To establish the effect of task oriented group circuit training for people affected by stroke in the public healthcare sector in RSA

Ballington, Megan Claire
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Stroke remains a serious public health problem in low, middle and high income countries worldwide. In low and middle income countries there has been a greater than 100% increase in stroke incidence. The impact of HIV associated vasculopathy is recognized as contributing to the increased prevalence of stroke in younger patients (Tipping et al., 2007) and is an independent risk factor for stroke (Cole et al., 2004). The impact of this increased stroke incidence has not only resulted in an increase in death rates in the developing world, but has also resulted in increases noted in long term disability as a result of stroke. The available resources for stroke care and rehabilitation are lacking in developing countries including Africa, particularly in rural areas. It has also been noted that 80% of the population live in areas where factors such as limited resources and cultural practices limit access to stroke services (Poungvarin 1998). Currently patients with stroke are discharged from hospitals in the public healthcare sector within six to 14 days of having a stroke, because of the pressure for beds (Mudzi, 2009; Reid et al., 2005; Hale, 2000). As a result patients are not benefitting from rehabilitation services and this leads to suboptimal recovery post stroke and to a large number of persons living with disabilities in under resourced communities. Because the patients with stroke are discharged so acutely after their stroke, carers become a necessity to cope with the burden of care. These conditions result in increased stroke survivor dependence in South Africa compared to the USA or New Zealand. While 80% of stroke survivors who are initially unable to walk achieve independent walking (Jorgensen et al., 1995), at three months post stroke 25%-33% still require assistance or supervision when walking (Jorgenson et al., 1995; Duncan et al., 1994; Richards et al., 1993). Unfortunately these independent walkers seldom achieve walking speeds that are sufficient for community ambulation (Schmid et al., 2007; Lord and Rochester, 2005; Lord et al., 2004). Walking competency is a term used to describe a certain level of walking ability allowing an individual to participate in the community safely and efficiently (Salbach et al., 2004). It should also be noted that even those with mild and moderate strokes experience limitations with higher physical functioning which impacts on their quality of life and ability to return to work (Duncan and Lai, 1997). The cerebral cortex has the ability to undergo functional and structural reorganization for several weeks and even months in more severe cases post stroke. Rehabilitation post stroke facilitates this process and can shape the reorganization of the adjacent intact cortex (Green, 2003). Further, it has been concluded that to facilitate the best possible functional outcome for people post stroke, engagement in intensive task oriented therapy is necessary (Kwakkel et al., 2004; Van Peppen et al., 2004). Considering these findings it is extremely concerning that there is little or no rehabilitation provided to stroke survivors in the public healthcare sector in South Africa (Mudzi, 2009; Rhoda and Hendry 2003; Hale and Wallner, 1996; Stewart et al., 1994). With this in mind, the aim of this study was to determine if an out -patient based task oriented group training programme would promote improved walking competency more than the current progressive resistance strength group training programmes that are common practice in persons who have had an acute stroke in the public healthcare system in South Africa. The specific objectives of this study were to establish the effect of a low intensity, namely once a week (for six weeks), out- patient based task programme on: walking competency, walking endurance, gait speed and health status in terms of physical functioning in persons with sub-acute stroke. Due to the high incidence of post stroke survivors with HIV it was important to establish if the training programme produced comparable effects in HIV positive and HIV negative subjects. This study used a stratified blocked randomised controlled trial design. Where group allocation was concealed. In addition assessor blinded evaluations were conducted at baseline, post intervention and at six months after the intervention had ceased. A total of 144 persons who had a stroke were stratified according to their walking speed – mild (able to walk at a gait speed > 0.8m/s), moderate (able to walk at a speed of 0.4-0.8 m/s) or severe (able to walk at a speed < 0.4m/s) – and randomly assiged to one of three training groups. One group received task oriented group circuit training (task group), the second group received progressive resistance strength training (strength group), and the third group participated in one multidisciplinary education group training session (control group). The task and strength interventions included 6 sessions, of 60 minutes each for six to 12 weeks. While the control intervention group participated in one three hour education session, which included advice on the importance of exercise and a 20-minute exercise session. All subjects had been discharged from the public healthcare sector and were less than six months post stroke at inclusion into the study. The primary objective was walking competency, which included the measurement of walking endurance, gait speed, functional balance and mobility (Salbach et al., 2004). The task group showed an improvement that was significantly greater than that achieved by the strength and control groups in walking endurance, gait speed, functional mobility and balance at the follow-up. These findings demonstrate that the provision of as little as six sessions of task training (in a developing country, where persons with sub-acute stroke have had no previous rehabilitation) improves walking competency to a significantly greater extent than either a strength intervention of equal intensity, or a control intervention programme consisting of one three hour education visit in the sub -acute phase post stroke. While the strength group received a more frequent and intensive training compared with the control group, there were no significant differences in terms of walking competency between these two groups over the study period. The task group showed significantly greater improvements in walking endurance, comfortable and maximum gait speed than the strength and control groups immediately post intervention. While post intervention, the task training led to superior gains in functional mobility and balance compared to the control group, it was not superior to the strength group. For subjects, with a moderate gait disability at baseline, the improvements in walking endurance and in comfortable and maximum walking speed in the task group were significantly more than the strength and control groups. For subjects with a severe gait deficit at baseline, the task group improved significantly more than the control group on all measures of walking competency but not significantly more than the strength group. There were no significant differences among the groups for subjects with a mild gait deficit at baseline. All three treatment intervention groups improved their score on the stroke impact scale 16 (SIS 16) over the course of the study period. The task group improved significantly more than the control group’s health status in terms of physical functioning measured by the SIS16. There were no significant differences among the groups in the change scores for the measures of walking competency between the HIV positive and HIV negative subjects throughout the study period. The results of this study demonstrate that an extremely limited number of task training sessions resulted in significantly greater improvements in walking competency than progressive strength training or a multidisciplinary education training approach. However, these results must be interpreted with caution, remembering the context of the sample population who had not received a period of inpatient rehabilitation prior to their inclusion into the study and were 10-15 years younger than subjects in numerous other studies. This appears to be the first study conducted with such a limited rehabilitative intervention post stroke. As a result, further research to evaluate the effectiveness of limited intensity task oriented training interventions for non -ambulant stroke survivors in the developing world where resources are limited, needs to be conducted. It is important to explore the benefits of different group based rehabilitative interventions for stroke survivors to alleviate the burden as a result of disability as much as possible. Key words: Stroke, Task Oriented, Rehabilitation, Walking, Walking Competency