Stroke remains a serious public health problem in low, middle and high income countries worldwide. In
low and middle income countries there has been a greater than 100% increase in stroke incidence.
The impact of HIV associated vasculopathy is recognized as contributing to the increased prevalence
of stroke in younger patients (Tipping et al., 2007) and is an independent risk factor for stroke (Cole et
al., 2004). The impact of this increased stroke incidence has not only resulted in an increase in death
rates in the developing world, but has also resulted in increases noted in long term disability as a
result of stroke.
The available resources for stroke care and rehabilitation are lacking in developing countries including
Africa, particularly in rural areas. It has also been noted that 80% of the population live in areas where
factors such as limited resources and cultural practices limit access to stroke services (Poungvarin
1998). Currently patients with stroke are discharged from hospitals in the public healthcare sector
within six to 14 days of having a stroke, because of the pressure for beds (Mudzi, 2009; Reid et al.,
2005; Hale, 2000). As a result patients are not benefitting from rehabilitation services and this leads to
suboptimal recovery post stroke and to a large number of persons living with disabilities in under
resourced communities. Because the patients with stroke are discharged so acutely after their stroke,
carers become a necessity to cope with the burden of care. These conditions result in increased
stroke survivor dependence in South Africa compared to the USA or New Zealand.
While 80% of stroke survivors who are initially unable to walk achieve independent walking
(Jorgensen et al., 1995), at three months post stroke 25%-33% still require assistance or supervision
when walking (Jorgenson et al., 1995; Duncan et al., 1994; Richards et al., 1993). Unfortunately these
independent walkers seldom achieve walking speeds that are sufficient for community ambulation
(Schmid et al., 2007; Lord and Rochester, 2005; Lord et al., 2004). Walking competency is a term
used to describe a certain level of walking ability allowing an individual to participate in the community
safely and efficiently (Salbach et al., 2004). It should also be noted that even those with mild and
moderate strokes experience limitations with higher physical functioning which impacts on their quality
of life and ability to return to work (Duncan and Lai, 1997).
The cerebral cortex has the ability to undergo functional and structural reorganization for several
weeks and even months in more severe cases post stroke. Rehabilitation post stroke facilitates this
process 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,
engagement in intensive task oriented therapy is necessary (Kwakkel et al., 2004; Van Peppen et al.,
2004). Considering these findings it is extremely concerning that there is little or no rehabilitation
provided to stroke survivors in the public healthcare sector in South Africa (Mudzi, 2009; Rhoda and
Hendry 2003; Hale and Wallner, 1996; Stewart et al., 1994).
With this in mind, the aim of this study was to determine if an out -patient based task oriented group
training programme would promote improved walking competency more than the current progressive
resistance strength group training programmes that are common practice in persons who have had an
acute stroke in the public healthcare system in South Africa. The specific objectives of this study were
to establish the effect of a low intensity, namely once a week (for six weeks), out- patient based task
programme on: walking competency, walking endurance, gait speed and health status in terms of
physical functioning in persons with sub-acute stroke. Due to the high incidence of post stroke
survivors with HIV it was important to establish if the training programme produced comparable effects
in HIV positive and HIV negative subjects.
This study used a stratified blocked randomised controlled trial design. Where group allocation was
concealed. In addition assessor blinded evaluations were conducted at baseline, post intervention and
at six months after the intervention had ceased. A total of 144 persons who had a stroke were
stratified according to their walking speed – mild (able to walk at a gait speed > 0.8m/s), moderate
(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
assiged to one of three training groups. One group received task oriented group circuit training (task
group), the second group received progressive resistance strength training (strength group), and the
third group participated in one multidisciplinary education group training session (control group). The
task and strength interventions included 6 sessions, of 60 minutes each for six to 12 weeks. While the
control intervention group participated in one three hour education session, which included advice on
the importance of exercise and a 20-minute exercise session. All subjects had been discharged from
the public healthcare sector and were less than six months post stroke at inclusion into the study. The
primary objective was walking competency, which included the measurement of walking endurance,
gait speed, functional balance and mobility (Salbach et al., 2004). The task group showed an
improvement that was significantly greater than that achieved by the strength and control groups in
walking endurance, gait speed, functional mobility and balance at the follow-up. These findings
demonstrate that the provision of as little as six sessions of task training (in a developing country,
where persons with sub-acute stroke have had no previous rehabilitation) improves walking
competency 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
post stroke. While the strength group received a more frequent and intensive training compared with
the control group, there were no significant differences in terms of walking competency between these
two groups over the study period.
The task group showed significantly greater improvements in walking endurance, comfortable and
maximum gait speed than the strength and control groups immediately post intervention. While post
intervention, the task training led to superior gains in functional mobility and balance compared to the
control group, it was not superior to the strength group.
For subjects, with a moderate gait disability at baseline, the improvements in walking endurance and
in comfortable and maximum walking speed in the task group were significantly more than the
strength and control groups. For subjects with a severe gait deficit at baseline, the task group
improved significantly more than the control group on all measures of walking competency but not
significantly more than the strength group. There were no significant differences among the groups for
subjects with a mild gait deficit at baseline.
All three treatment intervention groups improved their score on the stroke impact scale 16 (SIS 16)
over the course of the study period. The task group improved significantly more than the control
group’s health status in terms of physical functioning measured by the SIS16. There were no
significant differences among the groups in the change scores for the measures of walking
competency between the HIV positive and HIV negative subjects throughout the study period.
The results of this study demonstrate that an extremely limited number of task training sessions
resulted in significantly greater improvements in walking competency than progressive strength
training or a multidisciplinary education training approach. However, these results must be interpreted
with caution, remembering the context of the sample population who had not received a period of inpatient
rehabilitation prior to their inclusion into the study and were 10-15 years younger than subjects
in numerous other studies. This appears to be the first study conducted with such a limited
rehabilitative intervention post stroke. As a result, further research to evaluate the effectiveness of
limited intensity task oriented training interventions for non -ambulant stroke survivors in the
developing world where resources are limited, needs to be conducted. It is important to explore the
benefits of different group based rehabilitative interventions for stroke survivors to alleviate the burden
as a result of disability as much as possible.
Key words: Stroke, Task Oriented, Rehabilitation, Walking, Walking Competency
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/12559 |
| Date | 19 March 2013 |
| Creators | Ballington, Megan Claire |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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