Author: Shiu, Hau Yee Clara
Title: Turning ability (timed 360° turn test) in patients with chronic stroke
Advisors: Ng, Shamay (RS)
Degree: DHSc
Year: 2019
Subject: Hong Kong Polytechnic University -- Dissertations
Cerebrovascular disease -- Patients -- Rehabilitation
Gait in humans
Department: Faculty of Health and Social Sciences
Pages: xxvii, 182 pages : color illustrations
Language: English
Abstract: The ability to turn safely is vital for people with chronic stroke as turning is an unavoidable maneuver in daily life especially in a heavily populated city like Hong Kong where living space is limited. A specific and reliable test for measuring turning ability in people with chronic stroke is essential to investigate the prevalence of turning difficulties in this population. As the ultimate goal of stroke rehabilitation is to help stroke survivours to reintegrate into the community, factors influencing their ability to perform Instrumental Activities of Daily Living (IADL) warrant special attention. Investigation of the relationship between turning ability and their performance in Instrumental Activities of Daily Living (IADL) is indispensable so as to have a better understanding on factors that contribute to performance of stroke survivours in the community. Research has been directed to put turning as part of the functional mobility and balance performance assessment, limited study has investigated the 360° turning ability in people with stroke and its association with other stroke specific impairments. On the other hand, previous studies have shown that motor function of lower limbs, walking tolerance, depression symptoms, as well as age significantly correlated to the performance of IADL in people with stroke. No study has been trying to look into the contribution of turning ability on their performance of IADL in stroke survivours. Two cross-sectional studies were undertaken in this thesis. Study 1 was discussed in Chapter 3 and Chapter 4. It looked into the reliability and validity of timed 360 turn test in stroke survivour. Minimal Detectable Change (MDC) value of timed 360° turn test in people with chronic stroke and cut-off scores of timed 360° turn test which could distinguish the performance between people with stroke and healthy older adults was also investigated. A total of 72 participants were recruited through poster advertisement. It comprises (1) 37 subjects with stroke (26 male, 11 female) of a mean age of 62.0 years and a mean years since stroke of 7.8 years from a local self-help group, and (2) 35 healthy older subjects (11 male, 24 female) with a mean age of 64.3 years from the community centres. All subjects with stroke were assessed in two different sessions separated with a time interval of 7 to 10 days. Timed 360° turn test was assessed simultaneously by two experienced assessors (Assessor A and Assessor B). The stroke specific impairments namely, Fugl-Meyer lower extremity assessment (FMA-LE), maximum isometric muscle strength of ankle dorsi-flexors and plantar-flexors, Berg Balance Scale (BBS), Five Time Sit to Stand (FTSTS) Test, 10-Meter Walk Test (gait speed m/s), Timed "Up and Go" (TUG) test times as well as Limit of Stability test were assessed in a random order by either Assessor A or Assessor B. In Session Two, only timed 360° turn test were assessed with same procedures as Session One. For the healthy older adults, three trials of timed 360° turn tests were assessed towards both dominant and non-dominant side in one session only. Their dominant leg was determined by asking them to kick a ball without specific instruction and the leg they used to kick the ball was their dominant leg. The mean 360° turn times for subjects with stroke towards the affected side and unaffected side was 4.38s ± 1.17s and 4.65s ± 1.45s respectively and there was no significant difference between the values. Excellent intra-rater reliability (ICC = 0.912-0.961) for both raters irrespective of turning towards affected or unaffected side. There was also excellent inter-rater reliability (ICC = 0.888-0.993) between rater A and B for both turning towards affected and unaffected side. Excellent test-retest reliability (ICC= 0.824-0.951) was also found for both raters. The MDC value calculated in this study was 0.759 seconds for turning towards affected side and 1.22 seconds for turning towards unaffected side, which represents the minimal change needed to reflect the true change in the 360° turn times. The 360° turn times showed significant negative correlation with FMA-LE scores ( r = -0.501, -0.462; p < 0.05), maximum isometric strength of dosiflexor of affected ankle (r = -0.505; -0.542; p = 0.001), maximum isometric strength of plantarflexors of the both ankles ( r = -0.419; -0.434, r = - 0.508; -0.481; p < 0.05), BBS scores (r = -0.758, -0.770; p < .001), MXE of LOS (r = -0.360, - 0.399; p < 0.05) towards the affected side as well as 10-MWT (r = -0.662, -0.684; p < .001). The 360° turn times showed significant positive correlation with TUG completion times (rs = 0.759, 00.707; p < 0.001) and FTSTST (rs = 0.560, 0.498; p < 0.001). The mean 360° turn times for the healthy subjects towards the non-dominant and dominant side were 2.53s ± 1.04s and 2.49s ± 1.06s respectively. With timed 360° turn test towards unaffected side, a cut-off score of 3.49s was found to give the best distinction between the healthy subjects and subjects with stroke (sensitivity = 84%, specificity = 91%, AUC = 0.930, p ≤ 0.000). On the other hand, for the test turning towards the affected side, a cut off score of 3.43s was found to give the best distinction between the two group of subjects (sensitivity = 84%, specificity = 89%, AUC = 0.926, p ≤ 0.000).
Study 2 is the main study and was discussed in chapter 5. It looked into the prevalence of turning difficulties and performance of IADL in stroke survivours recruited. It also investigated the correlation of demographic data, motor function of lower limb, Geriatric Depression Scale (GDS), The Activities-specific Balance Confidence (ABC) Scale, Six Minutes Walk Test (6MWT), timed 360° completion time with performance of IADL in stroke survivours. The independent contribution of 360° completion time to performance of IADL in people with chronic stroke was also scrutinized. A total of 75 community dwelling stroke survivours comprising 48 men and 27 women were recruited from local self-help groups through advertisement. The mean age of the participants was 61.35 ± 7.07 years. They had an average of 8.19 ± 4.08 years post-stroke. With reference to the cut-off scores produced in study 1, only 8 out of 75 stroke survivours in this study achieved a turning time below or equal to the cut off score while turning towards the unaffected side (3.49 seconds) and only 6 out of 75 achieved a turning time below or equal to the cut off score while turning towards the affected side (3.43 seconds). This reflects that amount to 89 to 92% of community dwelling stroke survivours in this study has turning difficulties. Regarding the performance of their IADL. The mean Lawton ADL scores was 14.41 ± 2.94. Seven subjects (9%), who scored full score of 18, were independent in all IADL. Twelve subjects (16%), who scored 17 out of 18, needed assistance in one activity. Ten subjects (around 13%), who scored 16 out of 18, needed assistance in one or two activities. The other 46 (around 62%) subjects, who scored 15 or less, needed assistance on 2 or more activities. No significant correlation was found between Lawton ADL scores and age, BMI, chronicity of stroke, AMT scores and frequency of fall in the previous six months. Highest significant negative correlation was found between average 360° turn times and Lawton ADL scores (r = -.642, p ≤ 0.001). Significant correlation was also found between the Lawton ADL scores and 6 MWT (r = .446, p ≤ 0.001), BBS scores (r = .475, p ≤ 0.001), ABC scores (r = .517, p ≤ 0.001) as well as GDS scores (r = -.382, p ≤ 0.001). FMA-LE was only approaching a significant correction with Lawton IADL scores after Bonferroni correction was done. After controlling for FMA and GDS scores, significant partial correlation was found between Lawton ADL scores and ABC scores (r = .324, p ≤ 0.017) and average 360° turn times (r = -.516, p ≤ 0.003) while partial correlation between Lawton IADL and 6MWT was not significant. A combined multiple linear regression model including the FMA-LE scores, GDS scores, 6MWT distance, ABC scores and average 360° turn times predicted a total of 43.9% (F1, 69 = 12.563, p ≤ 0.001) of the variance in the Lawton ADL scores. After adjusting for the other variables, the average 360° turn times remained independently associated with the Lawton ADL scores, accounting for 12.2% of the variance, and model prediction significantly improved (F change, 16.069; p ≤ .001). The average 360° turn times were the best predictor of Lawton ADL scores as indicated by the magnitude of the standardized regression coefficient ( β = -0.525, p ≤ .001) and the highest Pearson correlation coefficient (r = -0.642, p ≤ .001). In summary, timed 360° turn test is a reliable and valid test for assessing the turning ability of stroke survivours in Hong Kong. It is also the most potent predictor of performance in their IADL. It was also found that prevalence of turning difficulties is high in stroke survivours. To conclude, turning is vital for stroke survivours in Hong Kong. With limited living environment, the amount of turning in daily life is profound. Timed 360° turn test is an easy-administered but reliable and valid test for assessing the turning ability of stroke survivours. It is also the most potent predictor of performance of their IADL. Results of the studies shed light on our present knowledge in stroke rehabilitation.
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