Latham NK, Jette DU, Slavin M, Richards LG, Procino A, Smout RJ, Horn SD. Physical therapy during stroke rehabilitation for people with different walking abilities.
To describe how physical therapy (PT) activities during post-stroke inpatient rehabilitation vary by admission walking ability and over time.
Observational cohort study.
Six inpatient rehabilitation hospitals in the United States.
People receiving post-stroke PT (N=715) who were classified as walking at admission.
Percentage of time spent in 11 activities, percentage of patients who participated in each activity, and the FIM instrument scores.
The majority of PT time was spent in gait activities. Even people with the most limited mobility spent 25% to 38% of PT time in gait activities during the first 6-hour treatment block. Treatment progression was evident, and a shift to more advanced activities occurred over time (eg, less bed mobility and more advanced gait). However, even in the final 6-hour block, a small proportion of time was spent on community mobility activities (1.2%-5.2%), and most people received no community mobility training.
PT activities focused on specific functional tasks at the ability level of each individual patient and provided higher-level activities as patients improved their function. However, although there is increasing recognition that the environment influences task performance, little time was spent in community mobility activities before discharge.
"While this may be trivial to healthy people it could be a substantial challenge to people with brain or spinal cord injuries or diseases. Spasticity, muscle weakness, diminished dynamic stability, osteoporosis and associated physical inactivity not only make walking cost-ineffective, but also seriously hinder locomotion mechanisms, and even increase the risk of falling
. Gait rehabilitation in neurologically impaired individuals takes advantage of neuroplasticity, a capability of the brain to form new neuron pathways and synapses
[Show abstract][Hide abstract] ABSTRACT: Background:
After neurological injury, gait rehabilitation typically focuses on task oriented training with many repetitions of a particular movement. Modern rehabilitation devices, including treadmills, augment gait rehabilitation. However, they typically provide gait training only in the forward direction of walking, hence the mechanisms associated with changing direction during turning are not practiced. A regular treadmill extended with the addition of rotation around the vertical axis is a simple device that may enable the practice of turning during walking. The objective of this study was to investigate to what extent pelvis and torso rotations in the transversal plane, as well as stride lengths while walking on the proposed rotating treadmill, resemble those in over ground turning.
Ten neurologically and orthopedically intact subjects participated in the study. We recorded pelvis and torso rotations in the transversal plane and the stride lengths during over ground turning and while walking on a rotating treadmill in four experimental conditions of turning. The similarity between pelvis and torso rotations in over ground turning and pair-matching walking on the rotating treadmill was assessed using intra-class correlation coefficient (ICC - two-way mixed single measure model). Finally, left and right stride lengths in over ground turning as well as while walking on the rotating treadmill were compared using a paired t-test for each experimental condition.
An agreement analysis showed average ICC ranging between 0.9405 and 0.9806 for pelvis and torso rotation trajectories respectively, across all experimental conditions and directions of turning. The results of the paired t-tests comparing left and right stride lengths showed that the stride of the outer leg was longer than the stride of the inner leg during over ground turning as well as when walking on the rotating treadmill. In all experimental conditions these differences were statistically significant.
In this study we found that pelvis rotation and torso rotation are similar when turning over ground as compared to walking on a rotating treadmill. Additionally, in both modes of turning, we found that the stride length of the outer leg is significantly longer than the stride length of the inner leg.
Journal of NeuroEngineering and Rehabilitation 08/2014; 11(1):127. DOI:10.1186/1743-0003-11-127 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Apoplectic stroke is a dramatic complication of the car- diovascular system's diseases and it has become one of the most distressing health problems of contemporary societies. Often it results in handicap, postapoplectic dementia, depression and high death rate. Around 70% of survivors have difficulties in walking, while the re- maining 30% suffer from acute motor impairment and require constant medical attention. Therefore, restora- tion or, at least, improvement of locomotion is the ma- in goal of rehabilitation of the cerebral hemorrhage su- rvivors. Studies on gait pathologies provide valuable clues for planning physiotherapy that would minimize or eliminate the given dysfunction. The aim of this stu- dy was qualitative and quantitative evaluation of gait in cerebral hemorrhage survivors with the right- or the left-sided hemiparesis. 25 patients (17 with the right-si- ded and 8 with the left-sided hemiparesis) were subjec- ted to functional evaluation of the paretic lower limb, gait evaluation (gait efficiency and gait ability) and wal- king distance assessment. Correlation between the neurological and locomotor status of the patients was evaluated. The analysis showed a statistically signifi- cant correlation between the examined traits. It also in- dicates a necessity for performing neurological and functional evaluation of patients after stroke and moni- toring of the rehabilitation progress. Lack of improve- ment may indicate that the rehabilitation scheme ne- eds to be altered, especially in the first months after the stroke. The final effect of rehabilitation depends, to a large extent, on the choice of appropriate physiothera- peutic strategy.
[Show abstract][Hide abstract] ABSTRACT: This thesis is based on the findings of the FuPro-Stroke study (the Stroke section of the Functional Prognostification and disability study on neurological disorders), which is a multicentre, prospective cohort study among patients with stroke, who were included during inpatient rehabilitation. The aim of the research reported on in the present thesis was to investigate the long-term prognosis of chronic stroke outcome up to 3 years after onset. Poor mobility status is a key concern in chronic stroke patients, especially since it may lead to ADL dependence and affect social reintegration. We found that mobility at one-year post stroke could be predicted by functional status, sitting balance, time between stroke onset and measurement, and age. We also investigated determinants that could predict decline in mobility status in chronic stroke patients. Inactivity in terms of instrumental activities of daily living (IADL), cognitive problems, fatigue and depressive symptoms at one year post stroke were the main predictors for deterioration in mobility. Community ambulation is an important outcome for stroke patients and we found that this variable was closely related to gait speed. The optimal cut-off point for community ambulation was 0.66 m/s. Balance, endurance and the use of an assistive walking device were determinants that confounded the relation between community ambulation and gait speed. The effectiveness of training programmes focusing on lower limb strengthening, cardio-respiratory fitness or gait-oriented tasks, in terms of the outcome of gait, gait-related activities and health-related quality of life (HRQoL) after stroke were also investigated. Twenty-one high quality RCTs were included, five of which focused on lower limb strengthening, two on cardio-respiratory fitness training and 14 on gait-oriented training. After conducting a meta-analysis we suggested that gait-oriented training is the most successful method to improve walking competency after stroke. Depression and fatigue are both well-known sequels after stroke. At three years post stroke, 19% of the patients showed depressive symptoms. Depression was best predicted by one-year IADL activity and fatigue. It was also shown that 68%, 74% and 58% of the patients experienced fatigue at 6, 12 and 36 months post stroke, respectively. Fatigue was significantly related to IADL and HRQoL, but not to ADL. Depression and motor impairment were important confounders in the relationship between fatigue and IADL and HRQoL. Since the number of stroke patients is rising and it is a chronic disease, it is important that appropriate care is provided to suit the needs of all these patients. We suggest in our study that 33% of the patients perceived at least one unmet care demand at three years after stroke. Younger age, motor impairment, fatigue and depressive symptoms were significantly related to the presence of unmet demands. These results suggest that our health care system is as yet not fully meeting the demands of patients with chronic stroke. Our advise is that the focus of care and research should be on improving our understanding of the course of functional recovery by monitoring patients over time, introducing innovative intervention strategies and exploring the underlying mechanisms of functional improvement after stroke.
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