Effectiveness of an innovative home-based rehabilitation program on lower limb functions in subjects with chronic stroke : a randomized, controlled trial

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Effectiveness of an innovative home-based rehabilitation program on lower limb functions in subjects with chronic stroke : a randomized, controlled trial


Author: Ng, Sheung-mei Shamay
Title: Effectiveness of an innovative home-based rehabilitation program on lower limb functions in subjects with chronic stroke : a randomized, controlled trial
Degree: Ph.D.
Year: 2005
Subject: Hong Kong Polytechnic University -- Dissertations
Cerebrovascular disease -- Patients -- Rehabilitation -- Evaluation
Cerebrovascular disease -- Patients -- Home care -- Evaluation
Leg -- Rehabilitation -- Evaluation
Department: Dept. of Rehabilitation Sciences
Pages: xxiv, 281 leaves : ill. ; 30 cm
Language: English
InnoPac Record: http://library.polyu.edu.hk/record=b1809972
URI: http://theses.lib.polyu.edu.hk/handle/200/1857
Abstract: The aim of the work presented in this thesis was to develop an innovative home-based rehabilitation program in order to reduce spasticity, improve muscle strength of affected lower extremity and improve locomotor capacities in subjects with chronic stroke. Two series of studies were undertaken in this thesis. The pilot study sought to quantify the reliability of the 5 outcome measures used in the main study. The main study investigated the efficacy of 3 active home-based treatment programs versus no active treatment on the motor recovery of lower extremity functions in subjects with chronic stroke. In the pilot study, 10 healthy elderly (mean age 63.5 +- 6.1 years) and 11 stroke subjects (mean age 61.1 +- 6.8 years) at least 1 year post-stroke (mean duration after stroke onset 5.6 +- 3.3 years) underwent 5 assessments: spasticity of ankle planatrflexor by the Composite Spasticity Scale, ankle muscle strength by maximum isometric voluntary contraction (MIVC) of ankle dorsi- and plantar-flexors, gait performance by the GAITRite Walkway System, walking endurance by the 6-Minute Walk test (6 MW) and the functional mobility by the timed "Up & Go" test (TUG). High test-restest repeatability were found in the measurements for spasticity of ankle planatrflexors (ICCs=0.40 to 0.94), MIVC of ankle dorsi- and plantar-flexors (ICCs=0.47 to 0.99), temporal spatial gait parameters (ICCs=0.36 to 1.00), distance covered in 6 MW (ICCs=0.91 to 0.98) and TUG scores (ICCs=0.95 to 0.97). Our findings also showed that subjects with chronic stroke had a significantly higher level of spasticity in their affected ankle plantarflexors, weaker planatrflexors, slower walking speed, poorer walking endurance and decreased functional mobility when compared with those of the healthy elderly. Strong relationships were found between TUG scores on the one hand, and strength of plantarflexors (r=-0.91, P<0.01), gait velocity (r=-0.86, P<0.01), and walking endurance assessed by the 6 MW (r=-0.93, P<0.01) on the other. These findings make the TUG test particularly useful for assessing functional mobility in ambulant patients with chronic stroke. For the main study evaluating the effectiveness of 3 home-based programs versus no active treatment in improving lower limb functions in subjects with stroke, a single-blinded placebo-controlled design was used. Eighty-eight subjects with chronic stroke (mean age 57.3 +- 8.1 years; mean duration after stroke onset 5.3 +- 3.5 years) were randomly allocated into 1 of 4 groups: TENS, TENS+TRT (task-related training), placebo-TENS (PLBO)+TRT, and control groups. Subjects in the 3 intervention group underwent the treatment program allotted once a day, 5 days a week for 4 weeks, while the control group received no active treatment. The 5 outcome measures mentioned above were assessed before (T0) and after (T1) treatment on Day 1; after 2 weeks (T2) and 4 weeks of treatment (T3); and at 4-weeks follow-up after treatment ended (TFU). The results showed no significant differences among the groups before treatment. The 2 TENS (TENS and TENS+TRT) groups produced significantly earlier reduction of plantarflexor spasticity (from T2on) and greater increase of peak dorsiflexion torque after 20 treatment sessions than the PLBO+TRT group, when compared with those of the control group (P<0.05). Only the 2 exercise (TENS+TRT and PLBO+TRT) groups maintained the increase in peak dorsiflexor torque 4 weeks after treatment ended. For plantarflexion, only the 2 exercise (TENS+TRT and PLBO+TRT) groups but not the TENS group had significant % increases in peak plantarflexion torque, IEMG of the MG muscle and reduction of EMG co-contraction ratio after 4 weeks of treatment, when compared with those of the control group. It is important to note that only the combined TENS+TRT group maintain most of the treatment effects 4 weeks after the treatment ended. With regard to locomotor capacities, the combined TENS+TRT group demonstrated significantly greater % increase in gait velocity at the end of the 4-week treatment, when compared with that of the other 3 (TENS, PLBO+TRT and control) groups (all P<0.01). Accompanying the increase in gait velocity, significant among-group increases in cadence, step and stride length, stance time, single-leg support duration and decrease of double-leg support duration were found (P<0.05). The same combined TENS+TRT group also demonstrated significantly greater % increase of the distance covered in 6 MW and % decrease of the TUG time scores than those of the TENS and control groups (P<0.01). To conclude, this thesis demonstrated that all 3 home-based rehabilitation programs involving TENS and/or task-related training is feasible and effective in reducing spasticity and in improving aspects of muscle functions in patients with stroke. The results further demonstrated that 20 sessions of combined TENS+TRT treatment was superior to either TENS alone or PLBO+TRT in enhancing the recovery of lower limb functions in chronic stroke survivors. Since the home program requires only minimal supervision from professional physiotherapists, it has the added benefit of being cost-effective to the patients and the society at large.

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