|Year : 2021 | Volume
| Issue : 1 | Page : 43-49
Effect of structured home exercises on functional independence in stroke survivors
AS Khader Basha
Department of Neuro Physiotherapy, Jaipur College of Physiotherapy, M.V. Global University, Jaipur, Rajasthan, India
|Date of Submission||05-Oct-2020|
|Date of Decision||29-Mar-2021|
|Date of Acceptance||26-Jul-2021|
|Date of Web Publication||19-Aug-2021|
Prof. A S Khader Basha
Jaipur College of Physiotherapy, M.V. Global University, NH 11C, Dhand, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
BACKGROUND AND PURPOSE: Many stroke survivors and their caregivers have limited resources or opportunities for engaging in exercise activities after discharge from hospital. Appropriate exercise prescription and patient education to improve functional status after discharge are major concerns. The purpose of this study was to determine the effect of Structured Home Exercises on functional independence in stroke survivors.
MATERIALS AND METHODS: A randomized control trial in which 100 stroke patients who were 1–6 months after stroke onset were randomly assigned to intervention group (n = 43) and control group (n = 45). The activity level of the patients was assessed using modified barthel index (MBI) score at baseline and 12 weeks. Structured home-based exercise program was prescribed to the Intervention group. The patients receiving physiotherapy in outpatient physiotherapy facilities formed the control group. Both groups performed the exercises for 12 weeks.
RESULTS: The results demonstrated that the MBI score of both the groups improved significantly after 12 weeks of intervention (P < 0.05) and no significant difference was seen in the improvement of the score between the two groups (P > 0.05).
CONCLUSION: The findings of this study indicate that the structured home exercise program can be considered an effective mode to continue patient care and improve function independence.
Keywords: Functional independence, stroke survivors, structured home exercises
|How to cite this article:|
Khader Basha A S. Effect of structured home exercises on functional independence in stroke survivors. Physiother - J Indian Assoc Physiother 2021;15:43-9
|How to cite this URL:|
Khader Basha A S. Effect of structured home exercises on functional independence in stroke survivors. Physiother - J Indian Assoc Physiother [serial online] 2021 [cited 2021 Dec 3];15:43-9. Available from: https://www.pjiap.org/text.asp?2021/15/1/43/324129
| Introduction|| |
Stroke is one of the leading causes of disability and reduced quality of life. With increasing life expectancy of the population and high prevalence of lifestyle diseases, low- and middle-income countries are facing great social and financial challenges in coping with disabled stroke survivors. With the many recent advances in stroke-related clinical care, there have been considerable improvements in post-stroke survival rate.
Many stroke survivors are physically deconditioned and have a high prevalence of cardiovascular and musculoskeletal problems resulting in functional limitations that are potentially modifiable with exercise.,, Activity intolerance is common among stroke survivors, especially in elderly. The magnitude of activity limitation is not only dependent on stroke-related body impairment but also on other factors including patient enthusiasm and mood, cooperation, cognition and learning ability, medical stability, physical endurance, and the amount and type of rehabilitation that the patient is receiving.,, Certainly, stroke survivors can benefit from counseling on participation in physical activity and exercise training. However, most healthcare professionals have limited experience and guidance in exercise programming. Although it is strongly believed that physical therapy and rehabilitation are very effective in improving functional status and independence in stroke survivors, the studies comparing the relative effectiveness of various intervention types generally are few in number and suboptimal in design.
Many stroke survivors continue to have minimal to moderate neurological deficits after getting discharged from the hospital. Poor balance, strength, and abnormal movement patterns make them dependent on others. Thus, functional independence in stroke survivors deserves special attention because of its importance in mobility and safety. Stroke recovery is an ongoing process that may continue for months or years. Many stroke survivors will have rehabilitation program either home-based or hospital/clinic based. Functional independence in stroke patients not only depends upon the appropriate medical and therapeutic management but also the care taken at their indwelling setup (home).
In India, rehabilitation facilities are underprovided in the government healthcare sector. These services in the private sector are expensive and beyond the economic reach for many of the people. Most stroke survivors discontinue Physical therapy within few weeks because of transportation difficulties and cost. As a result, most of them confined to bed. Consequently, Stroke survivors are predisposed to a sedentary lifestyle that limits the performance of activities of daily living, increases falls risk and may contribute to a heightened risk for recurrent stroke and cardiovascular disease. All of these are potentially modifiable with exercises. Previous studies have demonstrated the trainability of stroke survivors and documented beneficial physiological, psychological, sensorimotor, strength, endurance, and functional effects of various types of exercise.,,,
After a stroke, most patients are anxious to leave the hospital and return home, but lack of facilities and limited resources at home turn out to be very difficult and challenging for stroke patients to perform exercises. These lacunae can be rectified by modifications at the home in a manner that is suitable to perform exercises. Thus, there is a need to build up a structured exercise program which is appropriate for the patient depending on his ability and need. Home-based rehabilitation was found to be a cost-effective method to improve physical function compared to day-hospital rehabilitation for patients with a stroke., There are studies suggesting home exercise program can improve Mobility, self-care, flexibility, strength, balance, endurance, and upper-extremity and lower-extremity function.,
Prescription of home exercise in rehabilitation clinical practice is often conflicting and inconsistent. Physiotherapists have limited resources from literature regarding appropriate selection of home exercise program for stroke patients. Hence, the exercises which are selected in this study as home program for post-stroke patients are an experimental effort to avoid the inconsistency and conflicts and were modified according to the patient's needs.
| Materials and Methods|| |
The study is a Single-blinded, randomized controlled trial in which 100 poststroke patients were recruited [Figure 1] after obtaining ethical clearance from Ethical Research committee of M. V. Global University, Jaipur, India. The study subjects included were post stroke patients who were 1–6 months after stroke onset, discharged from the hospital, both male and female adults aged up to 70 years, without cognitive impairment (Mini–Mental State Examination ≥24), either left or right side involved, whose modified Barthel index (MBI) score ranges between 61 and 75 and who can able to tolerate activity for at least 20 min. The subjects who cannot follow instructions, subjects with other neuromuscular or musculoskeletal condition, who are suffering from any other unstable medical conditions, and uncooperative patients were excluded from the study.
Modified Barthel index score
The Barthel Index is one of the best activities of daily living (ADL) measurement scales. The scoring of the BI was modified to further improve its sensitivity. MBI Score is a highly reliable and validated measure used by various health professionals to evaluate the functional independence in neuromuscular or musculoskeletal disorders. The advantage of the MBIS is its simplicity. It is useful in evaluating a patient's state of independence before treatment, his progress as he undergoes treatment, and his status when he reaches maximum benefit. It can easily be understood by all who work with a patient and can accurately and quickly be scored by anyone who adheres to the definitions of items listed on the scale.
Structured home exercise program
The Structured home exercise program was a tailored intervention program conducted at the participants' homes. The exercises are based on “Stroke exercises for your body: Saebo, Inc., the HOPE – “A Stroke Recovery Guide from the National Stroke Association” in accordance with the “The American Academy of Neurology.” These exercises provide an opportunity for post stroke patients to enhance and/or maintain their functional mobility and independence. The structured home exercise program consists of 7 simple components with various illustrated exercise instruction posters with recommendations on the procedure and sequence of exercises.
The exercises program consists of the following components:
- Head and neck exercises
- Shoulder exercises
- Arm exercises
- Hand exercises
- Lying down exercises
- Hip and trunk exercises
- Leg and ankle exercises.
The exercise program follows cephalocaudal rule, i.e., the treatment begins from the head and proceeds downwards. The subjects performed 10–15 repetitions, depending on the exercise. The speed of movement must be slow, uniform, and controlled. The movement is performed in smooth manner in the pain-free anatomical range. Details of structured home exercises can be found in Appendix A.
The outpatient physiotherapy may be a hospital-based outpatient physiotherapy unit or an independent physiotherapy clinic. The services are provided by qualified Physiotherapists using a range of therapeutic exercises and equipment that focus on mobility, self-care, strength, endurance, and overall functional ability.
The Subjects who met the inclusion criteria were randomized into either intervention or control group with 50 subjects in each group. Randomization was done by an independent researcher using cards in unmarked envelopes. The functional independence of all the patients was assessed using MBI score. Structured home exercises were administered to the intervention group. The control group was formed by the patients receiving outpatient physiotherapy. Both groups received the intervention six times in a week for 12 weeks. Functional independence was again assessed after 12 weeks of intervention.
General characteristics of the study groups were compared using Unpaired t-test and Chi-square test. As the data did not follow the normal distribution, Mann–Whitney U-test was used to compare the baseline data of the MBIS. For post-intervention analysis, Wilcoxon signed-rank test and Mann–Whitney U-test were performed to find out the degree of significance within group and between groups, respectively. Results were considered statistically significant when two-tailed P < 0.05. Graphpad Prism 8.3.1 (GraphPad Prism is a commercial scientific 2D graphing and statistics software. It is a privately held California corporation) was used to perform all analyses.
| Results|| |
In the intervention group of 50 participants, 43 completed the 12 weeks of the study and in the control group of 50 participants, 45 completed the 12 weeks of the study. Of the total 88 percipients who completed the study, 49 were males and 39 were females; 53 were left-sided stroke and 35 were right-sided stroke patients. The percipients were between 51 and 70 years old. [Table 1] shows that there was no significant difference between the groups in respect to age, gender, side of the stroke, and baseline measure of MBI score.
|Table 1: Baseline characteristics of the subjects of both intervention and control groups|
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[Table 2] presents the results of within-group analysis for MBIS scores. Both the groups improved significantly after the 12 weeks of intervention. For the intervention group, the Wilcoxon signed-rank test indicated that the median posttest ranks (mdn = 78) were significantly higher than the median pretest ranks (mdn = 65) where Z = ‒5.57, P < 0.00001. On the other hand, the Wilcoxon signed-rank test for control group also indicated that the median posttest ranks (mdn = 75) were significantly higher than the median pretest ranks (mdn = 66) where Z = ‒5.54, P < 0.00001. Thus, both the groups showed significant improvement after completion of the training.
|Table 2: Comparison of pre- and post-intervention mindfulness-based interventions scores|
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However, Mann–Whitney U-test [Table 3] indicated that there was no significant difference between the two group in MBIS after completion of the training (Z = ‒1.36, P > 0.05).
|Table 3: Comparison of post-intervention mindfulness-based interventions scores between the groups|
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| Discussion|| |
The structured home exercise program was proved to be as good as the exercises those are prescribed in outpatient rehabilitation clinic for stroke survivors. Many studies examined the effects of home-based rehabilitation on functional outcome of patients with stroke and reported benefits in physical function. The study conducted by Gjelsvik et al. found that the improvement in ADL function in the intervention groups which received home-based therapy was better than in the control group. The intervention group of the present study also performed better than the control group. However, there was no significant difference between the two groups in functional independence after 12 weeks of treatment.
The positive effects of the range of exercises those are performed in the outpatient rehabilitation clinics are well known., The reason for the positive effects of home-based rehabilitation on physical function may be the direct in-home visits that provide convenient and patient-centered care. Providing rehabilitation in the home setting can increase environmental adaptation and encourage continual self-practice. Home-based rehabilitation mostly focuses on training to be independent in performing daily activities. Previous studies found that providing self-care training and physical activities was correlated with physical functioning of community-dwelling stroke patients., Accordingly, home-based rehabilitation featuring training for daily activities could help stroke survivors achieve a better ability to perform ADLs.
Parallel to the present study results, Widén Holmqvist et al. also reported no statistical significant differences in outcomes they used. It was observed in some studies that the experimental group (home based exercises) performed significantly better than control group. Whereas other studies showed no significant difference between the experimental and control groups, i.e., both the groups improved after receiving their respective therapy. These dissimilarity in findings of various studies may be due to the difference in sample such as the type of stroke, stage of the stroke (acute or chronic stage) and interventional characteristics such as the number of home visits, interventions performed by an individual practitioner or a multidisciplinary team, and types of rehabilitation, including exercise, ADL training, physical therapy and Occupational therapy. Most importantly, the results also depend on whether the control group is an active control group (e.g., outpatient rehabilitation) or inactive control group (e.g., usual care, health education, or no treatment). The present study involved active control group to examine whether the intervention of interest was inferior or superior compared to existing treatments.
It is apparent that an appropriate rehabilitation program at any setting can generate good results. The main advantage of home-based rehabilitation is that it is a cost-effective method to improve physical function compared to day-hospital rehabilitation for stroke survivors., The other advantages are that the patient and caregivers can get rid of difficulties associated with transportation and time. Although rehabilitation services are provided free of cost in some facilities, people have to travel long distances and some may not afford for the travel to get these free services. Time and money are main factors that prevent them from regular visit to the facility. In India, stroke survivors are unable to meet the rehabilitation needs due to the lack of availability and affordability of stroke rehabilitation services, and the demand for available and affordable stroke rehabilitation services becomes substantial.
The findings of a recent systematic review and meta-analysis suggested that the characteristics of home-dwelling stroke patients can significantly affect their functional improvement with home-based rehabilitation. Most disabled stroke patients and their families tend to accept home-based rehabilitation because of its environmental familiarity, convenience, and continuity of care., A structured home exercise program can be considered appropriate when choosing rehabilitation method for stroke patients after hospital discharge as it is convenient for patients and their caregivers.
| Conclusion|| |
The stroke patients who performed the structured home exercises improved significantly, similar to the patients who were treated in outpatient physiotherapy clinics. Thus, the structured home exercise program can be considered an effective mode to continue patient care and improve functional independence.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
Appendix A: Structured home exercises
Head and neck exercises
- Bend the head forward keeping the chin tucked in. Then raise the head to the ceiling. Do not extend the head all the way back
- Turn the head to look over the right shoulder, then over the left shoulder
- Bend the head sideways; bring the right ear towards right shoulder, then left ear towards left shoulder.
- Shrug the shoulders
- Rotate the shoulders in forward direction
- Pinch the shoulder blades together, and then hunch the shoulders forward.
The movement should be performed in such way that no pain is elicited. Pain around the shoulder would indicate that sensitive structures around the joint were being compromised
Starting Position: Clasp the hands with fingers entwined, making sure that the affected thumb is on top.
- Raise the hands over the head, keeping elbows straight
- With elbows bent at shoulder level, move hands to the right, then to the left
- Stretch the arms in front at shoulder level. Twist the arms to the right, then to the left
- Place the clasped hands on right knee, then raise them to the left shoulder. Repeat with clasped hands on the right knee raised to right shoulder
- With elbows bent and hands clasped at chest, bend the wrists to the right, then to the left.
- Place the affected hand on affected leg with the palm up. Hold the affected thumb by the base and gently move it to the side
- Holding the affected hand by the base of the thumb, turn the affected palm up and down to relax the fingers
- When the fingers are relaxed, turn the palm down. Gently open the hand by straightening the fingers. Spread the thumb and fingers apart, then close them.
Hip and trunk exercises
- Shift the weight to lift up right buttock. Then shift the weight to lift up your left buttock
- Bend forward slowly from the waist, then rise up slowly until you are sitting upright. Do not do this if felt giddy
- Raise up the knee as in marching. Repeat with the other leg.
Leg and ankle exercises
- Raise the leg to straighten the knee
- Move the leg out to the side, and then move it back to the front
- Move the leg forward and put the heel down on the floor. Repeat the exercises for both legs
- Sit with the knees crossed. Move the free foot up and down at the ankle
- Sit with the knees crossed. Rotate the free ankle clockwise, then anti-clockwise
- If the foot cannot be moved, cross the affected leg over the good leg and rotate the ankle with hand. Do not overstretch the ankle.
Lying down exercises
- Lie on the back with knees bent and hands clasped. Turn the head to one side. Bring the clasped hands to the same side, and then turn the hips over. Repeat with the other side
- Lie on the back with knees slightly bent and arms at sides. Raise the hips and buttocks by pushing down on feet. Do not arch the back
- Holding the bent knees together, roll both the hips and legs to the right, then to the left
- Lower the affected leg down and sideways, controlling the motion so that the leg does not flop down. Then slowly raise it back up. Repeat with the other leg
- Bring the affected knee towards chest. Then lower it slowly, controlling the motion. Repeat with the other leg (10–15 repetitions).
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[Table 1], [Table 2], [Table 3]