Neurological Rehabilitation 6e NEUROLOGICAL REHABILITATION UMPHRED .pdf |BEST|
Barbra Mothershed
Stroke is one of the major causes of permanent disability1. Stroke can have many causes and occurs mainly in old age, although it can occur at any age2. Most stroke survivors can perform limited activities of daily living (ADL) due to motor, sensory, emotional, and cognitive impairments3. Stroke patients commonly exhibit symptoms of hemiplegia and thus, as a result, have defects in voluntary movements, asymmetrical weight-shifts, gait, and body balance4. Stroke patients have decreased balance ability due to their centre of gravity shifting towards the unaffected side4. In the standing posture, approximately 61% to 80% of their body weight is concentrated on the unaffected lower extremity5. Due to these asymmetric postures, stroke patients may have frequent falls, limited independent gait, and reduced gait velocity6. This asymmetric gait in hemiplegic patients may cause reduced bone density on the affected side and an overall increase in energy expenditure on walking7,8. In addition to normal walking, stroke survivors fall during transfers between beds and the wheelchair and during standing turns9,10. These gait dysfunctions after stroke are the main cause of impaired functional ambulation, which in turn causes decreased social participation and poor quality of life. Therefore, enhancing the tolerance and capability to bear weight on the affected lower extremity and achieving good body balance during various functional activities and symmetric gait patterns are the main goals of rehabilitation for stroke patients11,12,13.
Neurological Rehabilitation 6e NEUROLOGICAL REHABILITATION UMPHRED .pdf
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A combination of cognitive, emotional, sensory, and motor impairments occurs in patients after stroke26. These impairments limit the ability of stroke survivors to perform basic ADL3. 80% of patients with early-stage stroke lose their walking ability and begin to recover in 6 months. Stroke survivors commonly show hemiplegia symptoms leading to asymmetric weight-shifts, gait and body balance, and impaired voluntary movements. Their ability to bear weight on the paretic limb is impaired17. In stroke patients, the paretic limb has reduced ability of weight-shifting in three directions of a step, i.e. forward, backward and lateral and particularly greater loss in the forward direction17. Weight-bearing by the lower limbs is necessary for normal functional mobility in various directions and positions17. All these impairments, along with muscle weakness and loss of coordination, lead to gait dysfunction and reduced balance ability27. All these dysfunctions lead to decreased gait velocity, hampered independent gait, and may lead to falls6. Therefore, in patients with hemiplegic stroke, they must be confident that the lower limb of the affected side are ready and trained to bear the full body weight and generate the necessary muscle force to match the speed of the unaffected side28. Therefore, a few main goals of post-stroke rehabilitation are to enhance the weight-bearing capability and tolerance of the paretic limb during different tasks and to enhance the gait symmetry and independent gait thereby improving stroke patients' functions and social activities11,29.
Most studies that have been conducted on the improvement of balance and functional gait performance in stroke population have used lavish equipment like force plate systems, gyroscopes etc. However, the exercises performed in the present study are extremely easy and convenient to follow up even in a community step-up without any use of appliances. Therefore, the physical therapist may consider adding MSE along with weight-shifting to the CTE program of stroke rehabilitation as it does not require sophisticated equipment and can easily be performed by stroke patients.
There is some scope for future studies and limitations in the present study. Firstly, stroke patients, irrespective of their disease duration, were recruited for the study. Acute stroke patients may respond differently to exercise protocol than chronic stroke patients. Also, depending upon the side, site and severity of the lesion in the brain, participants' responses to exercises may differ. Therefore, future studies may consider these factors while recruiting participants and designing their protocol. The sample size was not large, and no long-term follow-up was performed. Improvements gained with the addition of MSE and weight-shifting may be temporary and short-lived; therefore, future studies should include a long-term follow-up with large sample size. At the time of data collection, the PT examiner missed taking the participants' height, weight, and BMI values. These demographic data could have provided additional information on the association of height, weight, and BMI with stroke patients' recovery and functional progress. In the present study, balance and gait performance were measured without sophisticated equipment; future studies should use equipment such as force plates and gait analyzers to assess balance and gait performance more accurately and precisely. Future studies may explore the role of MSE in other neurological disorders where normal balance and gait are affected, e.g. cerebral palsy.