Short-term effects of physiotherapy combining repetitive facilitation exercises and orthotic treatment in chronic post-stroke patients (2024)

Abstract

[Purpose] This study investigated the short-term effects of a combination therapyconsisting of repetitive facilitative exercises and orthotic treatment. [Subjects andMethods] The subjects were chronic post-stroke patients (n=27; 24 males and 3 females;59.3 ± 12.4 years old; duration after onset: 35.7 ± 28.9 months) with limited mobility andmotor function. Each subject received combination therapy consisting of repetitivefacilitative exercises for the hemiplegic lower limb and gait training with an ankle-footorthosis for 4 weeks. The Fugl-Meyer assessment of the lower extremity, the StrokeImpairment Assessment Set as a measure of motor performance, the Timed Up & Go test,and the 10-m walk test as a measure of functional ambulation were evaluated before andafter the combination therapy intervention. [Results] The findings of the Fugl-Meyerassessment, Stroke Impairment Assessment Set, Timed Up & Go test, and 10-m walk testsignificantly improved after the intervention. Moreover, the results of the 10-m walk testat a fast speed reached the minimal detectible change threshold (0.13 m/s). [Conclusion]Short-term physiotherapy combining repetitive facilitative exercises and orthotictreatment may be more effective than the conventional neurofacilitation therapy, toimprove the lower-limb motor performance and functional ambulation of chronic post-strokepatients.

INTRODUCTION

The mobility of many stroke survivors is limited, and most identify walking as a toppriority for rehabilitation1⁾. One way tomanage ambulatory difficulties is with an ankle-foot orthosis (AFO) or a foot-drop splint,which aims to stabilize the foot and ankle while weight-bearing and lift the toes whilestepping1⁾. In stroke rehabilitation,various approaches, including robotic assistance, strength training, andtask-related/virtual reality techniques, have been shown to improve motor function2⁾. The benefits of a high intensity strokerehabilitation program are well established, and although no clear guidelines existregarding the best levels of intensity in practice, the need for its incorporation into atherapy program is widely acknowledged2⁾.

Repetitive facilitative exercises (RFE), which combine a high repetition rate andneurofacilitation, are a recently developed approach to rehabilitation of stroke-relatedlimb impairment2^,3^,4^,5⁾. In the RFE program, therapists use muscle spindle stretching andskin-generated reflexes to assist the patient’s efforts to move an affected joint5⁾. Previous studies have shown that an RFEprogram improved lower-limb motor performance (Brunnstrom Recovery Stage, foot tapping, andlower-limb strength) and the 10-m walk test in patients with brain damage3⁾.

An AFO is an assistive device to help stroke patients with hemiplegia walk and stand. Aproperly prescribed AFO can improve gait performance and control abnormal kinematics arisingfrom coordination deficits6⁾. Gait trainingwith an AFO has been also reported to improve gait speed and balance in post-strokepatients7^, 8⁾.

Therefore, we hypothesized that short-term physiotherapy combining RFE and orthotictreatment would improve both lower-extremity motor performance and functional ambulation.The present study aimed to confirm the efficacy of a combination therapy consisting of RFEfor the hemiplegic lower limb and gait training with AFO.

SUBJECTS AND METHODS

The subjects consisted of 27 inpatients (24 males and 3 females) diagnosed with cerebralhemorrhage (15 patients) or cerebral infarction (12 patients). The patients’ average age was59.3 ± 12.4 years (33–73 years), the duration after onset was 35.7 ± 28.9 months (5–115months), and Brunnstrom Stage medians and quartiles of the hemiplegic lower limb were Stage4.0 and 4–4.5 (stage 3–6), respectively. Eleven patients had right hemiplegia, and 16patients had left hemiplegia. Among the 27 study participants, one used a rigid AFO with amedial stainless steel upright9⁾, two useda posterior spring leaf10⁾, and 24 used ahinged AFO10⁾.

The inclusion criteria were as follows: age, 30–80 years; hemiplegia of the lower limb(Brunnstrom stage 3–6); ability to walk without assistance using a T-cane and/or AFO;diagnosis of hemiplegia due to stroke; morbidity period, 5 months or more; ability tounderstand the purpose of the study and follow instructions, and agreement to participate inthis study. The exclusion criteria were as follows: onset of stroke, <4 weeks previously;abnormal gait prior to the onset of stroke (such as joint disability or peripheralneuropathy); any medical condition that limited the study design (such as severecardiopulmonary disease or severe sensory disturbance); severe aphasia and dementia thatmade it impossible to follow verbal instructions; and lesions on both sides of the cerebralhemisphere.

The procedures complied with the 1975 Declaration of Helsinki, as revised in 2013. Thestudy was conducted after obtaining approval from the ethics committee of the Tarumizu ChuoHospital, and all participants provided written informed consent.

The subjects were enrolled in a before-after study. Intervention was combination therapyconsisting of RFE for the hemiplegic lower limb and gait training with AFO. According to aprevious study, all subjects underwent an RFE program consisting of 7 specific exercisepatterns3⁾, which were used to elicitmovement of the hip, knee, and ankle in a manner designed to minimize synergistic movements.This technique involved the use of rapid passive stretching of the muscles in conjunctionwith tapping and rubbing the skin to assist in generating contractions of the targetedmuscles5⁾. Exercises were performed astwo sets of 50 repetitions with a 1–2 minute rest period in between sets5⁾. In addition, all patients underwent gaittraining with a self-made AFO.

This intervention was performed 40 minutes/day, 6 days/week for 4 weeks. Outcomes weremeasured before intervention and after 4 weeks of intervention. The outcome measures used toassess motor performance were the Fugl-Meyer Assessment of the lower extremity (FMA-LE)11⁾ and the Stroke Impairment Assessment Set(SIAS)12⁾. Functional ambulation wasassessed with a Timed Up & Go Test (TUG)13⁾ and a 10-m walk test (10MWT).

To determine whether physiotherapy that combined RFE and orthotic treatment improved thelower-limb motor performance and functional ambulation, the Wilcoxon Signed-Rank Test wasperformed, because the Shapiro-Wilk’s test showed that the data were not normallydistributed. The analysis was performed with the statistical analysis program SPSSStatistics for Windows version 22.0 (IBM Corporation, Armonk, NY, USA) with a significancelevel of α=0.05.

RESULTS

Table 1 shows the changes in FMA-LE, SIAS, TUG, and 10MWT (comfortable gait speed andfast gait speed). In terms of lower-limb motor performance, FMA-LE increased significantlyfrom 22.96 ± 4.07 to 25.85 ± 4.03 (p<0.01), and SIAS increased significantly from 46.59 ±8.34 to 53.63 ± 7.63 (p<0.01). In terms of functional ambulation, TUG decreasedsignificantly from 17.35 ± 5.57 seconds to 14.02 ± 4.46 seconds (p<0.01), comfortablegait speed increased significantly from 0.68 ± 0.22 (m/sec) to 0.81 ± 0.24 (m/sec)(p<0.01), and fast gait speed increased significantly from 0.80 ± 0.28 (m/sec) to 0.96 ±0.31 (m/sec) (p<0.01).

DISCUSSION

In this study, short-term combination therapy consisting of RFE and orthotic treatment wasconducted to improve the lower-limb motor performance and functional ambulation of chronicpost-stroke patients. There were statistically significant improvements in FMA-LE, SIAS,TUG, and 10MWT after the intervention. Furthermore, the results of the 10MWT at a fast gaitspeed reached the minimal detectible change threshold (0.13 m/s)14⁾.

Recently, some systemic reviews of AFO have reported that gait training with AFO canimprove walking ability and balance in people with stroke1^, 15⁾. However, few studieshave focused on the correlation between AFO and motor performance changes of the lower limbin post-stroke patients16^,17^,18⁾. Changes seen inthis study were more marked in the lower-limb motor performance, with a substantialclinically meaningful change in fast walking speed (0.13 m/s) being achieved by allparticipants who completed the study protocol. The results of this study show thatshort-term combination therapy consisting of RFE and gait training with AFO may enhancelower-limb motor function, thereby improving walking ability in patients with chronicstroke, which is beneficial for comprehensive stroke treatment.

Several studies suggested that RFE might promote functional recovery of hemiplegia andactivities of daily living to a greater extent than conventional neurofacilitation therapy,using a randomized controlled design2^,3^,4^,5^, 19^, 20⁾. Especially, RFE with other interventions(i.e., neuromuscular electrical stimulation, direct application of vibratory stimulationrepetitive transcranial magnetic stimulation, and pharmacological treatments) may be moreeffective than RFE only for the recovery of limb motor performance. In the present study,patients who received RFE with gait training with AFO showed significant functional andambulatory improvements.

This study had some limitations because it involved a small number of subjects, and itsintervention period of four weeks was short. In addition, this was not a randomizedcontrolled trial, and the efficacy of RFE with orthotic treatment could not be compared;therefore, it is difficult to generalize its results. Further, this study could not excludeobserver bias and subject bias because the same staff implemented assessment andtraining.

In conclusion, the differences in FMA-LE, SIAS, TUG, and 10MWT demonstrated thatapplication of a short-term combination therapy consisting of RFE and orthotic treatment hasbeneficial therapeutic effects on improving functional ambulation and motor performance ofthe lower limb in chronic post-stroke patients.

REFERENCES