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CLINICAL STUDIES / ETUDES CLINIQUES
 
SOME CLINICAL AND PSYCHOSOCIAL DETERMINANTS OF INDEPENDENT WALKING ATTAINMENT BY POST STROKE PATIENTS

FACTEURS CLINIQUES ET PSYCHOLOGIQUES INTERVENANT DANS L’AUTONOMIE DE LA MARCHE APRÈS UN ACCIDENT VASCULAIRE CÉRÉBRAL


  1. Department of Physiotherapy, College of Medicine, University of Ibadan, Nigeria

E-Mail Contact - HAMZAT Tal-hatu Kolapo : tkhamzat (at) comui (dot) edu.ng


ABSTRACT

Background
It is not uncommon for post stroke patients or their caregivers to ask the attending physiotherapist when the patient would regain ability to walk. This is often difficult to predict as many clinical and non-clinical factors influence when this function is accomplished.

Objective
To investigate the influence of some clinical and psychosocial factors on the time post stroke individuals commence independent walking.

Methods
The one-group, pre-experimental study carried out in a teaching hospital facility involved 27 (14 males and 13 females) fully conscious, unilateral, first-episode stroke patients admitted to the facility and referred for physiotherapy over 5 months. A daily, structured physiotherapy care including Bobath technique was administered on the patients for 12 weeks. Ages, marital status, years of formal education, occupation, personality type (Eysenck classification), level of disability, co-morbid factors and admission-referral interval were obtained. Main outcome measure was time taken to attain ability to walk a continuous, level floor 10m distance unaided.

Results
The mean time independent walking was attained was 7.4 ± 2.6 weeks. Participants with mild disability level at baseline commenced independent walking significantly earlier (4.00 ± 0.01 weeks) than those with moderate disability (7.72 ± 2.53 weeks). Independent walking attainment time showed no significant difference (p>0.05) across the psychosocial factors. A significant relationship were found between age (r = - 0.57), functional independence measure (r = - 0.55) and commencement of independent walking.

Conclusion
Age and the initial level of disability had significant influence on commencement of independent walking by the participants.

Key Words: Africa, Independent Walking, Psychosocial, Stroke


RESUME

Introduction
Il n’est pas inhabituel pour les patients victimes d’un accident vasculaire cérébral (AVC) et pour leur soignants, de demander aux rééducateurs fonctionnels le délais permettant la reprise de la marche. Ce délai est souvent difficile à prévoir compte tenu des facteurs multiples, à la fois cliniques et non cliniques intervenant dans cette fonction motrice.

Objectif
L’objectif est de définir quelques facteurs cliniques et psychologiques influençant la durée de récupération post-AVC permettant l’autonomie de la marche.

Méthodes
Un groupe préliminaire a été étudié dans un centre hospitalier universitaire et concernaient 27 patients (17 mâles et 13 de sexe féminin) conscients, présentant un déficit unilatéral après un premier épisode d’accident vasculaire. Il ont été suivis dans un centre de physiothérapie durant cinq mois. Une prise en charge quotidienne incluant la technique de Bobath a été instituée pendant douze semaines. Les paramètres suivants ont été étudiés : âge, statut marital, niveau de formation et d’éducation, profession, personnalité (classification d’Eysenck), degré d’invalidité, facteurs de co-morbidité, et de délai de prise en charge. La principale mesure attestant de la capacité à marcher de manière continue a été une marche continue, sur distance plane de 10 mètres, sans aide.

Résultats Le temps moyen de reprise de la marche sans aide était de 7.4 ± 2.6 semaines. Les patients avec un handicap moyen ont eu une récupération plus précoce modéré (4.00 ±0.01 semaines) que ceux qui avaient un handicap (7.72 ± 2.53 semaines). Les facteurs psychosociaux n’étaient pas significatifs (p>0.05). Une relation a été objectivée entre l’âge (r = - 0.57), le degré d’indépendance (r = - 0.55), et le début de la marche de manière autonome.

Conclusion
L’âge et le degré d’invalidité avaient une influence significative sur le délai de reprise d’une marche autonome.

Mots clé : Accident vasculaire cérébral, Afrique, Autonomie, facteurs psychosociaux, Marche, Nigéria, Réeducation fonctionnelle.

INTRODUCTION

Stroke is an important cause of long-term disability worldwide, as it results in considerable impairment of sensory, motor, mental, perceptual and language functions [11]. Loss of mobility, major motor function impairment in this group of patients, is closely related to specific medical and non-medical factors such as age 75 years and above, and existence of cognitive disorders [9]. Interventions to improve motor function and mobility therefore forms an important component of stroke management and rehabilitation lead to improved movement pattern regardless of sex, co-morbidity and initial severity of stroke [10].

Independent walking is often used as an indicator of functional recovery in stroke. It is not uncommon for the stroke patients or their carers to ask the Physiotherapist managing the patient when s/he would regain ability to walk. The time this level of function will be attained is usually difficult to predict as many clinical and non-clinical factors such as socio-demographic attributes [2] exert significant influence on stroke outcome, including when the patient would commence independent walking. For example, a study by Warlow [13] had concluded that age; initial mild deficit and early resolution of symptoms, as well as absence of cognitive impairment are good prognostic signs at two weeks post stroke. A retrospective study had also observed that the neurological outcome of stroke was poorer in patients who have diabetes mellitus as co-morbidity than those without [4]. Psychological problems such as mood disorders are reported to have negative impact on rehabilitation outcome [12], while socio-cultural issues like gender-based traditional roles and responsibility assignment practice, as may be found in some cultures including Africans, have also been identified to have potentially significant influence on a post stroke individual in terms of motivation to become independent.

Whereas various studies have been carried out on mobility after stroke, there is paucity of an individual study that considered how some clinical and psychological factors influence the time taken to recover independent walking by individuals who have suffered a stroke. This study was aimed at investigating the possible influence of selected psychosocial and clinical factors on commencement of independent walking in individuals who have suffered a stroke. Specifically this study considered the possible influence of age, marital status, educational qualification, occupation, personality type, disability status, and co-morbidity on recovery of this functional ability. Independent walking was defined in this study as ability to walk a distance of 10 metres on a level floor continuously and unaided.

MATERIALS AND METHODS

Participants

Twenty-seven (14 males and 13 females), unilateral and first episode, freely consenting in-patient stroke victims referred for physiotherapy at the University College Hospital Ibadan, Nigeria were consecutively recruited over a period of 5 months. Ten of them had left-sided and 17 right-sided hemiplegia; 19 had suffered ischaemic while 8 had haemorrhagic CVD, radiologically or clinically diagnosed by the neurologist in charge of the patients. Only subjects who met the underlisted inclusion criteria participated in the study:
a. Individuals with hemiplegia resulting from first incidence of stroke.
b. Subjects who were not independently ambulant at the time of referral but fully conscious and well oriented in time and place, and had no difficulty communicating and comprehending instructions.

Procedure

The protocol of this study was approved by the Joint Ethical Committee of the University of Ibadan/University College Hospital, Ibadan, Nigeria (IRC Protocol No: UI/IRC/03/0080). Every new stroke patients referred for physiotherapy was initially evaluated by one of the authors to determine whether they meet the study criteria or not. The procedure involved was explained to the prospective participants who satisfied the inclusion criteria before obtaining their informed consent. They were however blinded to the main outcome measure (independent walking attainment time). The following parameters were obtained at the point of recruitment:

Social Factors: Age in years, sex, marital status, level of formal education, total years of education and occupation. Occupations were categorized into: Trading; civil-service; artisan; retired.

Psychological Factors: The personality type of the patients was determined using the Eysenck personality type questionnaire (EPQ). A validity of 0.9 and internal consistency of 0.84 has been reported for this instrument [3]. It was researcher-administered and each subject responded to the questions by answering either “Yes” or “No”. A score of 1 was given to “Yes” and zero to “No”. The total score was added up in each category of 4 different personality types- introvert, extrovert, psychotic and neurotic. The personality type where the subject scored the highest determined his/her personality.

Clinical Factors: Side of affectation, presence of co-morbid factors (hypertension and or diabetes mellitus only), the time interval between admission to the hospital and when referred for physiotherapy (admission-referral interval) were also determined, as appropriate, from physical examination and the medical records of each participant.

Level of disability was determined by administering the functional independent measure (FIM) instrument, which assesses the physical and cognitive level of disability in the hemiplegic stroke subject. Each subject was asked to perform the basic life activities listed on the FIM instrument and scored accordingly. The FIM has a reliability coefficient of 0.93 and a validity score 0.84.

Structured Physiotherapy Intervention

Each participant received structured physiotherapy care. This included positioning in bed, respiratory physiotherapy and functional mobility activities which were based on the Bobath approach to management of hemiplegia. Treatment was administered daily, each session lasting 45 minutes. This was continued until the subject was ready to commence walking. Independent walking was determined by asking the subject to perform a continuous 10-metre floor walk in the physiotherapy gymnasium at his/her self selected walking velocity and without any assistive device or support from the therapist. The duration of participation in this study by each subject was 12 weeks. This is the most common upper limit admission time for stroke patients receiving physiotherapy at this hospital facility. Treatment of individual patient however continued until discharge from the physiotherapy unit on out-patient basis. Obtained data were analysed using SPSS package. Mann-Whitney U, Kruskal-Wallis and Pearson correlation coefficient (r) were calculated, as appropriate, at 0.05 alpha.

RESULTS

Twenty eight participants were recruited but one of them could not complete this study, as he was transferred to another hospital upon request by his family members. The results presented in this report are therefore with respect to the 27 subjects (13 females and 14 males) that completed the study. The mean quantifiable parameters of the participants such as age, independent walking attainment time and admission-referral interval are presented in table 1. The results of Mann-Whitney U statistical test as presented in table 2 shows that participants with mild disability level at baseline commenced independent walking earlier than those with moderate disability (p<0.05). Comparison of independent walking attainment time by psychosocial factors showed no significant difference (p>0.05) across these factors (Table 3). Correlation analysis using Pearson product moment correlation coefficient (r) showed that both age and functional independence measure have statistically significant association (p<0.05) with independent walking attainment time (Table 4).

DISCUSSION

One of the indicators of functional recovery from stroke is independent walking, which promotes discharge home. Many clinical and non-clinical factors would affect when this functional level is attained. The objective of this study was to investigate the influence of some clinical and psychosocial factors on the time independent walking was attained by stroke patients who received a 12- week structured physiotherapy care. In this study, independent walking was taken to be ability of a stroke patient to walk a distance of 10 metres unaided and continuously.

The mean time for commencement of independent walking was 7.4 ± 2.6 weeks in this study. Whereas no statistically significant sex differential was observed in the time of commencement of independent walking, it took the female participants a longer period (7.92 ± 2.81 weeks) than their male counterparts (7.00 ± 2.54 weeks) to achieve this task. Only 25% of the participants commenced walking within five (5) weeks and 70% within twelve (12) weeks of the structured physiotherapy care. Pomeroy and Tallis [10] had reported that 56% of their stroke patients regained independent walking 6 weeks after referral to physiotherapy. In general the time independent walking status is attained by stroke victims differ greatly and this variation can be attributed to several factors such as age, severity of the stroke, co-morbidity and rehabilitation approach. Differences in these factors may account for the disparity in the result of this study and the earlier report [10].

Age was found to have a negative correlation with time of commencement of independent walking, suggesting that the older the subjects, the earlier they commence independent walking. Contrary to this observed trend, a previous report had concluded that the cumulative effects of aging on the cardiovascular system and many chronic illnesses commonly seen in older adults are predictive of worse functional outcome, longer length of stay in the hospital and greater disability following rehabilitation [8]. The disparity in the findings may be attributed to other associated psychosocial and clinical factors that vary in the stroke subjects in these two studies.

Each of marital status, level of formal education, total years of education and occupation had no significant influence on time of commencement of independent walking, and by inference are not determinants of this important measure of functional recovery. Other studies had however reported that socio-economic factors [6] and the presence of a spouse at home [5] are factors that may accelerate functional recovery and discharge home of stroke patients. In this study only one-fifth of the patients were not married. This non-significant difference in the marital status of the patients could have accounted for the non-difference observed in the recovery time of independent walking across marital status. In addition, unlike the earlier study[5] which identified presence of a spouse at home as a positive influencing factor on recovery from stroke, the participants in this present study were still hospitalized at the time of this study. Therefore, the likely influencing effect of a spouse at home on recovery may not be established at this stage of recovery. The distribution of participants by occupation and level of formal education was also not significantly different in this study.

The side of affectation, admission-referral interval and co-morbid factors did not significantly influence the time of commencement of independent walking by our subjects. However we observed that the subjects who had hypertension as the only co-morbid factor commenced independent walking earlier than their counterparts who were both hypertensive and diabetic. The neurological outcome of stroke has been observed to be poorer in patients with diabetes than those without diabetes [4], thus suggesting that occurrence of diabetes mellitus as a co-morbid factor in stroke patients may prolong functional recovery in stroke. A stroke patient who has associated diabetes mellitus especially with complication such as peripheral polyneuropathy, which causes tingling sensation and numbness in the feet, may not be motivated to practice standing which is a prerequisite to walking.

Level of disability of the subjects had a significantly negative influence on the time they commenced independent walking in this study. The trend was such that subjects with mild disability at baseline commenced independent walking earlier (4.00 ±0.01 weeks) than those with moderate disability (7.72 ± 2.53 weeks). Initial disability would therefore be a negative influencing factor on recovery of independent walking by post stroke victims. A group of researchers[9] who observed that patients with mild and moderate disability had functional recovery within 2 months and 3 months respectively had concluded that the most important factor for functional recovery from stroke remains the initial severity of stroke.

Time of commencement of independent walking was not significantly different across the four personality types in these subjects. This suggests that their personality, a cognitive function, did not influence commencement of independent walking,although cognitive make-up had been observed to be one of the psychological factors that exert a major impact on patient’s rehabilitative functioning. Psychological adjustment was also reported to significantly enhance rehabilitation from a physical disability and a major contributing factor to the disability itself [7]. It is possible that other clinical and non-clinical factors modulated the potential influence of personality of the participants in this study. These include non-clinical factors like socio-cultural practice in this African community where the extended family practice ensures that a hospitalized stroke patient is surrounded by family caregivers. The regular presences of these family caregivers may serve as motivational factor that may dampen the likely influence of the patient’s own personality profile on recovery post stroke. A major drawback of this study is the relatively small sample size. Also, although the participants received structured physiotherapy care, they were at different stage of recovery at the time of recruitment to the study. This could have contributed to some of the trends observed in this study.

CONCLUSION

The mean time for commencement of independent walking was 7.4 ± 2.6 weeks for all subjects and 4.00 ±0.01 weeks for those with mild disability at the point of recruitment into the study. Older age and a high score on the FIM scale generally characterized early commencement of independent walking.

Acknowledgement
The authors would like to acknowledge all patients who participated in the study and the physiotherapists working at the department of physiotherapy, University College Hospital, Ibadan Nigeria for their cooperation during this study. The editorial assistance from Bisi Hamzat of Bital Consultancy Nigeria while preparing this manuscript is also acknowledged.

Table 1: Mean Quantifiable Parameters of the Subjects (N=27)

Variables range mean ± SD
Age (years) 38.0 - 75.0 56.96 ± 10.49
Years of education 0.0 - 18.0 11.52 ± 5.93
Admission-referral interval (Days) 1.0 - 30.0 8.11 ± 6.58
Functional Independence measure 60.0 - 94.0 76.63 ± 7.88
Independent walking attainment time (days) 4.0 - 14.0 7.44 ± 2.61

Table 2: Comparison of the Mean Independent Walking Attainment Time by Clinical Factors Using Mann-Whitney U (N = 27).

Variable Mean ± SD U-Value p
Sex
Male (n = 14) 7.00 ± 2.54 73.00 0.38
Female (n = 13) 7.92 ± 2.81
Side of affectation
Right (n = 17) 7.47 ± 2.37 72.00 0.64
Left (n = 10) 7.40 ± 3.13
Co-morbid factor
HTN (n = 21) 7.00 ± 2.28 40.50 0.18
HTN + DM (n = 6) 9.00 ± 3.35
Level of disability
Mild (n = 2) 4.00 ± 0.001 1.00 0.03*
Moderate (n = 25) 7.72 ± 2.53

Key: * = significant U at p ≤ 0.05, HTN = hypertension, DM = Diabetes Mellitus

Table 3 Comparison of the Mean Independent Walking Attainment Time by Psychosocial Factors Using Kruskal Wallis K (N = 27).

Variable Mean ± SD K-value p
Personality types
Psychotic (n = 8) 8.57 ± 3.20
Neurotic (n = 10) 7.25 ± 2.26 2.57 0.46
Extrovert (n = 6) 6.40 ± 3.29
Introvert (n = 3) 7.33 ± 1.15
Level of education
None (n = 2) 5.00 ±1.41
Primary (n = 8) 8.38 ±2.83 4.62 0.20
Secondary (n = 5) 8.40 ± 2.70
Tertiary (n = 12) 6.83 ± 2.41
Occupation
Trading (n = 10) 8.10 ± 3.35
Civil-servant (n= 7) 6.86 ± 2.91 2.32 0.51
Retired (n = 6) 6.50 ± 1.22
Artisans (n = 4) 8.25 ±1.26
Marital status
Single (n = 0) 0.00
Married (n = 22) 7.18 ± 2.34 2.40 0.30
Separated (n = 2) 11.00 ± 4.24
Widowed (n = 3) 7.00 ± 3.00

Table 4: Correlation between Independent Walking Attainment Time and Age, Years of education, Admission-Referral Interval and F.I.M score.

Variables r - value p - value
Age - 0.57 0.00*
Years of education - 0.08 0.71
Admission-referral interval 0.02 0.91
Functional independence measure - 0.55 0.00*

Key: * = significant r at p ≤ 0.05

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