I n / . Drscrbrl. Siudies, 12, 119 - 122
Gait recovery after hemiplegic stroke PAUI .I. FRIEDMAN Stroke Rehabilitation Unit, Waikato Hospital, Hamilton, New Zealand Acceprrd,for publicorion: October 1990 Con-e.v~iondence 10: Paul J . Friedman, FRACP, Stroke Rehabilitation Unit, Waikato Hospital, Hamilton, New Zealand
Disabil Rehabil Downloaded from informahealthcare.com by York University Libraries on 03/03/15 For personal use only.
Ke) words Cerehrovascular disorders
-
gair
~
rehabilitation
Summary We prospectively evaluated gait recovery in 197 elderly subjects after hemiplegic stroke by measuring serial walking speed. Fiftyseven per cent of subjects (113/197) could not walk without human assistance on day 7 post-stroke. About 40% of this group achieved gait independence at months I , 2, 3, and 4 post-stroke. In contrast, about 95% of those walking on day 7 maintained gait independence I . 2, 3, and 4 months post-stroke. Using multiple logistic regression, the best predictors of independent ambulation among the I13 subjects not walking on day 7 were age, line bisection error, and leg power.
Introduction
Immobility is common in the first weeks after stroke. In a study o f 976 acute stroke patients only 27% could walk independently during the first week.’ Three weeks after stroke, however, 60% of survivors could walk independently, and by 6 months 85% could d o s0.I Functional outcome of initially immobile stroke subjects is variable. In one study of 60 3-month survivors, 52% of subjects still immobile during week 1 achieved independent mobility.2 The present study had three objectives: 1. To examine gait recovery among elderly subjects with hemiplegic stroke. 2. To determine which factors were associated with inability to walk without human assistance on day 7 post-stroke. 3. To assess predictors of gait recovery among subjects unable to walk without human assistance on day 7 post-stroke. Methods Waikato Hospital provides early rehabilitation for elderly stroke registry subjects. Within 1 - 3 days of admission stroke team therapists initiate rehabilitation programmes for subjects able to participate. The author examined all persons aged 60 years and above admitted with suspected stroke. Only those with a clinically definite stroke syndrome related to cerebral infarction or intracerebral haemorrhage enter the Stroke Registry without CT scanning or autopsy confirmation of the diagnosis. Subjects with subarachnoid haemorrhage were excluded. Lacunar stroke was defined by the presence of one of the lacunar syndromes3 and the absence of a larger lesion on CT scan, if performed. Stroke Registry subjects aged 6 0 + meeting the following criteria were included in this study: (1) initial hemiplegia or bilateral limb weakness, (2) ambulatory prior to current stroke, and (3) survival for at least 90 days post-stroke with follow-up gait measurements. Exclusion criteria were: (1) severe dependency prior to stroke, as measured by a Modified Barthel ADL score < 11/20, (2) previous lower limb amputation, and (3) other illness sufficiently severe to preclude gait recovery. Subjects meeting inclusion and exclusion criteria were then divided into those able and unable to walk without human assistance seven days after stroke onset. The Waikato Hospital Medical Research Committee approved the study. 0379-0797/91 $3.00
Motor loss was measured as the minimum power in the affected limbs during the first 5 days after stroke using the Medical Research Council scale (0 =total paralysis to 5 = full power). Arm power was the average of the power in the biceps and finger abductors. Leg power was calculated as the average power of the hip extensors, knee extensors, and ankle dorsiflexors. Minimum arm and leg power reflected the lowest average power scores obtained during the first 5 days after admission. Thus subjects admitted with mild motor loss who progressed would be scored according to the power scores after progression. Arm and leg power measured on the Medical Research Council scale at the time of admission have been shown to predict subsequent extremity f ~ n c t i o nCognitive .~ performance was assessed with the Mini-Mental State Examination.’ To identify homonomous hemianopia, visual fields were tested by confrontation using the examiner’s fingers. In testing for visual extinction two simultaneous stimuli were presented. If the subject had any suggestion of hemianopia both stimuli were placed within the intact visual hemispace. Line bisection was performed using a 200 mm long line. T o test for constructional apraxia, subjects were asked to copy a drawing of a house. Walking speed was the primary outcome variable. Walking speed is strongly correlated with other gait parameters such as stride length,6 and functional gait score.6-8 Gait speed is more easily measured than stride length or cadence. Hence serial measurement of gait speed is feasible for subjects in hospital and at home. Gait speed among hospitalized subjects was measured electronically over a 2 m walkway. After discharge, gait speed was measured with a digital stopwatch over a similar distance. In a subset of 12 subjects the mean difference in walking speed between the two methods performed simultaneously was less than 10%. Subjects unable to walk without human assistance were scored as having a walking speed of 0. Gait was measured weekly while in hospital, at discharge, and at approximately days 30.60, 90, 120, and 180 post-stroke. Healthy elderly people have a mean walking speed of approximately 1200 mm/s.9 Independent gait was defined as a walking speed of at least 150 mm/s; subjects with walking speed below this cutoff are too dependent to live alone or in rest homes, and require either a long-term hospital or a fit and dedicated caregiver.I0 Maximal walking speed at any time during the first 6 months post-stroke was used as the time-independent measure of gait recovery.
( ~ 21991
Taylor & Francis Lld
119
FRIEDMAN:Gait recovery after hemiplegic stroke Table 1 Comparison of subjects able and unable to walk without human assistance on day 7 post-stroke with respect to demographic and pre-stroke characteristics.
Immobile
Mobile
113 62 (55%) 74.5 i 6 . 4 9/113 (8%) 19.5 i 1.3. 27/113 (24%)
84 53 (63%) 74.5 f 7.5 3/84 (4%) 19.8 k 0 . 6 22/84 (26%)
95% CI ~~~
n
Male (percentage male) Age Pre-stroke residence institution Pre-stroke Barthel ADL Prior stroke
-22% to + 6 % - 2 . 0 to + 2 . 0 -2% to + I I % - 0 . 6 to 0 - 14% to + 10%
Data reported as mean i SD. CI represents 95% confidence intervals.
* pco.05.
Disabil Rehabil Downloaded from informahealthcare.com by York University Libraries on 03/03/15 For personal use only.
Table 2 Comparison of subjects able and unable to walk at day 7 post-stroke with respect to indices of stroke severity
Alert on admission Lacunar syndrome stroke Arm power Leg power Homonomous hernianopiat Visual extinction? Line bisection error (rnm)? Copy house drawing? Mini-Mental State score?
Immobile
Mobile
95% CI
89/113 (79%)* 15/113 (13%)" 1.00 k 1*36* 1.71 i 1.60' 46/109 (42%)** 27/72 (38%)*** 15.0 f 18.7'" 14/63 (22%)** 14.6 i 10*7*
81/84 (96%) 28/84 (33010) 3.07 f 1-40 3.49 i 1.27 17/83 (20%) 16/76 (21%) 7 . 5 f 11.5 35/70 (50%) 22.0 i 1 . 6
-26% to -9% -32% to - 8 % - 2 . 4 6 to - 1.68 - 2 . 2 0 to -1.36 9% to 34% 2% to 3 I Vo 2 . 3 to 12.7 - 43% to - 12% -10.1 to - 4 . 6
CI represents 95% confidence intervals. * p
Gait recovery after hemiplegic stroke PAUI .I. FRIEDMAN Stroke Rehabilitation Unit, Waikato Hospital, Hamilton, New Zealand Acceprrd,for publicorion: October 1990 Con-e.v~iondence 10: Paul J . Friedman, FRACP, Stroke Rehabilitation Unit, Waikato Hospital, Hamilton, New Zealand
Disabil Rehabil Downloaded from informahealthcare.com by York University Libraries on 03/03/15 For personal use only.
Ke) words Cerehrovascular disorders
-
gair
~
rehabilitation
Summary We prospectively evaluated gait recovery in 197 elderly subjects after hemiplegic stroke by measuring serial walking speed. Fiftyseven per cent of subjects (113/197) could not walk without human assistance on day 7 post-stroke. About 40% of this group achieved gait independence at months I , 2, 3, and 4 post-stroke. In contrast, about 95% of those walking on day 7 maintained gait independence I . 2, 3, and 4 months post-stroke. Using multiple logistic regression, the best predictors of independent ambulation among the I13 subjects not walking on day 7 were age, line bisection error, and leg power.
Introduction
Immobility is common in the first weeks after stroke. In a study o f 976 acute stroke patients only 27% could walk independently during the first week.’ Three weeks after stroke, however, 60% of survivors could walk independently, and by 6 months 85% could d o s0.I Functional outcome of initially immobile stroke subjects is variable. In one study of 60 3-month survivors, 52% of subjects still immobile during week 1 achieved independent mobility.2 The present study had three objectives: 1. To examine gait recovery among elderly subjects with hemiplegic stroke. 2. To determine which factors were associated with inability to walk without human assistance on day 7 post-stroke. 3. To assess predictors of gait recovery among subjects unable to walk without human assistance on day 7 post-stroke. Methods Waikato Hospital provides early rehabilitation for elderly stroke registry subjects. Within 1 - 3 days of admission stroke team therapists initiate rehabilitation programmes for subjects able to participate. The author examined all persons aged 60 years and above admitted with suspected stroke. Only those with a clinically definite stroke syndrome related to cerebral infarction or intracerebral haemorrhage enter the Stroke Registry without CT scanning or autopsy confirmation of the diagnosis. Subjects with subarachnoid haemorrhage were excluded. Lacunar stroke was defined by the presence of one of the lacunar syndromes3 and the absence of a larger lesion on CT scan, if performed. Stroke Registry subjects aged 6 0 + meeting the following criteria were included in this study: (1) initial hemiplegia or bilateral limb weakness, (2) ambulatory prior to current stroke, and (3) survival for at least 90 days post-stroke with follow-up gait measurements. Exclusion criteria were: (1) severe dependency prior to stroke, as measured by a Modified Barthel ADL score < 11/20, (2) previous lower limb amputation, and (3) other illness sufficiently severe to preclude gait recovery. Subjects meeting inclusion and exclusion criteria were then divided into those able and unable to walk without human assistance seven days after stroke onset. The Waikato Hospital Medical Research Committee approved the study. 0379-0797/91 $3.00
Motor loss was measured as the minimum power in the affected limbs during the first 5 days after stroke using the Medical Research Council scale (0 =total paralysis to 5 = full power). Arm power was the average of the power in the biceps and finger abductors. Leg power was calculated as the average power of the hip extensors, knee extensors, and ankle dorsiflexors. Minimum arm and leg power reflected the lowest average power scores obtained during the first 5 days after admission. Thus subjects admitted with mild motor loss who progressed would be scored according to the power scores after progression. Arm and leg power measured on the Medical Research Council scale at the time of admission have been shown to predict subsequent extremity f ~ n c t i o nCognitive .~ performance was assessed with the Mini-Mental State Examination.’ To identify homonomous hemianopia, visual fields were tested by confrontation using the examiner’s fingers. In testing for visual extinction two simultaneous stimuli were presented. If the subject had any suggestion of hemianopia both stimuli were placed within the intact visual hemispace. Line bisection was performed using a 200 mm long line. T o test for constructional apraxia, subjects were asked to copy a drawing of a house. Walking speed was the primary outcome variable. Walking speed is strongly correlated with other gait parameters such as stride length,6 and functional gait score.6-8 Gait speed is more easily measured than stride length or cadence. Hence serial measurement of gait speed is feasible for subjects in hospital and at home. Gait speed among hospitalized subjects was measured electronically over a 2 m walkway. After discharge, gait speed was measured with a digital stopwatch over a similar distance. In a subset of 12 subjects the mean difference in walking speed between the two methods performed simultaneously was less than 10%. Subjects unable to walk without human assistance were scored as having a walking speed of 0. Gait was measured weekly while in hospital, at discharge, and at approximately days 30.60, 90, 120, and 180 post-stroke. Healthy elderly people have a mean walking speed of approximately 1200 mm/s.9 Independent gait was defined as a walking speed of at least 150 mm/s; subjects with walking speed below this cutoff are too dependent to live alone or in rest homes, and require either a long-term hospital or a fit and dedicated caregiver.I0 Maximal walking speed at any time during the first 6 months post-stroke was used as the time-independent measure of gait recovery.
( ~ 21991
Taylor & Francis Lld
119
FRIEDMAN:Gait recovery after hemiplegic stroke Table 1 Comparison of subjects able and unable to walk without human assistance on day 7 post-stroke with respect to demographic and pre-stroke characteristics.
Immobile
Mobile
113 62 (55%) 74.5 i 6 . 4 9/113 (8%) 19.5 i 1.3. 27/113 (24%)
84 53 (63%) 74.5 f 7.5 3/84 (4%) 19.8 k 0 . 6 22/84 (26%)
95% CI ~~~
n
Male (percentage male) Age Pre-stroke residence institution Pre-stroke Barthel ADL Prior stroke
-22% to + 6 % - 2 . 0 to + 2 . 0 -2% to + I I % - 0 . 6 to 0 - 14% to + 10%
Data reported as mean i SD. CI represents 95% confidence intervals.
* pco.05.
Disabil Rehabil Downloaded from informahealthcare.com by York University Libraries on 03/03/15 For personal use only.
Table 2 Comparison of subjects able and unable to walk at day 7 post-stroke with respect to indices of stroke severity
Alert on admission Lacunar syndrome stroke Arm power Leg power Homonomous hernianopiat Visual extinction? Line bisection error (rnm)? Copy house drawing? Mini-Mental State score?
Immobile
Mobile
95% CI
89/113 (79%)* 15/113 (13%)" 1.00 k 1*36* 1.71 i 1.60' 46/109 (42%)** 27/72 (38%)*** 15.0 f 18.7'" 14/63 (22%)** 14.6 i 10*7*
81/84 (96%) 28/84 (33010) 3.07 f 1-40 3.49 i 1.27 17/83 (20%) 16/76 (21%) 7 . 5 f 11.5 35/70 (50%) 22.0 i 1 . 6
-26% to -9% -32% to - 8 % - 2 . 4 6 to - 1.68 - 2 . 2 0 to -1.36 9% to 34% 2% to 3 I Vo 2 . 3 to 12.7 - 43% to - 12% -10.1 to - 4 . 6
CI represents 95% confidence intervals. * p
