To establish the effect of task oriented group circuit training for people affected by stroke in the public healthcare sector in RSA
Year: 2013
Type: dissertation
Abstract: Stroke remains a serious public health problem in low, middle and high income countries worldwide. In \nlow and middle income countries there has been a greater than 100% increase in stroke incidence. \nThe impact of HIV associated vasculopathy is recognized as contributing to the increased prevalence \nof stroke in younger patients (Tipping et al., 2007) and is an independent risk factor for stroke (Cole et \nal., 2004). The impact of this increased stroke incidence has not only resulted in an increase in death \nrates in the developing world, but has also resulted in increases noted in long term disability as a \nresult of stroke. \nThe available resources for stroke care and rehabilitation are lacking in developing countries including \nAfrica, particularly in rural areas. It has also been noted that 80% of the population live in areas where \nfactors such as limited resources and cultural practices limit access to stroke services (Poungvarin \n1998). Currently patients with stroke are discharged from hospitals in the public healthcare sector \nwithin six to 14 days of having a stroke, because of the pressure for beds (Mudzi, 2009; Reid et al., \n2005; Hale, 2000). As a result patients are not benefitting from rehabilitation services and this leads to \nsuboptimal recovery post stroke and to a large number of persons living with disabilities in under \nresourced communities. Because the patients with stroke are discharged so acutely after their stroke, \ncarers become a necessity to cope with the burden of care. These conditions result in increased \nstroke survivor dependence in South Africa compared to the USA or New Zealand. \nWhile 80% of stroke survivors who are initially unable to walk achieve independent walking \n(Jorgensen et al., 1995), at three months post stroke 25%-33% still require assistance or supervision \nwhen walking (Jorgenson et al., 1995; Duncan et al., 1994; Richards et al., 1993). Unfortunately these \nindependent walkers seldom achieve walking speeds that are sufficient for community ambulation \n(Schmid et al., 2007; Lord and Rochester, 2005; Lord et al., 2004). Walking competency is a term \nused to describe a certain level of walking ability allowing an individual to participate in the community \nsafely and efficiently (Salbach et al., 2004). It should also be noted that even those with mild and \nmoderate strokes experience limitations with higher physical functioning which impacts on their quality \nof life and ability to return to work (Duncan and Lai, 1997). \nThe cerebral cortex has the ability to undergo functional and structural reorganization for several \nweeks and even months in more severe cases post stroke. Rehabilitation post stroke facilitates this \nprocess and can shape the reorganization of the adjacent intact cortex (Green, 2003). Further, it has been concluded that to facilitate the best possible functional outcome for people post stroke, \nengagement in intensive task oriented therapy is necessary (Kwakkel et al., 2004; Van Peppen et al., \n2004). Considering these findings it is extremely concerning that there is little or no rehabilitation \nprovided to stroke survivors in the public healthcare sector in South Africa (Mudzi, 2009; Rhoda and \nHendry 2003; Hale and Wallner, 1996; Stewart et al., 1994). \nWith this in mind, the aim of this study was to determine if an out -patient based task oriented group \ntraining programme would promote improved walking competency more than the current progressive \nresistance strength group training programmes that are common practice in persons who have had an \nacute stroke in the public healthcare system in South Africa. The specific objectives of this study were \nto establish the effect of a low intensity, namely once a week (for six weeks), out- patient based task \nprogramme on: walking competency, walking endurance, gait speed and health status in terms of \nphysical functioning in persons with sub-acute stroke. Due to the high incidence of post stroke \nsurvivors with HIV it was important to establish if the training programme produced comparable effects \nin HIV positive and HIV negative subjects. \nThis study used a stratified blocked randomised controlled trial design. Where group allocation was \nconcealed. In addition assessor blinded evaluations were conducted at baseline, post intervention and \nat six months after the intervention had ceased. A total of 144 persons who had a stroke were \nstratified according to their walking speed – mild (able to walk at a gait speed > 0.8m/s), moderate \n(able to walk at a speed of 0.4-0.8 m/s) or severe (able to walk at a speed < 0.4m/s) – and randomly \nassiged to one of three training groups. One group received task oriented group circuit training (task \ngroup), the second group received progressive resistance strength training (strength group), and the \nthird group participated in one multidisciplinary education group training session (control group). The \ntask and strength interventions included 6 sessions, of 60 minutes each for six to 12 weeks. While the \ncontrol intervention group participated in one three hour education session, which included advice on \nthe importance of exercise and a 20-minute exercise session. All subjects had been discharged from \nthe public healthcare sector and were less than six months post stroke at inclusion into the study. The \nprimary objective was walking competency, which included the measurement of walking endurance, \ngait speed, functional balance and mobility (Salbach et al., 2004). The task group showed an \nimprovement that was significantly greater than that achieved by the strength and control groups in \nwalking endurance, gait speed, functional mobility and balance at the follow-up. These findings \ndemonstrate that the provision of as little as six sessions of task training (in a developing country, \nwhere persons with sub-acute stroke have had no previous rehabilitation) improves walking \ncompetency to a significantly greater extent than either a strength intervention of equal intensity, or a control intervention programme consisting of one three hour education visit in the sub -acute phase \npost stroke. While the strength group received a more frequent and intensive training compared with \nthe control group, there were no significant differences in terms of walking competency between these \ntwo groups over the study period. \nThe task group showed significantly greater improvements in walking endurance, comfortable and \nmaximum gait speed than the strength and control groups immediately post intervention. While post \nintervention, the task training led to superior gains in functional mobility and balance compared to the \ncontrol group, it was not superior to the strength group. \nFor subjects, with a moderate gait disability at baseline, the improvements in walking endurance and \nin comfortable and maximum walking speed in the task group were significantly more than the \nstrength and control groups. For subjects with a severe gait deficit at baseline, the task group \nimproved significantly more than the control group on all measures of walking competency but not \nsignificantly more than the strength group. There were no significant differences among the groups for \nsubjects with a mild gait deficit at baseline. \nAll three treatment intervention groups improved their score on the stroke impact scale 16 (SIS 16) \nover the course of the study period. The task group improved significantly more than the control \ngroup’s health status in terms of physical functioning measured by the SIS16. There were no \nsignificant differences among the groups in the change scores for the measures of walking \ncompetency between the HIV positive and HIV negative subjects throughout the study period. \nThe results of this study demonstrate that an extremely limited number of task training sessions \nresulted in significantly greater improvements in walking competency than progressive strength \ntraining or a multidisciplinary education training approach. However, these results must be interpreted \nwith caution, remembering the context of the sample population who had not received a period of inpatient \nrehabilitation prior to their inclusion into the study and were 10-15 years younger than subjects \nin numerous other studies. This appears to be the first study conducted with such a limited \nrehabilitative intervention post stroke. As a result, further research to evaluate the effectiveness of \nlimited intensity task oriented training interventions for non -ambulant stroke survivors in the \ndeveloping world where resources are limited, needs to be conducted. It is important to explore the \nbenefits of different group based rehabilitative interventions for stroke survivors to alleviate the burden \nas a result of disability as much as possible. \nKey words: Stroke, Task Oriented, Rehabilitation, Walking, Walking Competency
Author: Megan Claire Ballington
Language: English
Subfield: Rehabilitation
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2108334796