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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 13  |  Issue : 3  |  Page : 200-210

Effectiveness of physical rehabilitation on clinical outcomes of patients following stroke


1 Department of Community Health Nursing, Faculty of Nursing, Menoufia University, Menoufia, Egypt
2 Department of Medical-Surgical Nursing, Faculty of Nursing, Menoufia University, Menoufia, Egypt

Date of Submission27-Aug-2016
Date of Acceptance11-Sep-2016
Date of Web Publication15-Feb-2017

Correspondence Address:
Naglaa M El-Mokadem
Department of Medical-Surgical Nursing, Faculty of Nursing, Menoufia University, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-6021.200182

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  Abstract 

Background and purpose
Stroke is a leading cause of gait impairment, resulting in long-term disability among adults, and frequently results in impaired mobility or motor function. More than half of the people with stroke are not able to walk, and walking impairments are still present among them due to abnormal muscle control, muscle weakness, abnormal muscle tone, abnormal muscle activation patterns, and altered energy expenditure, mostly affecting the paretic side. Thus, the purpose of the current study was to examine the effectiveness of using combined gait training and treadmill walking technique on selected clinical outcomes of patients with stroke.
Patients and methods
A quasi-experimental design was used to test the research hypotheses. A convenience sample of 50 adult patients with stroke were recruited.
Setting
This study was conducted in the outpatient clinics of neurology and physiotherapy unites at Shebin El Kom City, Menoufia University Hospital, Menoufia Governorate.
Tools
Interviewing Questionnaire, the Barthel Index, the Simplified Stroke Rehabilitation Assessment of Movement Scale, the Berg Balance Scale, the Oxford Scale, and the Modified Ashworth Scale were used to collect data.
Results
There was a statistically significant improvement in voluntary movement of subscale scores of the upper and lower limb and basic mobility after intervention. There was a statistically significant improvement in the mean scores of activities of daily living and body balance after intervention. There was a statistically significant improvement in the mean score of muscle tone and muscle strength after intervention.
Conclusion
Combined gait training and treadmill walking technique is effective in improving clinical outcomes in patients with stroke.
Recommendation
Rehabilitation nurses should be encouraged to implement the combined gait training and treadmill walking technique as a routine practice in rehabilitation facilities for patients with stroke.

Keywords: clinical outcomes, gait training, physical rehabilitation, stroke


How to cite this article:
Mohsen MM, El-Mokadem NM, Abdullah SE. Effectiveness of physical rehabilitation on clinical outcomes of patients following stroke. Egypt Nurs J 2016;13:200-10

How to cite this URL:
Mohsen MM, El-Mokadem NM, Abdullah SE. Effectiveness of physical rehabilitation on clinical outcomes of patients following stroke. Egypt Nurs J [serial online] 2016 [cited 2018 Oct 22];13:200-10. Available from: http://www.enj.eg.net/text.asp?2016/13/3/200/200182


  Introduction Top


Stroke is the third common cause of mortality and serious long-term disabilities in developed countries. Each year, 15 million people suffer from stroke, including seven million people with loss of motor functions. Approximately 750 000 individuals each year are diagnosed with stroke in the USA, and 90% of those individuals survive loss of ability to work and loss of direct patient self-care (American Stroke Association, 2007).

The National Center for Health Statistics (2011) reported that two-thirds of the immediate survivors of stroke have initial mobility deficits for the first 3–6 months after a stroke in American patients; more than 30% of individuals still cannot walk independently in the USA. However, the relatively high rate of walking independently may mask substantial mobility deficits. This limitation in walking function is frequently responsible for long-term disability and handicap because recovery of gait is central to regaining independent living for individuals after a stroke (National Center for Health Statistics, 2011).

In Egypt, there is no available documented data specific to the incidence and mortality of stroke. According to the statistical records of Menoufia University Hospital in the year of 2010, about 351 patients with stroke were admitted to the Inpatient Physiotherapy Department of Menoufia University Hospital with gait impairment (Statistical Office of Menoufia University Hospital, 2010).

Motor dysfunction is one of the most frequently encountered and therapeutically persistent problems after stroke. Therefore, recovery of motor function is a major emphasis in almost all rehabilitation efforts for stroke patients. One of the most desired outcomes of rehabilitation is the improvement in ambulatory function as it determines to a large degree the status of the patient with respect to activities of daily living (ADL) and associated quality of life (States et al., 2009; Mayo et al., 2002).

Intensive rehabilitation services, including physical therapy and repetitive gait training using treadmill walking, can aid significantly in recovery within the first 3–6 months and improve motor abilities (Duncan et al., 2005). Thus, the current study focused on this period because most improvements in physical and motor functioning occur within the first 3–6 months after stroke.

Nurses play an important role during rehabilitation stage, especially in the caring of patients with stroke that can result in movement dysfunction that alters or completely impedes walking ability. Nurses’ role in rehabilitation programs are designed to restore and maintain an individual’s functional level within normal limits through the application of specific nursing care or protocols (Bates et al., 2005).

Early combined gait training and treadmill walking intervention has been generally recognized as beneficial because the stroke survivor gains the ability to ambulate and more likely independent walking would be re-established (Jette et al., 2005). It may result in better outcomes after stroke and it provides enough assistance to facilitate walking and ADL. Establishing self-care abilities, effective support, and stability, preventing or correcting deformities, and substituting for functional components of ambulation are a few of the primary nursing goals.

A conventional physical rehabilitation of patient with stroke typically ended within several months after stroke because it was believed that most of the patient’s motor function improvement did not occur during this interval. Nevertheless, the current study has shown that gait rehabilitation beyond this time period, including gait training with treadmill walking, increases muscle tone, muscle strength, and motor function and helps the patient to perform ADL that can be difficult to perform after a stroke (Cauvaugh et al., 2008; Davalos et al., 2008). However, there is evidence suggesting that this approach was clearly better than other techniques for improving upper and lower muscle strength, gait balance, and the ability to perform everyday tasks. In addition, stroke survivors can benefit from counseling on participation in gait training program. Thus, the findings of the study will provide important information that can be used to train nurses working with these patients to improve gait and motor function (Wei Hsieh et al., 2004; Werner et al., 2008). Thus, the purpose of the current study was to examine the effectiveness of exercise rehabilitation (combined gait training and treadmill walking technique) on clinical outcomes of patients following stroke.

Research hypotheses

The following research hypotheses were formulated to achieve the aim of the study:

  1. The patients who receive exercise rehabilitation are more likely to show improvement of voluntary movement and basic mobility compared with the patients who receive routine care.
  2. The patients who receive exercise rehabilitation are more likely to show improvement in body balance during sitting, standing, and walking compared with patients who receive routine hospital care.
  3. The patients who receive exercise rehabilitation are more likely to show improvement in dependency level in ADL compared with patients who receive routine hospital care.
  4. The patients who receive exercise rehabilitation are more likely to show increased muscle strength compared with the patients who receive routine hospital care.
  5. The patients who receive exercise rehabilitation are more likely to show increased muscle tone compared with the patients who receive routine hospital care.



  Patients and methods Top


Research design

A quasi-experimental design was utilized to examine the effectiveness of using combined gait training and treadmill walking technique on selected clinical outcomes after stroke.

Ethical considerations

An official permission for conducting the study was obtained from the Faculty of Nursing and from hospital director to carry out the study after explaining the purpose of the study.

Oral consent was obtained from subjects who met the study inclusion criteria to participate in the study at the initial interview. Subjects were informed about the nature of the study, purpose, procedure, and the potential benefits of the study. The investigator explained that participation in the study is voluntary and the patient can withdraw from the study at any time without penalty. It was also emphasized that refusal to participate or to withdrawal would not affect any aspect of care received from the hospital. Confidentiality and anonymity of patients was assured through coding all data and put all files in a closed cabinet.

Sample

A convenient sample of 62 adult patients were approached over a 9-month period from the beginning of October to the end of June 2012. Fifty-three patients consented to participate in the study. These patients met the following study inclusion criteria: (a) age between 19 and 65 years; (b) stable medical condition; (c) being able to walk on treadmill; (d) gait score above 19 in the Dynamic Gait Index (DGI); and (e) being able to comprehend simple command during the initial screening using the Mini-Mental State Examination (MMSE). Patients were excluded if they had (a) a past medical history of seizures, (b) severe multi-infarct sites, (c) traumatic brain injuries, (d) compromised diseases such as heart failure, myocardial infarction, and uncontrolled hypertension, and (e) visual perceptual problems. Patients with such conditions were excluded because these conditions led to severe impairments in the brain and might influence the study outcomes. Moreover, compromised diseases were contraindication in treadmill walking. Fifty participants completed the planned follow-up measurement points. Among the three participants who did not complete the planned follow-up measurement points, two were excluded from the study because they traveled outside the country. The remaining one participant refused to complete the interview, because he did not have time. The final sample consisted of 50 participants. Fifty adult patients with acute ischemic stroke 3 months after stroke were randomly assigned to two equal groups (25 each). The study group received the combined gait training and treadmill walking technique. The control group received routine hospital care.

Setting

The study was conducted at the physiotherapy unit at Shebin El Kom, Menoufia University Hospital, Menoufia Governorate. Menoufia University Hospital was selected because it contains a special unit that is equipped with rehabilitation and contains the facilities required for the training program. Moreover, it contains a high flow rate of cases.

Tools of data collection

Six tools were used for data collection.

Interviewing questionnaire

It was developed by the researcher and includes the following: (a) sociodemographic data such as patient’s age, sex, level of education, occupation, monthly income, and marital status; (b) medical-related data such as date of admission to the hospital, onset of stroke, past medical history, which included current health status such as onset, duration, and symptoms such as headache, vomiting, convulsion, sensory, and language disturbances, and paralysis. Other variables such as physical activities, smoking, and family medical history such as history of ischemic heart disease, myocardial infarction, hypertension, and cerebrovascular accidents were also collected.

Barthel Index Scale

The Barthel Index Scale was adopted from the study by Mahoney and Barthel (1965) and was modified by Shah et al. (1989) to measure independency in ADL for patients after stroke. The scale consisted of 10 weighted items: feeding, bathing, grooming, dressing, bladder control, bowel control, toileting, chair/bed transfer, mobility, and stair climbing. The scores ranged from 0 (totally dependent) to 100 (independent). The scoring system of the scale was interpreted in accordance with previous studies as follows: 0–50 severely disabled; 51–94, moderately disabled (interdependent); and 95–100, functionally independent. The reliability of the Barthel Index was reported in a study on 120 adult patients who had a stroke. Internal consistency was evaluated using Cronbach’s α and was 0.95 for the total scale (Granger et al., 1979). The validity of the Barthel Index was shown to be high when used in patients with stroke; Spearman’s correlation coefficient was −0.91 (Shah et al., 1989). In the current study, the test–retest reliability of the total Barthel Index was 0.92.

Simplified Stroke Rehabilitation Assessment of Movement Scale

The Simplified Stroke Rehabilitation Assessment of Movement Scale (S-STREAM) was used to measure voluntary movement and basic mobility. The scale was adopted from the study by Daley et al. (1997) and modified by Hsueh et al. (2002). The 15-item S-STREAM Scale was developed on the basis of the original 30-item STREAM, expert opinions, and Rasch analysis. The scale consisted of three subscales: upper-limb movements, lower-limb movements, and basic mobility items.

The limb subscales were scored out of 10 points and the mobility subscale was scored out of 15 points. The S-STREAM’s scoring scheme, while remaining simple to preserve reproducibility, provides information on both the amount and quality of movement. A three-point ordinal scale was used for scoring voluntary movement of the limbs: a patient is scored 0 if he or she is unable to perform the test movement; 1 if a movement can be only partially completed; and 2 if he or she is able to complete the movement in a manner that is qualitatively and quantitatively near normal. The same scoring scheme is used for the basic mobility subscale, except that a category has been added to allow for independence with the help of an aid. If a test item cannot be performed because of pain or limited passive range of motion (ROM), then this must be indicated by scoring an X and indicating the reason. A subscale scoring form was used for summing item scores and transforming scores to scores out of 100. The scoring of the S-STREAM Scale was intended to be as simple as possible. The scoring of movement had three ranges: no or minimal movement (<l0% of normal movement); complete movement (or at least 90% of full movement); and any movement between these two extremes (partial amplitude with normal pattern). The reliability of the S-STREAM Scale scores was reported in a study on 350 adult patients who had a stroke and demonstrated with generalizability correlation coefficients of 0.99 for total scores and of 0.96–0.99 for subscale scores. The internal consistency of S-STREAM scores was demonstrated using Cronbach’s α greater than 0.98 on the subscales and overall. Cronbach’s α was 0.932 and Spearman’s correlation coefficient was −0.91 (Daley et al., 1999). In the current study, the test–retest reliability of the total S-STREAM Scale was 0.94.

Berg Balance Scale

The Berg Balance Scale was used to measure body balance (Berg et al., 1999). The scale consists of 14 common tasks of everyday life. The items test the participant’s ability to maintain gait or movement and balance of increasing difficulty by diminishing the base of support from sitting, standing, to single leg stand. The ability to change positions is also assessed. Each item is scored on a scale from 0 to 4. The scores ranged from 0 (using wheelchair) to 56 (independent). The scoring system of the scale was interpreted as follows: 0–20 wheelchairs; 21–40 walking with assistance; and 41–56, independent. The reliability of the Berg Balance Scale was excellent for assessing patients who had stroke. The Cronbach’s α for the total score was 0.96 and inter-rater reliability total score was 0.99. The validity is also high. Spearman’s correlation coefficient was 0.91 in a sample of 200 patients who had stroke (Berg et al., 1999). In the current study, the test–retest reliability of the total Berg Balance Scale was 0.90.

Oxford Scale

The Oxford Scale was used to measure muscle strength (Smyth, 2009). The scale was used for the assessment and recording of muscle power. The muscle is rated on the Oxford Scale from 0 to 5 and written down as 2/5 or 4/5 at times with a plus or minus sign to show that the muscle has more or less strength. The scale is a professional judgment as to the resistance to be applied for the test, and the physiotherapist has to consider the health, age, activity, and weight of the patient. If a muscle is to be graded 5/5, it must be of normal power. The reliability of the Oxford Scale was demonstrated by means of inter-rater and intrarater reliability for the measurement of power and ranged from 0.84 to 0.96. Intrarater reliability for the measurement of tone in the elbow, wrist, and knee flexors ranged from 0.77 to 0.96. Inter-rater and intrarater reliability and the measurement of tone in the ankle plantar flexors were ranged from 0.68 to 0.72. Validity of the scale is high and Spearman’s correlation coefficient was −0.91 in a sample of 540 patients who had stroke (Mishra et al., 2002). In the current study, the test–retest reliability of the Oxford Scale was 0.92.

Modified Ashworth Scale

The scale was developed by Bohannan and Smith (1987) and was used for measuring the muscle tone of patients with stroke. The scores ranged from 0 to 5: 0 indicates no increase in muscle tone; 1 indicates a slight increase in muscle tone; 2 indicates a slight increase in muscle tone; 3 indicates highly marked increase in muscle tone through most of the ROM, but affected part(s) are easily moved; 4 indicates considerable increase in muscle tone and difficult passive movement; and 5 indicates that affected part(s) are rigid in flexion or extension. Internal consistency was evaluated using Cronbach’s α and was 0.95 for the total scale. Inter-rater reliability for the two raters was very good for the hip adductor and the knee extensor (weighted κ=0.82, P<0.0001) and good for the ankle plantar flexor (weighted κ=0.74, P<0.0001) (Bohannan and Smith, 1987). In the current study, the test–retest reliability of the Modified Ashworth Scale was 0.94.

Initial screening tools

  1. The DGI was developed as a clinical tool to assess gait, balance, and fall risk. It evaluates not only usual steady-state walking, but also walking during more challenging tasks. The participants performed eight functional walking tests. They are marked out of three according to the lowest category, amounting to 24 as the total individual score. Scores of 19 or less have been related to increased incidence of falls. Participants with a score above 19 were included in the study (Sandraet al., 2008). The reliability of the DGI was excellent for assessing patients who had stroke. The Cronbach’s α for the total score was 0.95 and inter-rater reliability total score was 0.96. Spearman’s correlation coefficient was 0.90 in a sample of 200 patients who had stroke (Flansbjeret al., 2005).
  2. MMSE is a brief 30-point questionnaire test that is used to screen cognitive impairment. Any score greater than or equal to 25 points (out of 30) is effectively normal (intact). A score below this can indicate severe cognitive impairment (≤9 points), moderate cognitive impairment (10–20 points), or mild cognitive impairment (21–24 points). Participants with a score above 24 were included in the study (Collenet al., 2002). The reliability of the mini-mental state examination (MMSE) or Folstein test was demonstrated by internal consistency was evaluated using Cronbach’s α and was 0.90 for the total scale. The validity of the MMSE or Folstein test was shown to be high when used in patients with stroke. Spearman’s correlation coefficient was 0.91 (Hsiehet al., 2000).


Data collection procedure

The permission for conducting the study was obtained from the Faculty of Nursing and an official letter was issued to Menoufia University Hospital for seeking permission to carry out the study after explaining the purpose of the study.

Pilot study

A pilot study was conducted on 10% of the study sample (five patients) to test the practicality of the questionnaire and to estimate the time needed to fill in the questionnaire. Participants included in the pilot study were excluded from the sample.

Protection of human subjects

Oral consent to participate in the study was obtained from the patients who met the inclusion criteria. During the initial interview, the purpose, nature, and benefits of the study were explained to participants by the researcher. The researcher explained to the patients that participation in the study is voluntary and that they can withdraw from the study at any time without penalty, and that information would be confidential to assure the confidentiality and anonymity of information; there was no cost to participate in the study.

Procedure and data collection

Patients who met the study inclusion criteria were interviewed individually by the researcher in the Physiotherapy Department before starting the session of the therapy. Both groups were matched against the study inclusion criteria as much as possible in relation to age, sex, and severity of disease. Fifty adult patients with acute ischemic stroke were randomly assigned to two equal groups, each of 25 patients. The participants were assigned to the study and the control group as follows: the names of the participants were written on slips of paper, placed in a container, mixed well, and then drawn out one at a time until assigning the sample required. The researcher drew the names out of the container. The study group received combined gait training and treadmill walking technique. The control group received routine hospital care.

Initial visit (preintervention)

The first time the researcher met the participants was considered the baseline measure. Participants were interviewed in the Physiotherapy Department to fill in the study questionnaires and to collect data. The tools used to included Interviewing Questionnaire, the Barthel Index, the S-STREAM Scale, the Berg Balance Scale, the Oxford Scale, and the Modified Ashworth Scale.

Study group

The study group received combined therapy that consisted of the following:

  1. Gait training exercise: The exercises used included moderate passive ROM on both upper and lower affected parts, a strengthening exercise on the major muscle group of the upper limb (biceps and flexor muscle) and lower limb (quadriceps and tibialis), and also weight-bearing exercise. Gait training was performed for 10–15 min every session, increasing 5 min every week until a maximum duration of 30 min was reached. The training sessions took place three times a week for 3 months.
  2. ROM exercises: Each participant in the study group received ROM exercises on both upper and lower affected parts. The researcher instructed the patients to perform ROM exercises and taught them how to stretch his or her arms, hips, legs, and knees. These exercises should be performed slowly and gently, with the patient sitting on a chair or lying on back. Upper extremity exercises including elbow flexion and extension, shoulder flexion and extension, shoulder internal and external rotation, finger and wrist flexion and extension, and thumb flexion and extension were performed. Lower extremity exercises including hip and knee flexion, hip rotation, hip abduction, ankle rotation, and toe flexion and extension were also performed. Participants were asked to repeat ROM exercises at home for 10–20 times daily.
  3. Strengthening exercise: It was performed 10–20 times. It was applied in the first week of adaptation to the program. The participants were asked to perform the exercise 10 times without extra resistance.

    In the second week, the patients were instructed to perform 10 times, with extra resistance provided with 1 kg arm weight and use a therapy band for hip, knee, and calf muscle. From the third week, resistance was maintained and the numbers of repetitions were increased to 20 times. If the patient suffered from spasticity, he would be taught to perform hot packs on the affected part by wrapping moist hot packs in several layers of towels for 10 min before starting the exercise, to decrease spasticity, decrease pain, improve circulation, relax the muscle, and facilitate the ROM or movement and exercise.
  4. Weight-bearing exercise: Participants were instructed to perform the weight-bearing exercise that was essential for building and maintaining healthy bones. A weight-bearing exercise is any activity performed on feet and legs that works muscles and bones against gravity and the bone becomes stronger and denser. Weight-bearing exercises include walking and stair climbing. All patients in the study group performed walking step with parallel bars and stair climbing as a weight-bearing exercise. Every session was for about 5–10 min three times a week. This exercise started ∼4 weeks before the beginning of the treadmill walking technique.
  5. Treadmill walking technique: The study group received treadmill walking for a maximum of 30 min, three times per week, for a total of 12 weeks. Before starting treadmill training protocol, two orientation sessions were carried out to familiarize participants with the training. All participants were trained in the physiotherapy unit only. They could also hold onto a horizontal bar attached to the front of the treadmill for stability. The treadmill permitted walking to be initiated from 0.2778 m/s and slowly advanced by 0.0554 m/s increments according to the patient’s tolerance. The researcher could assist the patient if he/she did not actively lift the affected leg. The speed was adjusted to the patient’s comfortable walking speed ranging between 0.38 and 0.49 m/s. Participants were given rest periods of 2 min when they felt tired.


Final visit (postintervention)

The researcher interviewed the participants again after 3 months at the end of the intervention and readministered the study questionnaires to identify the level of improvement and how the combined gait training and treadmill walking technique improved the examined selected clinical outcomes.

The control group received routine hospital care, which included goal-oriented physical therapy or faradic stimulation three sessions every week for 10 min each. It was administered by a trained neurorehabilitation team, which consisted of a physical therapist and two physical therapy assistants. Faradic transcutaneous stimulation takes place on the skin through surface electrodes and the electrode gets closer to the nerve/muscle. The best findings are obtained by removing hairs from under the electrodes (through clipping not shaving) and using a conducting gel between the skin and the electrode.


  Results Top


Characteristics of the study sample

Fifty adult patients with acute ischemic stroke participated in the study. The mean age of the study group was 55.12 years, and the mean age of the control group was 56.56 years. The majority of the participants were over the age of 50 years. The majority of the participants of both the study and control groups were male (68 and 64%, respectively) and most of them were married (64 and 72%, respectively). It is also observed that more than one-third of the patients in both the study and control groups were illiterate (52 and 60%, respectively). Forty percent of the study group and 48% of the control group were blue-collar ([Table 1]).
Table 1: Sociodemographic characteristics of the study sample (N=50)

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The initial screening showed that 40 and 48% of participants in the study and the control group, respectively, had partial movement. The majority of participants in the study group (64%) and (48%) in the control group were able to walk with assistance. The majority of participants in both the study and the control group were dependent in ADL (80 and 80%, respectively) ([Table 2]).
Table 2: Physical impairments of the study sample (N=50)

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Effect of combined gait training and treadmill walking technique on voluntary movement and basic mobility

The mean score of voluntary movement and basic mobility for the study group was 75.08, whereas in the control group the mean was 51.84 after interventions (P<0.05) ([Table 3]).
Table 3: Effect of combined gait training and treadmill walking technique on voluntary movement and basic mobility in the study sample (N=50)

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Effect of combined gait training and treadmill walking technique on body balance

The mean score of body balance in the study group was 43.00, compared with 29.4 in the control group (P=<0.001) ([Table 4]).
Table 4: Effect of combined gait training and treadmill walking technique on body balance in the study sample (N=50)

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Effect of combined gait training and treadmill walking technique on activities of daily living

The mean score of the ADL in study group was 86.80 compared with 66.20 in the control group after intervention (P<0.001) ([Table 5]).
Table 5: Effect of combined gait training and treadmill walking technique on activities of daily living in the study sample (N=50)

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Effect of combined gait training and treadmill walking technique on muscle strength

The mean scores of muscle strength of biceps muscle, flexor digitorum muscles, quadriceps, and tibialis muscle in the study group were 3.2, 3.2, 3.13, and 3.16, respectively, compared with 2.3, 2.3, 2.2, and 1.96, respectively, in the control group after intervention (P<0.001) ([Figure 1]).
Figure 1: Mean scores of muscle strength of the study and the control group.

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Effect of combined gait training and treadmill walking technique on muscle tone

The mean scores of muscle tone of biceps muscle, flexor digitorum muscles, quadriceps, and tibialis muscle in the study group were 4.06, 3.9, 3.2, and 2.33, respectively, compared with 3.2, 2.26, 2.9, and 2.00, respectively, in the control group after intervention (P<0.001) ([Figure 2]).
Figure 2: Mean scores of muscles tone of the study and control groups.

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  Discussion Top


The current study examined the effectiveness of using combined gait training and treadmill walking technique on basic mobility and voluntary movements of patients with stroke.

Voluntary movement and basic mobility

The study hypothesized that the patients who received the combined gait training and treadmill walking technique are more likely to show improvement in voluntary movement and basic mobility compared with patients who received routine hospital care. Findings of the study supported the study hypotheses and showed that there were statistically significant differences between the control and the study group as regards the total score of voluntary movement and basic mobility after intervention. Finding of the current study is similar to that reported by Karen et al. (2008), who studied the effect of gait training technique and treadmill walking program after stroke and reported that there was a statistically significant increase in total scores of voluntary movement and basic mobility after intervention compared with preintervention scores. Similar findings have been reported by Nadeau et al. (2011), who studied the effect of treadmill walking program on motor function and reported that there was a statistically significant improvement in voluntary movement and basic mobility score after intervention.

Considering voluntary movement of upper, lower, and basic mobility, the current study revealed that there was a statistically significant improvement in voluntary movement of upper, lower, and basic mobility score after intervention than that before intervention. These findings are similar to the findings of Moreland and Thomson (2010), who studied the effect of gait training program with treadmill walking on motor performance among adult patients with stroke. They found that there was a statistically significant improvement in the voluntary movement of upper, lower, and basic mobility after intervention. However, the study’s findings are different from that reported by Dromerick et al. (2008), who examined the effectiveness of combined gait training and treadmill walking on voluntary movement of lower limbs in the early stage after stroke for 1-month training program and found no statistically significant difference between preintervention and postintervention results as regards voluntary movement and basic mobility of lower limb. This may be explained by the short duration of the previous study. Another possible explanation of the study findings is the fact that the majority of patients with stroke who received the intervention were totally dependent due to their early stage of disease and their inability to perform the required exercises properly.

Body balance

The current study hypothesized that the patients who receive the combined gait training and treadmill walking technique are more likely to show improvement in body balance during sitting, standing, and walking compared with patients who receive routine hospital care. Findings of the current study supported the study hypothesis and showed that there was a statistically significant difference between the control and study groups as regards body balance after intervention. The current study findings are consistent with the findings of Au-Yeung et al. (2012), who examined the effect of combined balance training and treadmill walking on gait balance and found that there was a statistically significant improvement in the mean scores of body balance after intervention compared with the baseline at 8 and 12 weeks after intervention. However, the study findings are different from that reported by Eser et al. (2009), who examined the effect of balance training program and treadmill walking on gait and posture balance among older adult patients with chronic motor deficits after a stroke and found no statistically significant difference between preintervention and postintervention scores in relation to body balance. These findings may be attributed to the severity of physical and cognitive impairment of the patients in the previous study. Another possible explanation of the current study finding is that the majority of patients with stroke who received the intervention were not able to comprehend instruction about gait training program due to their cognitive impairment.

Activities of daily living

The study hypothesized that the patients who received the combined gait training and treadmill walking technique are more likely to show improvement in dependency level in ADL compared with the patients who received routine hospital care. Findings of the current study revealed that there was a statistically significant difference between the control and the study group as regards feeding, bathing, grooming, toilet use, and transferring from bed to chair and back, mobility, and ascending and descending stairs. Moreover, a statistically significant difference was found between the control and study groups as regards total functional dependency after interventions. These findings are similar to that reported by Carl van et al. (2010), who examined the effect of gait training with treadmill walking program on motor function and performance of ADL in patients with stroke and found that the combined gait training and treadmill walking technique achieved a higher level of functional independency in performance. However, the study findings are different from that reported by Dinesh et al. (2011), who examined the effectiveness of repetitive gait training and treadmill walking on function performance in nonambulatory elder hemiparetic patients for 8-week training program and found no statistically significant difference between preintervention and postintervention scores. This finding may be attributed to the fact that the majority of participants in the study group were totally dependent due to their advanced ages.

Muscle strength

The study hypothesized that the patients who receive the combined gait training and treadmill walking technique are more likely to show increased muscle strength compared with patients who receive routine hospital care. Findings of the study supported the study hypothesis and showed that there was a statistically significant difference between the control and study groups as regards the muscle strength, which includes biceps muscle, flexor digitorum muscles, quadriceps, and tibialis muscle, after intervention. Findings of the study are similar to that reported by Cooke et al. (2012), who examined the effects of gait training strategies and treadmill walking technique to optimize muscle strength ability and found that there was a statistically significant increase in the mean scores of muscle strength after intervention compared with the baseline scores. In addition, the current study findings revealed that there was an increase in muscle strength of biceps muscle and tibialis after 3 months of intervention. The study findings are similar to that reported by Bale et al. (2010), who examined the effect of gait training and lower-intensity treadmill exercise on improving muscle strength in patients with stroke and found that there was a statistically significant increase in the muscle strength of biceps muscle and tibialis score after intervention than that before intervention.

Muscle tone

The study hypothesized that the patients who receive the combined gait training and treadmill walking technique are more likely to show increased muscle tone compared with patients who receive routine hospital care. Findings of the current study supported the study hypothesis and showed that there was a statistically significant difference between the control and study groups as regards muscle tone of the biceps, flexor digitorum, quadriceps, and tibialis muscles after intervention. The study findings are similar to that reported by Blennerhassett and Dite (2010), who studied the effect of intensity gait training rehabilitation and treadmill walking in the lower and upper limb on improving muscle tone, and they found that there was a statistically significant increase in the mean scores of muscle tone after intervention. In addition, the study findings are similar to that reported by Miller et al. (2008), who studied the effect of gait training and treadmill exercise on improving muscle tone and found that there was a statistically significant increase in muscle tone, especially biceps muscle and flexor digitorum muscle score, after intervention compared with that before intervention. However, the study findings are different from that reported by Andrews and Davis (2005), who examined the effectiveness of gait training program using treadmill walking technique on muscle tone in nonambulatory hemiparetic patients for 4 weeks at the early stage after stroke, and they found no statistically significant difference between preintervention and postintervention scores. This finding can be attributed to the short duration and performance of gait training in the early stage after stroke. Another possible explanation of the study finding is that the majority of the study group had spasticity that occurs after stroke that can affect the upper and lower extremity and may cause significant physical disability and pain. Moreover, spasticity is the disinhibition of central nervous system tone-regulating mechanisms, which results in significantly increased tone and reduction in both passive and active ROM in the affected extremity.

Limitations of the study

  1. The results of the study are limited in their generalizability because of the convenience sample.
  2. Another limitation relates to the small sample size of the current study and the use of a single setting for data collection.



  Conclusion Top


The combined gait training and treadmill walking intervention has led to improvement in voluntary movement and basic mobility, ADL, body balance, muscle tone, and muscle strength.

Recommendations

Findings from the current study provided valuable information on combined gait training and treadmill walking intervention and the improvement of all clinical outcomes among patients with stroke. Findings of the present study recommend the following:

  1. Nurses should be encouraged to implement the combined gait training and treadmill walking after 3 months of stroke to improve motor impairment and gait balance.
  2. Replication of this study is recommended with several design changes such as the use of randomized selection to achieve appropriate representation of population and a large sample size.
  3. The study period should be extended more than 3 months. Extending the follow-up period to 6 months will provide more comprehensive information about the effect of combined gait training and treadmill walking on the improvement of all clinical outcomes.
  4. Replication of this study in a larger scale to include more clinical settings (multicenters).


Implications for research

Using randomized controlled group studies would be valuable to determine the efficacy of comparing combined gait training with treadmill walking intervention with conventional treatment alone or the use of a combined gait trainer alone in gait rehabilitation after stroke. It is essential to explore alternative forms of training that may be effective for more than one area for stroke patients.

Implications for nursing practice

The current study findings revealed the importance of addressing the relationship between muscle strength and performance of ADL. In light of such findings, it would be important to screen patients with stroke for muscle strength. Furthermore, comparing combined gait training with treadmill walking intervention needs to investigate the intensity, frequency, and specificity of strength training required for improving performance in daily activities. Moreover, it is important to examine the reasons for gait training program that are used very frequently at each stage of stroke rehabilitation. [38]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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