Measuring community walking in stroke survivors using physiotherapists’ perspectives and the International Classification of Functioning, Health and Disability (ICF) framework

Introduction and Aim: Stroke is a neurological injury, which occurs due to interruption of blood supply to the brain, it is the 3rd most common cause of death in India. Stroke results in multiple disabilities in human and the most common disabilities are in the hand and leg. Rehabilitation and exercises are playing a major role in stroke recovery. Though there are various exercises pertaining to the management of stroke, one of the common exercises usually prescribed is task specific training, PNF is also one of the common techniques, which is used in stroke management. This study aims to identify the effect of task specific training and PNF on various functions in stroke survivors. Materials and Methods: True experimental study with 50 MCA stroke survivors is included in the study after due consideration of the selection criteria, they all randomly divided into two groups. First group of participants were named as TST group (Task specific training) who received therapy for 10 weeks, second group of participants named as PNG group (Proprioceptive neuromuscular facilitation), who received therapy for 10 weeks. Written consent was obtained from each of the participants. Outcomes selected in the study were Modified Ashworth scale, Action reach arm scale, Berg balance scale, and Dynamic gait index. All the components were assessed before and after the study. All the analyses were done using SPSS 20.0. Results: The results of this study show that modified Ashworth scale was 6.16, action reach arm test was 10.2, Berg balance scale was 18.9 and dynamic gait index was 10.3 at the level of p value 0.0001. Conclusion: This study concluded that task specific training group shows better improvement than the PNF group in chronic stroke survivors. Keywords: Task specific training; proprioceptive neuromuscular facilitation training; modified Ashworth scale; Berg balance scale; action reach arm test; dynamic gait index and stroke.

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

Introduction Culture has been defined as: “a tradition of knowledge and practice that is shared, albeit imperfectly, across the members of a society and across its generations” [Zou et al 2009]. It shapes people's experiences and their emotional reactions [Gard et al 2005], including their understandings of what it means to be healthy, the meanings of symptoms, attitudes towards disability and treatment, and coping strategies [Dean et al 2006; Gallaher et al 2001]. The study suggested here may offer new insights by exploring how culture shapes the experience of stroke care through the perceptions of Physical therapists working in the state of Qatar. Qatar is one of the wealthiest countries in the world. The culture reveals the modernising influences associated with oil exploration and technological advances whilst preserving collective traditions. The state provides extensive financial support for its own citizens including generous pensions and access to health care. However, in common with other Gulf st...

Objective To observe the effects of ICB orthopedic sole combined with rehabilitation training on balance and walking function in stroke survivors. Methods Thirty hemiplegic stroke patients were recruited and divided into a study group (n=15) and a control group (n=15) by using a random number table. Both groups took exercises based on the principles of a motor relearning program and conducted core stability control training, and the study group additionally undertook hemiplegic lower extremity weight-bearing exercises and walking with ICB orthopedic sole used in daily living. The program was administered 20 min twice per day for 4 weeks. All patients were evaluated with Rest Calcaneus Standing Position (RCSP), Malleolar Position (MP), Forefoot Position (FP), Berg Balance Scale (BBS), 10 m Maximum Walking Speed (MWS) and walking section of Motor Assessment Scale (MAS) before and after the program. Results After 4 weeks of intervention, all the measurements except the FP in both groups improved significantly, and significant differences were observed between the two groups. After 4 weeks of training, the average RCSP (1.78±0.32)° and MP (13.33±2.51)° were improved significantly compared to those of the control group [(2.58±0.59)° and (12.45±3.31)°, respectively]. Moreover, the average BBS, MAS and MWS improved significantly compared to the control group. Conclusions ICB orthopedic sole combined with rehabilitation training can improve the weight-bearing, balance and ambulation abilities of stroke survivors. Key words: ICB orthopedic sole; Stroke; Balance; Ambulation

Objective To observe the effects of functional ambulation training in a realistic environment based on the activities of daily living among stroke patients with hemiplegia. Methods Thirty-two stroke survivors with hemiplegia were randomly divided into an experimental group and a control group, each of 16. Both groups were given routine rehabilitation training, while the experimental group was additionally given functional ambulation training based on the activities of daily living in a realistic environment for 60 min per day, five days a week for six weeks.Both groups were evaluated using the mini-mental state examination (MMSE), the Holden walking functional class assessment (HWFCA), the Berg balance scale (BBS), functional gait assessment (FGA), the 5 times sit to stand test (FTSST), the timed up and go test (TUGT), and rated using the specific activity balance confidence scale (ABC) and the modified Barthel index (MBI). Results Before the training, no significant differences between the two groups were found in terms of any of the measurements. After the six weeks of training, significant improvement was observed in all of the outcome measures except the MMSE and the HWFCA, with the experimental group scoring significantly better, on average, than the control group. Conclusion When combined with routine rehabilitation training, functional ambulation training based on the activities of daily living in a realistic environment can significantly enhance the functional gait, balance and postural control of stroke survivors. This should facilitate their activities in daily life and improve their confidence in maintaining their balance. Key words: Stroke; Environment; Functional ambulation training; Balance; Activities of daily living

Objective To observe the effect of iliopsoas tensile vibration training on the walking ability of stroke survivors. Methods Thirty stroke survivors were randomly divided into an observation group and a control group, each of 15. Both groups were given traditional rehabilitation treatment, while the observation group was additionally provided with iliopsoas tensile vibration training. Both groups were evaluated in terms of the root mean square (RMS) of iliopsoas, active range of motion (A-ROM) of the hip joint, the kinematic parameters of gait and Berg balance scale (BBS) scores before and after the 4-week treatment. Results Before the treatment there were no significant differences between the two groups in any of the measurements. After the treatment improvement in all of the measurements was observed in both groups, with the average RMS iliopsoas, A-ROM, step length, step velocity and BBS score of the observation group significantly better than those of the control group. Conclusions Tensile vibration training of the iliopsoas can significantly improve the muscle excitability of the affected iliopsoas in stroke survivors, and improve their balance and walking ability. Key words: Vibration training; Stroke; Iliopsoas; Lower limb function

Objective To observe the effect of body weight supported treadmill training (BWSTT) on function of lower extremities in stroke survivors, and analyze the influence of quadriceps femoris muscle tone on the therapeutic effect of BWSTT. Methods Thirty-six stroke survivors were randomly divided into a BWSTT group and a conventional therapy group (CT group) according to a random number table, each of 18. Both groups were given routine rehabilitation training, while the BWSTT group was additionally provided with BWSTT for 4 weeks. Before and after the treatment, Fugl-Meyer assessment for lower extremity (FMMS-LE), Berg balance scale (BBS) and Holden walking function rating scale (Holden) were used to assess the motor function of lower extremities, balance function and walking ability of both groups. Meanwhile, the patients in BWSTT group were further divided into a mild-spasm subgroup and a seriously-spasm subgroup according to the modified Ashworth scale assessment result of quadriceps muscle, and the results of their efficacy indexes were further compared. Results No significant difference was found in the average FMMS-LE, Berg and Holden scores between the BWSTT group and CT group before the treatment (P>0.05). However, significantly improvement was found in all the above measurements of both groups after the treatment (P 0.05). The change of FMMS (△FMMS) and Holden (△Holden) after treatment in the mild-spasm subgroup increased more significantly compared with those in the seriously-spasm subgroup, but no significant differences were observed regarding the change of Berg (△Berg) between the two subgroups. Conclusions BWSTT can significantly improve the motor function of lower extremities, balance function and walking ability of stroke survivors. However, hypertone of quadriceps femoris might have adverse effects on the therapeutic effect of BWSTT. Key words: Stroke; Body weight supported treadmill training; Motor function; Muscle tension

Objective To explore the effects of sole desensitization physical therapy on standing balance and walking function among recovering stroke patients. Methods Stroke patients who met the inclusion criteria were randomly assigned to the observation group (40 cases) or the control group (40 cases). All patients received traditional rehabilitation. In addition, the observation group received sole densensitization physical therapy. The total course of treatment lasted for 1 month. The Berg balance scale (BBS) and Holden's functional ambulation classification (FAC) were used to evaluate balance and walking ability before and after treatment. The Fugl-Meyer assessment (FMA) was used to assess the motor function of the affected ankle, and footprint analysis was used to measure and record any changes in time and distance walked and to analyze improvements in gait. Results After the sole desensitization training, the BBS (37.41 ± 8.14), FAC ( 3.91 ±0.92) and FMA motor function (6.42 ± 1.12) results of the observation group were all significantly better than before training. Walking time and distance also improved.Conclusions Sole desensitization can affect foot proprioception. As a result, stroke patients' soles adapt to the surroundings, recover their ability to provide physiological support and promote improved motor function of the ankle.Sole desensitization can thus improve the standing balance and walking of stroke patients. Key words: Desensitization; Standing balance; Walking function; Physical therapy; Stroke

Partial or total unilateral vestibular loss is the third most common cause of peripheral vestibular dysfunction. Dysfunction of one or both of the vestibular mechanisms can manifest physically as abnormalities of posture, balance, and/or visual acuity. This case report describes physical therapy examination and individualized intervention with vestibular rehabilitation for a patient with unilateral vestibular hypofunction. The patient was an 80-year-old male with electronystamographically confirmed unilateral vestibular loss of 98.3%. He demonstrated altered balance and gaze stability classifying him as having an increased risk for falling. After 5 weeks of individualized vestibular rehabilitation, the patient significantly decreased his fall risk from 11 to 20 of 24 on the Dynamic Gait Index. His gaze stability also improved from a 4 to 1 line disparity with dynamic visual acuity testing. The patient also had a decrease in perceived disability on the Dizziness Handicap Inventory from 30/100 at evaluation to 12/100 at discharge. Individualized vestibular rehabilitation decreased fall risk and improved gaze stability for a patient with significant unilateral vestibular hypofunction.

Objective To explore the effect of functional electrical stimulation combined with treadmill training and botulinum toxin type A injection on foot-drop and strephenopodia among stroke survivors. Methods Sixty-seven stroke survivors with foot-drop and strephenopodia were randomly divided into an electrical stimulation group (n=23), a conventional treatment group (n=22) and a combined treatment group (n=22). All 3 groups received a 400 U injection of BTX-A and electrical stimulation. After 24 hours, the patients in the conventional treatment group received conventional treatment including a brain protection agent, limb function exercises, gait training, balance training and training in the activities of daily living. The patients in the combined treatment group received that conventional treatment, plus functional electrical stimulation and weight loss training on a treadmill. The patients in the electrical stimulation group received functional electrical stimulation treatment supplementing the conventional treatment. Therapeutic effects were evaluated before and after six weeks of treatment using integral electromyography (iEMS) of the anterior tibial muscle and the lateral head of the gastrocnemius muscle, the co-contraction ratio (CR) during ankle dorsiflexion, the modified Ashworth Scale (MAS), the Berg balance scale (BBS), a functional walking score (FAC), and the active range of motion (AROM) of the ankle in dorsiflexion and eversion. Results After the treatment, significant improvement was observed in all three groups in the average iEMS value of the anterior tibial muscle and the lateral head of the gastrocnemius muscle, the CR in ankle dorsiflexion, and in their MAS, BBS, FAC and AROM results. There was no significant difference among the three groups after treatment in their average iEMS values at the lateral head of the gastrocnemius. The average values of the other indicators were, however, significantly better in the combined treatment group than in the other 2 groups. Conclusion Functional electrical stimulation combined with treadmill training and botulinum toxin type A injection can significantly improve foot-drop, strephenopodia and the walking function of stroke survivors. This combined treatment deserves popularization and application in clinical practice. Key words: Stroke; Botulinum toxin type A; Surface electromyography; Functional electrical stimulation; Exercise; Treadmill training

How to Address Physical Activity Participation After Stroke in Research and Clinical Practice.

Comparative accuracy of the figure-of-eight walk test and 10-meter walk test in classifying walking abilities in stroke survivors.

Although disability is a complex phenomenon, the articles in this special issue illustrate that we are making considerable progress in the ability to conceptualize, measure, predict, and intervene to change disability. Conceptual models such as the International Classification of Function, Disability and Health (ICF)1 have greatly aided our understanding of disability and our ability to investigate it using different research designs. The ICF describes the many factors that may contribute to disability or participation restriction, including impairments, activity limitations, and environmental and personal factors. Physical therapy research traditionally has focused on the impairment end of the ICF model. However, this special issue contains many articles that reflect the growing recognition of the importance of the other domains in the ICF. For instance, several articles in this issue focus on the impact that personal factors, such as self-efficacy and other psychological attributes, have on participation. Robinson et al2 explored participation in community walking by survivors of stroke. They found that balance self-efficacy was the single factor that was most strongly associated with differences in measurements of participation. In people with Parkinson disease, Ellis et al3 found that exercise self-efficacy was the major predictor of participation in physical activity. In fact, self-efficacy was much more predictive than other factors—such as disease severity, impairments, and functional limitations—that might have been expected to influence exercise participation in people with Parkinson disease. Two studies highlighted the complexity of identifying the factors that contribute to disability in people with painful conditions. Hart and colleagues4 explored the role that psychosocial variables play in functional status changes in people receiving outpatient physical therapy services for lumbar spine syndromes. This study found that psychosocial factors, in particular fear-avoidance behavior, were significant predictors of functional status outcomes. In a large observational cohort study, White …

The caregiver (CG) of a stroke survivor (SS), usually a family member needs to cope up with the challenges of the new role. “Immediate family” who more often than not is the primary CG is included in the “support and relationships” chapter of the environmental factors of the International Classification of Functioning. An insight into the burden of care on the CG in India necessitates a review so as to address it. Publications were overviewed from the search engine “PUBMED” and “Google Scholar” for studies in Indian urban/rural/slum settings either hospital or community based having outcome measures for CG burden, quality of life (QOL), health issues, and CG satisfaction. Interventional studies on CG, hired CG, or with more than one CG were excluded. Seven cross-sectional studies from North, Western, and South India met the inclusion criteria. Sample size ranged from 54 to 201 SSs of duration 28 days to >1-year poststroke. Majority of the CG s were females. The mean score was lowest in physical health and highest in social health in all the studies for WHO-QOL. CG burden was high in all the studies. Burden perceived by female CGs was more than males. The CGs services impacts the treatment outcome hence there is a need to educate and sensitize healthcare professionals to treat CG with dignity and empathy so that caregiving is less stressful. Physiotherapists while being actively involved in rehabilitation of individuals with stroke should train the CG in appropriate home exercises and management, which is ergonomically effective to both SS and CG, cost-effective, and practically feasible so that CG strain and stress can be reduced.

Objectives: Upper limb motor impairment causes limited activities of daily living in stroke survivors. Bimanual therapy is based on Bimanual movement that facilitates cortical balancing by simultaneous movement of paretic and non-paretic arms while performing a task. Studies aimed at exploring the effects of resisted Bimanual therapy with rhythmic auditory cues on arm function, balance, and endurance in stroke survivors. Methods: A pilot study was commenced after the institutional ethical committee approval. Twenty stroke survivors were randomly allocated into two treatment groups; Group A received conventional therapy along with resisted bimanual therapy with rhythmic auditory cues and group B received only conventional therapy. All patients received 14 treatment sessions within three weeks. Each session lasted for 45-60 minutes. The outcome measures used to assess hand function, trunk function, balance, gait, and endurance were Wolf Motor Function (WMFT), Trunk Impact Scale (TIS), Berg’s Balance Scale (BBS), Dynamic Gait Index (DGI), and Six Minute Walk Test (6MWT), respectively. Results: Pre-post-analysis in resisted bimanual therapy with rhythmic auditory cues showed statistically significant difference in WMFT (P=0.005), TIS (P=0.005), BBS (P=0.005), DGI (P=0.008), and 6MWT (P=0.003). Pre-post-analysis in conventional therapy showed statistically significant difference in WMFT (P=0.005), TIS (P=0.016), and BBS (P=0.014). Inter-group analysis of mean difference between resisted bimanual therapy with rhythmic auditory cues and conventional showed statistically significance difference in WMFT (P=0.037), TIS (P=0.003), BBS (P=0.0001), and DGI (P=0.004). Discussion: Although both groups showed improvement individually in arm function, balance, and functional capacity among stroke survivors, resisted bimanual therapy with rhythmic auditory cues showed better improvement than conventional therapy in all three components: arm function, balance, and functional capacity in stroke survivors.