Ocena wpływu postępowania fizykalnego u chorych po udarze mózgu na funkcjonowanie w życiu codziennym

Włodzisław Kuliński1,2, Oktawia Bębenek1

1Department of Physical Medicine, Faculty of Medicine and Health Science, Jan Kochanowski University, Kielce, Poland

2Department of Rehabilitation, Military Institute of Medicine, Warsaw, Poland

Abstract

Introduction: Stroke is one of the most important health problems of our time.

The aim: The aim of the study was to assess the functional status of stroke patients and the effects of physical therapy on patient functioning.

Material and methods: The study included 28 patients (10 women, 18 men) after ischaemic stroke. The patients underwent kinesitherapy , verticalisation, gait training, and physical therapy.

Results: 1. After treatment, patients showed functional improvements in all the activities of daily living assessed in the study. 2. The improvement depended on the time from stroke, with the most dynamic changes occurring in the first 3 months after stroke.

Conclusions: 1. Appropriate patient-specific physical therapy plays an extremely important role in rehabilitation. It may prevent a number of complications and reduce disability. 2. Physical therapy and rehabilitation constitute the basis for stroke patient treatment.

STRESZCZENIE

Wstęp: Udar mózgu jest jednym z najpoważniejszych problemów zdrowotnych współczesnego świata.

Cel pracy: Ocena sprawności chorych po udarze mózgu i wpływu postępowania fizykalnego na funkcjonowanie chorych.

Materiał i metody: Badaniem objęto grupę 28 chorych (10 kobiet, 18 mężczyzn) po przebytym udarze niedokrwiennym mózgu. Prowadzono u nich postępowanie fizykalne: kinezyterapia, pionizacja, nauka chodu, fizykoterapia.

Wyniki: 1. We wszystkich obserwowanych czynnościach dnia po leczeniu u chorych uzyskano poprawę funkcjonalną. 2. Poprawa jest zależna od czasu, który upłynął od udaru i najbardziej dynamiczna była w okresie do trzech miesięcy od wystąpienia udaru.

Wnioski: 1. Właściwe zindywidualizowane postępowanie fizykalne odgrywa ogromną rolę w usprawnianiu pacjenta. Może uchronić go przed szeregiem powikłań, jak również zmniejszyć jego niepełnosprawność. 2. Postępowanie fizykalno-usprawniające jest podstawowym elementem leczenia tych chorych.

Wiad Lek 2018, 71, 8, -1503

INTRODUCTION

Stroke is one of the most important health problems of our time. It is the third leading cause of death worldwide and the fourth cause of death in Poland (after accidents). According to a report prepared by the Expert Team of the National Programme for the Prevention and Treatment of Stroke, there are 60,000 new cases of stroke in Poland annually. The risk of stroke increases with age. In Poland, the incidence of stroke is 177 per 100,000 men and 125 per 100,000 women. Stroke is often a factor contributing to permanent disability in people over the age of 40 years and should be considered directly life-threatening [1−7].

Moreover, disability reduces the level of functioning in the family, at work, and in one’s community [8−10]. Stroke has many very extensive complications. Most patients experience irreversible disability and function impairment, which, in turn, make patients partially or completely dependent on other people in their everyday lives. Studies assessing the functional status in stroke patients indicate that 6 months after stroke, paresis or hemiparesis become persistent in approx. 50% of patients, motor coordination impairment in 30% of patients, and speech impairment in 20% of cases. More than a third of stroke patients experience anxiety and depression. About 50% of patients require help and care due to their worsened mental and physical status [11, 12].

Comprehensive rehabilitation is an indispensable part of treatment. Systematic physical therapy and rehabilitation improve disability and allow for avoiding numerous sequelae that might lead to future hospital admissions [13−25].

80% of all stroke cases are due to ischaemia. Cerebral haemorrhage is the cause of stroke in only 20% of patients [3−6].

The dynamics and mechanism of focal cerebral ischaemia may vary. Usually, it is caused by stenosis or complete occlusion of a vessel supplying blood to a given area of the brain. The resulting reduction in oxygen and glucose delivery leads to changes in brain metabolism, which, in turn, produce focal abnormalities.

The most commonly reported focal symptoms are motor symptoms (limb weakening), sensory symptoms (paraesthesia, visual field defects), cognitive impairment, and balance and speech disturbances. Magnetic resonance imaging (MRI) is an important imaging study used in the diagnostic work-up of stroke patients. Persistent sequelae of ischaemic stroke depend on the extent and location of the ischaemia, pre-stroke health status, peri-stroke complications, and treatment. Physical therapy and rehabilitation used in this group of patients include electrotherapy, light therapy, laser therapy, low-frequency variable magnetic fields, cryotherapy, and kinesitherapy.

AIM OF STUDY AND METHODS

The aim of the study was to assess the condition of stroke patients, their functional status, and level of functioning in everyday life after physical therapy and rehabilitation. The study used a survey that allowed for collecting information about the objective and subjective status of patients and their functioning in everyday life.

The study was conducted at the Pińczów healthcare centre in 2016 and included 28 patients (10 women, 18 men) after ischaemic stroke (mean age: 48-76 years), who were treated at the rehabilitation day ward. The study used the Barthel scale. The study patients received physical therapy and rehabilitation in the form of passive, active-passive, and active exercises, verticalization, gait training, massage, polarised light, laser therapy, and electrical stimulation.

The results were analysed with the programme PQStat (ver. 1.6). Correlations were studied with Fisher’s test. The significance level was set at p<0.05 and results with p<0.01 were deemed highly significant.

The study group consisted of ten females and eighteen males (28 patients). Three functional status levels were distinguished:

• level I – dependent

• level II – partially independent

• level III – independent.

Three women and eight men were classified as level I (dependent), two women and seven men were classified as level II (partially independent), and five women and three men were classified as level III (independent). No significant correlation was found between sex and the level of independence (Fisher’s exact test p=0.2313) (Tab. I).

The study group was divided into age groups. No significant correlation was found (Fisher’s exact test p=0.8635) between sex and age group. There was no significant correlation (Fisher’s exact test p=0.2425) between sex and type of work. Finally, there was no significant correlation (Fisher’s exact test p=0.9030) between leisure activities and age group (Tab. II).

The study group was divided by place of residence. Six women and eight men lived in a rural area while four women and ten men lived in an urban area. No significant correlation was found (Fisher’s exact test p=0.6946) between sex and place of residence. The majority of patients living both in urban areas and in rural areas were male.

The study patients were also divided into three groups based on their functional status.

The first group, classified as level I, scored 0-25 points. 27% of the group were women and 73% were men (Fig. 1). These patients were fully dependent and required help from other people to perform most basic activities of daily living.

The second group, classified as level II, scored 40-65 points (Fig. 2). These patients required help only with some activities of daily living.

The third group, classified as level III, scored 70-100 pts. 63% of these patients were women and 37% were men (Fig. 3). They were independent and did not require any help with most daily activities. In the study group, patients who scored 0-25 points were dependent, those with 40-65 were partially independent, and those who scored 70-100 points were independent.

Patient classification in basic
activities of daily living

Patients could score 0 to 10 points for eating. Three women and five men in the first group scored 0 points; they were unable to eat unassisted. In the second group, three women and four women scored 5 points; they required help cutting and spreading butter. In the third group, four women and nine men scored 10 points; they were fully independent and did not require any help.

For getting out of bed, patients could score 0-15 points. In the first group, two women and three men scored 0 points (no sitting balance). In the second group, one woman and eight men scored 5 points; they were able to sit, but needed someone to assist them. In the third group, five women and five men scored 10 points.

Patients could score 0-10 points for personal hygiene. In the first group, four women and nine men scored 0 points; they needed urgent help with these activities. In the second group, six women and nine men scored 5 points; these patients were independent when it came to washing their face and brushing their teeth.

Patients could score 0-10 points for toilet use. The first group, which included four women and five men, scored 0 points. In the second group, three women and eight men scored 5 points (they required some help). In the third group, three women and five men scored 10 points; they were fully independent.

Patients could score 0-5 points for bathing. The first group, including three women and ten men, scored 0 points; the patients were largely dependent on other people. In the second group, seven women and eight men scored 5 points.

The score for mobility ranged from 0 to 15 points. In the first group, three women and seven men scored 0 points (unable to ambulate). Two women and five men in the second group scored 5 points (independent in a wheelchair). The third group, including three women and five men, scored 10 points; these patients were able to ambulate with the help of another person.

Patients could score 0-10 points for using stairs. In the first group, which consisted of four women and five men, patients scored 0 points; they were dependent on other people. The second group, three women and eleven men, scored 5 points (they required help). In turn, three women and two men from the third group scored 10 points; they were independent and did not require assistance. There was no significant correlation (Fisher’s exact test p=0.3308) between sex and level of independence when using stairs.

Patients could score 0-10 points for dressing and undressing. The first group (two women and six men) scored 0 points and were fully dependent on other people. The second group (three women and seven men) scored 5 points and were able to perform some activities, but required help. The third group (five women and five men) scored 10 points and were independent. No significant correlation (Fisher’s exact test p=0.6140) was found between sex and independence when dressing.

Patients could score 0-10 points for bowel function. Three women and six men from the first group scored 0 points (incontinence). The second group, consisting of three women and six men, scored 5 points (occasional accidental bowel movements). The third group (four women and five men) scored 10 points (continence). No significant correlation (Fisher’s exact test p=0.8871) was found between sex and independence when it came to bowel control.

Patient could score 0-10 points for urinary continence. The first group (three women and eight men) scored 0 points (incontinence). Four women and seven men from the second group scored 5 points (occasional accidental incontinence). The third group, which consisted of three women and three men, scored 10 points (continence). There was no significant correlation (Fisher’s exact test p=0.7013) between sex and urinary continence.

Patients underwent physical medicine procedures and rehabilitation in the form of classic massage, polarised light, laser therapy, electrical stimulation, passive, active-passive, and active exercises, verticalisation, gait training, and breathing exercises.

There was no significant correlation (p>0.05) between the patients’ sex and the frequency of undergoing any of these procedures.

No significant correlation (Fisher’s exact test p=0.0505) was observed between age and the paretic side, although the probability value was very close to α=0.05.

Half of the study patients (fourteen subjects) used orthopaedic aids (wheelchair, walking frame, crutches).

The table 3 shown above presents the health status of study patients before and after treatment. The percentage of patients unable to eat meals without assistance decreased from 28% to 21%. The percentage of patients who required help cutting and spreading butter decreased from 25% to 21%. In turn, the percentage of independent subjects increased from 47% to 68%.

The percentage of patients unable to transfer from bed decreased from 17% to 14%. The percentage of those who need more physical help decreased from 32% to 10%. Finally, the percentage of independent patients increased from 15% to 58%.

Before treatment, thirteen patients required help with personal hygiene. The number of fully independent patients increased from 15 to 21.

In the toilet use category, 32% of patients were dependent on other people; the percentage decreased to 11% after rehabilitation. The percentage of partially dependent patients was 39% before treatment and 11% after treatment. The percentage of independent patients before treatment was 29%, but after the procedures, 78% of the subjects did not require assistance.

The percentage of dependent patients in the bathing category decreased from 46% to 18%. The percentage of independent patients was 54% before treatment and 82% after treatment.

Before treatment, 36% of patients were unable to ambulate, but after rehabilitation the percentage decreased to 18%. The percentage of patients who were independent in a wheelchair was 25% before treatment and 18% after treatment. The percentage of patients requiring the help of another person decreased from 29% to 7%, while the percentage of independent subjects increased from 10% to 57%.

Before rehabilitation, 32% of patients were dependent on other people when it came to using stairs; after rehabilitation, the percentage decreased to 25%. The percentage of patients requiring help to use the stairs was 50% before rehabilitation and 36% after rehabilitation. The percentage of independent patients increased from 18% to 39%.

The percentage of dependent patients in the dressing and undressing category decreased from 28% to 14%. The percentage of patients requiring help decreased from 36% to 22%, while the percentage of independent patients increased from 36% to 64%.

The percentage of patients with faecal incontinence decreased from 32% to 22%. The percentage of subjects with occasional incontinence decreased from 36% to 14%. The percentage of patients showing faecal continence increased from 32% to 64%.

Finally, the percentage of patients with urinary incontinence decreased from 39% to 28% and that of patients with occasional urinary incontinence decreased from 39% to 22%, while the percentage of patients with urinary continence increased from 22% to 50%.

Significant (p<0.05) and highly significant (p<0.01) improvements in results after treatment were found for the “transferring from bed to chair”, “toilet use”, “bathing, washing entire body”, “mobility”, and “faecal continence/anal sphincter control” categories. Differences between pre- and post-treatment scores in the other domains were insignificant (p>0.05).

Patients were asked about their subjective status before and after their physical therapy and rehabilitation programme. As shown in Table IV, the number of patients reporting no symptoms decreased from 12 to 0, while the number of patients experiencing slight improvements increased from 2 to 4. Marked improvements were reported by a considerably higher number of people (an increase from 0 to 10). There was a highly significant (Fisher’s exact test p<0.0001) correlation between health problems and time point, with the results being considerably better after physical therapy and rehabilitation. Consequently, it can be concluded that the physical therapy and rehabilitation procedures used in the patients produced positive effects.

Table V with changes between the pre- and post-rehabilitation period shows improvements in the study patients. There was a highly significant (Fisher’s exact test p=0.0049) correlation between health problems assessed before and after physical therapy and rehabilitation and the considerably better outcomes observed.

DISCUSSION

The present results were obtained in patients after stroke in the period of functional prevention and early rehabilitation in the hospital and at home.

An analysis of changes in restoring independence with respect to different basic activities of daily living shows that before physical therapy and rehabilitation, problems with bathing, washing entire body, going up and down the stairs, dressing and undressing, and faecal and urinary continence were definitely the most important obstacles to patient independence. However, systematic, considerable improvements were possible during the rehabilitation process.

The effectiveness of rehabilitation in stroke patients is measured based on restoring independent mobility and improving upper limb function (grasping, manipulating). The ability to ambulate and the quality of this activity may reflect the effectiveness of rehabilitation. Rehabilitation should be focused on gait, since 4 out of 5 stroke patients may be able to walk again [21, 22].

An analysis of improvements in everyday functioning showed no worsening in the quality of the activities performed. The ability to bathe and wash one’s entire body turned out to be the most difficult to improve; it is undoubtedly a complex activity that requires the coordination of different organ functions and senses. It was much easier to restore independence with respect to eating and transferring from bed to chair and back.

The study showed that the level of independence in everyday functioning in stroke patients improved considerably with time.

These effects were possible due to comprehensive post-stroke rehabilitation and the efforts of an interdisciplinary team.

Woldańska-Okońska et al. studied correlations between rehabilitation and the age and sex of their patients, but found no important impact of the two factors on final rehabilitation results [13]. The results of the present study show no correlation between physical therapy and the patients’ sex and age. Even elderly stroke patients, both female and male, may achieve an improvement of their functional status after physical therapy. Moreover, the stroke-affected side of the body had no influence on the prognostic and long-term scores. This was confirmed by Czernicki et al. [13]. Many authors stress that early, comprehensive, and uninterrupted rehabilitation ensures functional improvements in stroke patients, even in cases with serious general and cardiac comorbidities [14,18, 19, 21].

Motor performance of stroke patients is often studied [12, 13, 17, 19, 22]. The studies encompass for instance basic everyday activities associated with the ability to ambulate and perform self-care. Considerable reductions in gait efficacy, the necessity to use orthopaedic aids, and cognitive impairment increase the risk of falls as well as social and health consequences of stroke.

CONCLUSIONS

1. Improvements obtained in stroke patients depend on the time from stroke, with the most dynamic changes occurring in the first 3 months after stroke.

2. Appropriate patient-specific physical therapy plays an extremely important role in rehabilitation. It may prevent a number of complications and reduce disability.

3. Physical therapy and rehabilitation constitute the basis for stroke patient treatment.

References

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Conflict of interest:

The Authors declare no conflict of interest.

Corresponding autor

Włodzisław Kuliński

ul. Karola Miarki 11 B, 01-496 Warszawa, Poland

e-mail: wkulinski52@hotmail.com

Received: 04.11.2018

Accepted: 26.11.2018

Table. I. Patients divided by age and functional status.

Sex

Level of independence

Dependent

Partially independent

Independent

Women

3 (27%)

2 (22%)

5 (62%)

Men

8 (73%)

7 (78%)

3 (38%)

Total

11

9

8

Table. II. Patients divided by age group, type of work, and leisure activities.

Age group

35-45

46-56

57-67

68-78

Women

2 (67%)

3 (30%)

4 (33%)

1 (33%)

Men

1 (33%)

7 (70%)

8 (67%)

2 (67%)

Physical work

2

5

7

2

Intellectual work

1

5

5

1

Passive leisure activities

2 (67%)

4 (40%)

3

2

Active leisure activities

1 (33%)

6 (60%)

2

3

Total

3

10

12

3

Fig. 1. Level I (0-25 pts).

Fig. 2. Level II (40-65 pts).

Fig. 3. Level III (70-100 pts).

Table. III. Health status before and after treatment.

Before

After

Fisher’s exact test

Eating

Unable to eat unassisted

8 (28%)

6 (21%)

p=0.2322

Needs help cutting, spreading butter

7 (25%)

3 (11%)

Independent

13 (47%)

19 (68%)

Transferring

from bed to chair

Unable to transfer, no balance

5 (17%)

4 (14%)

p=0.0069

More physical help

9 (32%)

3 (10%)

Less physical help

10 (36%)

5 (18%)

Independent

4 (15%)

16 (58%)

Personal hygiene

Needs help

13 (46%)

7 (25%)

p=0.1625

Independent

15 (54%)

21 (75%)

Toilet use

Dependent

9 (32%)

3 (11%)

p=0.0009

Needs help, but can do it unassisted

11 (39%)

3 (11%)

Independent

8 (29%)

22 (78%)

Bathing, washing entire body

Dependent

13 (46%)

5 (18%)

p=0.0437

Independent

15 (54%)

23 (82%)

Mobility

Cannot ambulate

10 (36%)

5 (18%)

p=0.0018

Independent in a wheelchair

7 (25%)

5 (18%)

Walking with verbal or

physical help

8 (29%)

2 (7%)

Independent, but may

need help

3 (10%)

16 (57%)

Going up and

down the stairs

Unable to use stairs

9 (32%)

7 (25%)

p=0.2563

Needs physical help and

support

14 (50%)

10 (36%)

Independent

5 (18%)

11 (39%)

Dressing and

undressing

Dependent

8 (28%)

4 (14%)

p=0.1066

Needs some help

10 (36%)

6 (22%)

Independent

10 (36%)

18 (64%)

Faecal

continence/anal

sphincter control

Incontinent

9 (32%)

6 (22%)

p=0.0499

Occasional accidents

10 (36%)

4 (14%)

Faecal continence

9 (32%)

18 (64%)

Urinary

continence

Incontinent

11 (39%)

8 (28%)

p=0.0764

Occasional accidents

11 (39%)

6 (22%)

Urinary continence

6 (22%)

14 (50%)

Table. IV. Changes in subjective status assessed before and after physical therapy and rehabilitation

Health problems

Before

After

Patient reports no improvement

12 (86%)

0 (0%)

Patient reports slight improvement

2 (14%)

4 (29%)

Marked improvement

0 (0%)

10 (71%)

Table. V. Changes in objective status assessed before and after rehabilitation.

Health problems

Before

After

Patient reports no improvement

10 (71%)

3 (21%)

Patient reports slight improvement

4 (29%)

5 (36%)

Marked improvement

0 (0%)

6 (43%)