 : paired t - test , 
 p<0.05 : independent t - test
this study aimed to examine the effect of upper extremity training in sitting and standing 
 positions on the trunk alignment of stroke patients . the result showed that the standing 
 group had no significant change in lumbar lordosis ( p>0.05 ) but significantly improved 
 thoracic kyphosis ( p<0.05 ) . on the other hand ,
the sitting group had no significant 
 changes before and after the intervention in lumbar lordosis or thoracic kyphosis 
 ( p>0.05 ) .
the comparison between the sitting and standing position groups showed that 
 there was no significant difference in the change lumbar lordosis ( p>0.05 ) but had a 
 significant difference in the change in thoracic kyphosis ( p<0.05 ) .
the asymmetrical posture of stroke patients in the median plane causes unstable posture , 
 however , balance training in the standing position can help normal weight distribution and 
 recover of a symmetrical posture12 .
the 
 static standing posture can also help the recover of asymmetrically affected trunk muscles 
 and reduce thoracic kyphosis .
the trunk muscles necessary for postural control are activated 
 by the reduction in thoracic kyphosis , thereby having an effect on trunk control and balance 
 adjustment13 .
activities of daily 
 living are negatively affected by hyperkyphosis , significantly degarding quality of life . 

twently to forty percent of the elderly population is affected by hyperkyphosis , and it is 
 closely related with aging .
in addition , it can slow gait , reduc balance , cause trunk 
 shaking , and increase risk of falls14 .
an 
 increase in thoracic kyphosis is characterized by a bending posture and center of gravity of 
 the trunk moveing in front of body , as well as affecting alignment of the joint of the lower 
 extremity .
thus , difficulties in accurate postural control due to reduced reaction to 
 postural sway and the normal gait pattern is reduced due to the disability in postural 
 control can be caused by hyperkyphosis .
the bending posture due to hyperkyphosis can 
 increase risk of falls risk and is one of the main risk factors fall due to the disability 
 in postural control , especially while walking15 .
it is important to improve balance during the rehabilitation of stroke patients because it 
 allows the independent performance of activities of daily living .
standing on two legs 
 without postural sway is easy for a healthy persons whereas it can be difficult for stroke 
 patients and may require a long period of rehabilitation to reacquire .
the cpo in sitting 
 and standing positions had more regular fluctuations in the standing position than the 
 sitting position and greater balance is required to maintain postural control while 
 standing16 .
thus , a standing position 
 is more effective in balance training for postural control than a sitting position .
results 
 of dual task training for the affected upper extremity side and gait training given to 
 stroke patients in a standing position showed improvements in ability and that long - term 
 rehabilitation was needed17 .
the present 
 results showed greater activation of trunk muscles during upper extremity training in the 
 standing position thereby reducing thoracic kyphosis .
however , upper extremity training 
 in a standing position can reduce the risk of falls by decreasing hyperkyphosis , 
 demonstrating that rehabilitation in the standing rather than sitting position is more 
 beneficial . during forward stretching movements of the upper extremity by stroke patients , 

trunk muscle activation differed between both sides and disabilities in anticipatory 
 postural adjustments occurred due to the weakening of trunk muscles on the affected side . 

disabilities in feedforward movement adjustments such as anticipatory postural adjustments , 
 lead to patients not being able to cope with unexpected trunk swaying due to the weakening 
 of trunk muscles .
upper extremity training can also provide training for anticipatory 
 postural adjustments and improve the ability to perform activities of daily living18 .
heads of stroke patients is typically 
 positioned more forwardly and it emphasizes a postures with round shoulders and thoracic 
 kyphosis while sitting affecting trunk alignment . however
, a standing position can maintain 
 the body s center of gravity in a vertical direction and increase changes in the nervous 
 system and muscle strength in trunk , thereby improving muscle strength and balance19 .
the present study result showed that 
 upper extremity training in a standing position had a greater effect on trunk alignment by 
 reducing thoracic kyphosis than training in a sitting position .
upper extremity training in 
 a standing position strengthened trunk muscles while maintaining the body s center of 
 gravity in a vertical direction and activated trunk muscles during upper extremity training 
 thereby improving postural adjustment due to the effect on trunk alignment .
furthermore , it 
 can help independent daily living through anticipatory postural adjustments as well as 
 reducing the risk of fall .
the limitations of this study were the small number of subjects and no comparison of 
 changes in scoliosis because of the focus only on lumbar lordosis and thoracic 
 kyphosis - related variables when examining trunk alignment . in the future , comparison of 
 changes in scoliosis as well as trunk alignment and balance
 [ purpose ] this study aimed to examine the effect of upper extremity training in the 
 standing position on trunk alignment of patients with stroke . [ subjects and methods ] 
 twelve stroke patients 
 were enrolled in the study and divided into two groups : a group of 
 six patients in a sitting position and a group of six patients in a standing position . 
 
 upper extremity training for 30  min per day , five times a week for six weeks was given to 
 subjects in both groups . in order to assess trunk alignment , lumbar lordosis and thoracic 
 kyphosis 
 were examined before and after upper extremity training using formetric 4d . 
 
 [ results ] after training the standing position group had no significant change in lumbar 
 lordosis but a significant change in thoracic kyphosis . 
 the sitting position group showed 
 no significant changes in either lumbar lordosis or thoracic kyphosis . 
 the comparison 
 between groups showed there was no significant difference in the change in lumbar lordosis 
 but there was a significant difference in the change in thoracic kyphosis . [ conclusion ] 
 examination of trunk alignment showed that upper extremity training conducted in a 
 standing position reduced thoracic kyphosis more than in a sitting position . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION