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Amir Iqbal & Ganeswara R Melam International Journal of Physical Therapy Research & Practice 2024;3(4):209-215
209
IJPRP | Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation
Original Article
Comparative Analysis of Physical Therapy
Outcomes in Acute Ischemic and Hemorrhagic
Stroke Rehabilitation
Amir Iqbal1*, Ganeswara R Melam2, Priyadarshani Bhat3
1. Rehabilitation Research Chair, College of Applied Sciences, King Saud University,
Riyadh 11433, Saudi Arabia.
2. NL Balance & Dizziness Centre, St.John’s, Newfoundland & Labrador, Canada
3. Department of physiotherapy, ITS institute of health and wellness sciences, Atal
Bihari Vajpayee University, Greater Noida 201310, UP, India
*Corresponding Author: ajamaluddin@ksu.edu.sa
Article Info Abstract
Received : April 01, 2024
Accepted : April 27, 2024
Published : April 29, 2024
To Cite: Amir Iqbal & Ganeswara R
Melam. Comparative Analysis of
Physical Therapy Outcomes in Acute
Ischemic and Hemorrhagic Stroke
Rehabilitation. International
Journal of Physical Therapy Research
& Practice 2024;3(4):209-215
Copyright: © 2024 by the authors. Licensee
Inkwell Infinite Publication, Sharjah Medical
City, Sharjah, UAE. This article is an open
access article distributed under the terms
and conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/ 4.0/).
Aims & Objective: Stroke rehabilitation demands an effective therapeutic approach to
enhance functional recovery. This study aims to compare the outcomes of physical
therapy in patients with acute ischemic and hemorrhagic stroke using the Motor
Relearning Programme (MRP). Methodology: Based on stroke type, confirmed via CT
thirty-eight participants were stratified into ischemic & hemorrhagic stroke group. Eligible
participants were over 35 years old, had a Glasgow Coma Scale score above 5, and
presented with hemiplegia. Exclusion criteria included trauma-induced hemorrhage,
cerebellar or brainstem stroke, severe cognitive impairment, or pre-existing disabilities.
The participants underwent a standardized four-week physiotherapy regimen based on
the MRP, with assessments using the Motor Assessment Scale (MAS) and Functional
Independence Measure (FIM) to evaluate the outcomes. Results: These results
underscore the significant improvements in the functional outcomes observed in both
ischemic and hemorrhagic stroke patients following physical therapy, with hemorrhagic
stroke patients showing more substantial gains in both MAS and FIM scores.
Conclusion: Our study contributes to a nuanced understanding of stroke rehabilitation,
emphasizing that while both ischemic and hemorrhagic stroke patients significantly
benefit from structured physical therapy interventions like MRP, the specifics of their
recovery processes vary.
Keywords: Stroke Rehabilitation, Physical Therapy Outcomes, Motor Relearning
Programme, Functional Recovery
Introduction
Stroke persists as a leading cause of hospitalization
due to central nervous system disorders across the
world, posing significant healthcare challenges.
Although advancements in medical practice have
reportedly diminished both fatality and incidence rates
of stroke (Brown J. A., 2006), its prevalence,
associated mortality, and the profound risk of lasting
disability in survivors render it a considerable concern
INTERNATIONAL JOURNAL OF
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Amir Iqbal & Ganeswara R Melam International Journal of Physical Therapy Research & Practice 2024;3(4):209-215
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IJPRP | Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation
at the turn of the millennium. The World Health
Organization delineates stroke as the rapid onset of a
focal or global neurological deficit of presumable
vascular origin, which endures for no less than 24
hours or culminates in death. This definition
encompasses spontaneous subarachnoid
hemorrhages but excludes transient ischemic attacks
and other forms of hematomas.
For individuals who have weathered the immediate
consequences of a stroke, their prospective recovery
and the prospect of sustained independence become
paramount. These concerns extend to their families
and healthcare providers, especially physiotherapists,
who are directly involved in their care. The significance
of outcome studies is accentuated in the
contemporary context of cost-managed healthcare
systems where such data critically inform treatment
guidelines and policymaking.
Studies concerning the functional outcomes of
ischemic and hemorrhagic strokes highlight that
survival, impairment, disability, and quality of life are
key variables in patient recovery. Research by Frank &
Silver, (1984) has underscored the importance of
analyzing early mortality, pointing to a bimodal
distribution with peaks in the first week due to brain
herniation and in subsequent weeks due to
complications from immobility. Factors such as age,
hypertension, comorbidities, blood glucose levels,
hemorrhage size, and ventricular spread have been
repeatedly identified as predictors of mortality.
Notably, early mortality is especially high for
hemorrhagic stroke patients.
Long-term survival analyses suggest better outcomes
for those who survive beyond the acute phase of a
hemorrhagic stroke, warranting strong advocacy for
intensive rehabilitation efforts. Studies like those of
Wei et al. (2024) have demonstrated positive
rehabilitation outcomes, particularly for subarachnoid
hemorrhage patients, with a significant portion
achieving sufficient independence to return home.
Despite the serious and often immediate implications
of stroke, certain studies indicate no significant
difference in long-term functional independence
between ischemic and hemorrhagic stroke survivors,
while others suggest a somewhat faster functional
gain in hemorrhagic stroke patients. The
heterogeneous nature of stroke outcomes indicates
that while some recovery predictors are well-
established, the individual patient's trajectory can be
difficult to predict, necessitating a personalized
approach to rehabilitation planning.
Existing literature presents a spectrum of findings.
Ikramuddin and colleagues (2019) found no significant
correlation between age, blood pressure at the time of
admission, and the interval between stroke onset and
hospital admission with functional improvement post-
stroke. Conversely, Kuriakose & Xiao (2020) reported
superior discharge outcomes for men with left-sided
cerebrovascular events compared to those affected
on the right side. Novack and colleagues (1984)
highlighted the temporal relationship between the
onset of stroke and admission to a rehabilitation
facility as an influential factor in patient outcomes.
Petty et al. (2000) identified discrepancies in
recurrence rates and post-stroke functionality among
different ischemic stroke subtypes, particularly noting
the lower survival rates for strokes originating from
cardiac embolism.
Other investigations (Salvadori et al., 2020), have
explored the potential variance in functional recovery
contingent on the nature of the stroke—hemorrhagic
versus ischemic—yielding mixed outcomes. Kelly
(2003) observed admission Functional Independence
Measure (FIM) score discrepancies between patients
with cerebral infarction and those with intracranial
hemorrhage. Kojic and colleagues (2009) underlined
the role of hematoma size and ventricular rupture in
determining mortality in hemorrhagic stroke cases,
advocating for assertive rehabilitation to foster
independence in survivors.
Considering these divergent findings, the precise
measurement of functional outcomes is crucial. The
Motor Assessment Scale (MAS) is an established tools
that have been widely utilized to gauge rehabilitation
progress. It’s recognized for its reliability in providing
objective results without the necessity of costly
equipment (Carr & Shepherd, 1985).
The disparities in stroke outcomes necessitate further
investigation. Therefore, this study is designed to
explore the functional outcomes of ischemic versus
hemorrhagic stroke during the acute phase, utilizing
the MAS and FIM as evaluative instruments. Through
this research, we aim to contribute to a more
discerning understanding of post-stroke recovery,
thereby justifying the need for a differentiated
approach in physiotherapy treatment strategies and
healthcare policies.
Amir Iqbal & Ganeswara R Melam International Journal of Physical Therapy Research & Practice 2024;3(4):209-215
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IJPRP | Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation
Methodology
This research employed a comparative cohort design
to examine and contrast the functional outcomes of
physiotherapy in patients with ischemic versus
hemorrhagic stroke. The participants were randomly
differentiated into two groups according to the nature
of their strokes as confirmed by computed
tomography (CT): Ischemic Stroke Group (ISG) and
Hemorrhagic Stroke Group (HSG).
The study's participant pool was carefully curated.
Individuals were included if they had experienced their
first stroke, evidenced by CT scans indicative of
ischemic or hemorrhagic pathology. Candidates were
required to be over the age of 35, with a minimal
Glasgow Coma Scale score of 5 to ensure
consciousness and potential for participation.
Neurological impairment was a necessity for
inclusion, specifically the presence of hemiplegia, and
candidates had to be accessible for enrollment within
one week following their stroke. Exclusion criteria were
put in place to ensure the homogeneity of the study
sample and the reliability of the outcome measures.
Individuals with hemorrhage due to trauma or tumor,
strokes impacting the cerebellum, brainstem, or
causing subarachnoid hemorrhage, were not
considered. Furthermore, severe cognitive
impairments or the presence of severe pre-existing
disabilities that could influence the rehabilitation
outcomes led to exclusion from the study.
All study participants underwent a standardized four-
week physiotherapy regimen based on the Motor
Relearning Programme (MRP). The MRP is a
comprehensive rehabilitation approach tailored to
stroke recovery, advocating for the relearning of motor
skills through repetitive, functional tasks that mimic
daily activities. It is a patient-centered protocol that
involves goal setting, task breakdown, and practice of
movements, such as transfers, walking, and upper
limb function, within a real-life context. The MRP was
delivered by skilled physiotherapists who were trained
in the method.
The study utilized the Motor Assessment Scale (MAS)
and the Functional Independence Measure (FIM) to
gauge recovery progress. The MAS, developed by Carr
and Shepherd (1985), is a brief, reliable scale that
evaluates essential motor functions without the need
for costly equipment. Studies by Poole et al. (1988)
established its concurrent validity with the Fugl-Meyer
scale, while Dean and Mackey (1992), recognized its
utility in documenting rehabilitation outcomes. The
FIM, widely used since 1987, addresses the need for
standardized disability and rehabilitation outcome
data. Research by Dodds et al. (1993), Donaghy &
Wass (1998) and Beninato et al. (2006) highlighted
FIM’s value as a prognostic indicator and functional
measure in stroke rehabilitation, respectively.
Comparisons with other indices like the Barthel Index
confirmed FIM’s superior reliability and validity, with a
study by Kidd et al. (1995) rating it as more valid for
disability assessment and found FIM to possess high
interrater reliability, especially in motor tasks. The FIM
was selected for this study due to its extensive
adoption, ease of scoring, and proven reliability and
validity, enhancing communication between
healthcare settings and contributing to ongoing efforts
to improve treatment outcomes for this significantly
disabling condition.
Following the acquisition of written informed consent,
baseline data including medical history, demographic
details, presence of hypertension, and the date of
stroke onset were meticulously recorded for each
subject. Initial evaluations using the MAS and FIM
scales were conducted to establish a starting point for
subsequent comparisons. Progress assessments
were then scheduled at the end of each week for the
entire duration of the physiotherapy program, resulting
in a comprehensive set of data points across the four
weeks of intervention.
Result
This research investigated the recovery patterns of two
cohorts of stroke patients by tracking the outcome
scores after a four-week MRP programme. Descriptive
statistics were used to describe the demographic data
of participants, offering a fundamental
comprehension of the sample. Following that, paired
and independent t-tests were used to detect
differences within each patient group over time and
between the two groups, respectively. This facilitated
the measurement of the impact of the MRP on patient
outcomes.
This research aimed to examine the functional results
during the acute stage of two types of strokes:
ischemic and hemorrhagic. It comprised 38
participants, 19 in each group. In the Ischemic Stroke
Group, there were fourteen men (73.7%) and five
females (26.3%); in the Hemorrhagic Stroke Group,
there were twelve men (63.2%) and seven females
(36.6%). Among the subjects, 57.9% had a right-sided
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IJPRP | Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation
stroke, whereas 52% suffered a left-sided stroke. Of
the participants, 18 had diabetes and 28 had
hypertension. Patients were evenly distributed across
the two groups.
Table 1: Effect of four weeks MRP on Ischemic Stroke
Outcomes
Baseline
Mean (SD)
N=19
Post
Treatment
Mean (SD)
N=19
t
p
Cohen's
d
MAS
21.7 (7)
27.1 (6.8)
-2.95
0.009
-0.676
FIM
55.2 (11.7)
79.1 (18.3)
-4.89
0.000
-1.122
When examining the paired samples test for within-
group comparisons (Table 1), the ischemic stroke
group showed a significant mean decrease in MAS
scores from admission to 4 weeks (t(18) = -2.945, p =
.009), with a large effect size (Cohen's d = .67). For FIM
scores, the decrease was even more pronounced
(t(18) = -4.889, p < .001), with a very large effect size
(Cohen's d = 1.12).
Table 2: Effect of four weeks MRP on Hemorrhagic
Stroke Outcomes
Baseline
Mean (SD)
N=19
Post
Treatment
Mean (SD)
N=19
t
p
Cohen's
d
MAS
20.5 (6.1)
33.6 (6.8)
-10.61
0.000
-2.434
FIM
54.6 (11.8)
90.1 (14.1)
-11.99
0.000
-2.750
Hemorrhagic stroke patients demonstrated an even
greater mean decrease in MAS scores (t(18) = -10.61, p
< .001), with a large effect size (Cohen's d = 2.43), and
in FIM scores (t(18) = -11.986, p < .001), with a very
large effect size (Cohen's d = 2.75) (Table 2).
Table 3: Comparison of MAS Outcomes across Stroke
group
ISG
Mean (SD)
N=19
HSG
Mean (SD)
N=19
t
p
Cohen's
d
Baseline
21.7 (7)
20.5 (6.1)
0.569
0.573
0.185
Post
Treatment
27.1 (6.8)
33.6 (6.8)
-2.929
0.006
-0.950
Patients with ischemic strokes had a baseline MAS
score of 21.68 (SD = 7.008), which increased to 27.11
(SD = 6.781) after 4 weeks of physical therapy (Table 3).
Hemorrhagic stroke patients began with a slightly
lower MAS score of 20.47 (SD = 6.068) and experienced
a more substantial increase to 33.58 (SD = 6.842) after
the intervention period. An independent samples t-test
indicated a statistically significant difference in the
change of MAS scores between the two stroke types
after 4 weeks (t(36) = -2.929, p = .006), with a large
effect size (Cohen's d = .95). The mean difference
between the groups was -6.474, favoring the
hemorrhagic stroke group. Furthermore, a paired
samples correlation for the hemorrhagic stroke group
(r = .658, p = .002) demonstrated a strong positive
relationship between initial and subsequent MAS
scores, suggesting consistent improvement.
Table 4: Comparison of FIM Outcomes across Stroke
group
ISG
Mean (SD)
N=19
HSG
Mean (SD)
N=19
t
p
Cohen's
d
Baseline
55.2 (11.7)
54.6 (11.8)
0.165
8.372
0.054
Post
Treatment
79.1 (18.3)
90.1 (14.1)
-2.080
-0.272
-0.675
The mean FIM score at admission for ischemic stroke
patients was 55.21 (SD = 11.712), improving to 79.11
(SD = 18.275) after 4 weeks. Similarly, hemorrhagic
stroke patients' mean FIM score improved from 54.58
(SD = 11.815) at admission to 90.11 (SD = 14.059) after
4 weeks (Table 1). The change in FIM scores was also
statistically significant (t(36) = -2.08, p = .045) with a
notable effect size (Cohen's d = 16.31), with the mean
difference of -11 indicating greater functional gains for
the hemorrhagic stroke group. Correlation analyses
revealed a significant relationship between initial and
final FIM scores for hemorrhagic stroke patients (r =
.513, p = .025), denoting a positive therapeutic effect.
These results underscore the significant
improvements in the functional outcomes observed in
both ischemic and hemorrhagic stroke patients
following physical therapy, with hemorrhagic stroke
patients showing more substantial gains in both MAS
and FIM scores. The high effect sizes suggest that
these improvements are both statistically and
clinically meaningful, indicating the efficacy of the
physical therapy interventions implemented in the
study.
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IJPRP | Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation
Discussion
The purpose of our research was to evaluate the
effects of the Motor Relearning Programme (MRP) on
the functional outcomes of individuals with acute
ischemic and hemorrhagic strokes. By doing thorough
analysis, we were able to identify important
observations on the impact of stroke type on the
progress and results of early rehabilitation. Both the
ischemic and hemorrhagic stroke groups showed
improvements in their motor skills and functional
independence, as measured by the Motor Assessment
Scale (MAS) and Functional Independence Measure
(FIM). The group of patients with hemorrhagic stroke
showed statistically significant improvements in both
MAS and FIM ratings, revealing a unique pattern of
recovery. The diverging path taken by hemorrhagic and
ischemic stroke patients may be due to a fundamental
difference in how they respond to early physical
therapy therapies. Despite not all differences achieved
statistical significance for tests, hemorrhagic stroke
patients showed quick improvement, sometimes
surpassing the ischemic group in functional recovery,
despite beginning from comparable baselines.
Previous research by Paolucci et al. (2003) has shown
that hemorrhagic stroke patients have a more
favorable improvement in mobility and neurological
outcomes compared to individuals with ischemic
strokes. The results of our study support these
observations and indicate that tailoring rehabilitation
regimens to the specific kind of stroke may play a
crucial role in maximizing recovery outcomes. Given
the rapid progress in treating hemorrhagic stroke
patients, it may be advantageous to enhance
rehabilitation programmes by adjusting the intensity
and timing of therapies to take full advantage of this
period of accelerated recovery.
The findings of Salvadori et al. (2020) align with our
results since they also identified specific difficulties in
the recovery process for patients with hemorrhagic
and ischemic strokes. Notably, the former group saw a
higher occurrence of complications. Our study
emphasizes the need for a proactive treatment plan in
these patients, which may include comprehensive
surveillance and integrated care that treats problems
with the administration of physical therapy. In line with
the principles stated by Wei et al. (2024), our study
emphasizes the need of starting rehabilitation as soon
as medically possible after a stroke. Prompt
intervention is crucial, as our findings demonstrate
that significant improvements in functionality may be
achieved from the beginning of treatment. This
discovery is very important for clinical practice,
supporting the development of recommendations that
emphasize the need of prompt rehabilitation efforts.
Furthermore, the lack of noticeable disparities in
certain functional activities across the groups may
suggest that although overall improvements are
evident, the detailed and individualized nature of
functional enhancement requires more complex and
personalized therapy approaches. This is supported by
the personalized therapy requirements described by
Kartashev et al. (2020).
The continuous improvement seen in both groups over
the four-week intervention highlights the potential
benefits of long-lasting and perhaps extended
rehabilitation programmes. This is consistent with the
perspective of Nas et al. (2015), who suggest that long-
term rehabilitation may help support continuous
healing. The findings of our research suggest that
providing rehabilitative treatment beyond the acute
period might enhance functional independence and
quality of life, especially in stroke patients with
significant initial impairments.
The current research highlights the ability of
hemorrhagic stroke patients to positively respond to
early and intensive rehabilitation. This challenges us to
improve our methods to take full advantage of this
responsiveness. Although therapies are beneficial for
ischemic stroke patients, the research suggests that
customized tactics are necessary to optimize the
therapeutic effectiveness for each kind of stroke,
thereby enhancing overall patient outcomes.
Conclusion
Our study contributes to a nuanced understanding of
stroke rehabilitation, emphasizing that while both
ischemic and hemorrhagic stroke patients
significantly benefit from structured physical therapy
interventions like MRP, the specifics of their recovery
processes vary. This variation underscores the
necessity for personalized rehabilitation strategies
that consider the unique physiological and recovery
needs of each stroke subtype. Moving forward, it is
crucial for future research to not only refine these
strategies but also to explore the integration of novel
therapeutic modalities that could complement
traditional physical therapy to optimize recovery
outcomes for all stroke patients.
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IJPRP | Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation
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