IJGG Journal

Introduction

The incidence of stroke has decreased over the last 50 years, but the seriousness of the disease has not. Stroke is the major cause of disability in the adult population with a life time risk of 14.5% for men and 16.1%for women [1]. Eighty percent of the patients are older than 65 years. Stroke patients have a high frequency of recurrence and mortality, and generate yearly over one million hospital days in Sweden [2]. Early admission to a highly specialized stroke unit improves the end result. After confirming the diagnosis and providing adequate medical treatment, care is focused on functional training programs that concern daily activities and movement exercises. Early mobilization decreases risks of complications, contributes to recovery and increases possibility of early return to independent living [3, 4].

Apart from residual weakness foot deformity and stiff knee gait can be a cause of walking impairment after stroke. Even if the clinical findings with mild deformity are subtle, they can still cause major functional problems. The identification of patients with treatable walking impairment is rarely considered. Technological investigation of gait that can contribute to a more specified diagnosis and provide a guide for treatment is available, but seldom used [5-7].

Both caregivers at the stroke unit, at the rehabilitation unit and in the community are often unaware of possible specific treatment which results in few referrals to the orthopedic surgeon.

There are several different treatment modalities. Stretching, orthosis/braces, botulinum toxin injections or surgery with tendon lengthening and transfer can be indicated [5, 8-13].

Several authors have reported on quality of life and activity of daily life among stroke survivors. However, gait impairment is seldom well defined and often limited to whether the individual is able to walk or not. Therefore, correlation between quality of life and more detailed walking capacity has not been well investigated in stroke patients [14-16].

The aim of this study was to identify variables which could have major effects on walking capacity after stroke and to investigate the correlation to quality of life. Additionally, we wanted to make an inventory of the frequency of walking aid and foot and ankle orthosis/braces.

Patients

Approval from the ethic committee was obtained for the study. Skövde County Hospital is the only stroke referral hospital for the 172 000 inhabitants in the region. Between July and November 2002, 253 consecutive patients with stroke possible for inclusion were registered. The patients were examined and diagnosed by a stroke physician according to the WHO criteria [17]. Inclusion criteria were first stroke ever. Patients with subarachnoid and subdural hemorrhage, transitory ischemic disease or amaurosis fugax, as well as patients with other diseases or deformities that could influence walking were excluded.

Three months after admission to the stroke unit the patients were contacted by letter and asked for participation. Fifty-five (22%) were dead. Fifty-seven (23%) patients did not participate in the follow up for different reasons, where 23 did not want to or lacked the energy to participate, 13 patients suffered from senile dementia, and 6 suffered from other conditions (1 hip fracture, 1 dizziness, 1 psychiatric disease, 1 dysphasia and two patients were excluded for unspecified other disease). Six lived in other regions at a long distance. Six could not walk and 3 patients were missed for follow-up.

The remaining 141 (55%) were available for follow up after a median of 5,4 months (range 3,0-8,2 months) and gave their written consent to participate.

Methods

All questionnaires regarding quality of life were sent out prior to the clinical examination. One specially trained and instructed physiotherapist from the Orthopedic Department examined and interviewed all patients according to a standardized protocol. Some patients wanted to and were examined in their home and the remaining visited the hospital.

Quality of life questionnaires

The Nottingham Health Profile (NHP) is a self-reporting questionnaire of quality of life that measures the subjective emotional, functional and social impact of disease. NHP consists of two parts and is validated, reliable and translated to Swedish [18-20]. In this part of the study the patients were stratified in age groups and compared to the corresponding normal population.

Functional assessments

The Barthel´s index of activities of daily living (Barthel) that measures functional independence in personal care and mobility was used [21]. It consists of 10 variables from daily life activities.

The functional and validated test Timed up and Go (TUAG) was used and provides information on the time and quality of movement from a sitting position to standing up, walking 3 meters and returning to sitting [22]. For measurement of the neurological impairment the Scandinavian Stroke Scale (SSS) was used [23].

Observational Gait analysis and clinical assessment

The patients walked 5 meters with and without shoes and measurement of speed and cadence was obtained. The positioning of the foot and knee during stance and swing phase was assessed. In stance phase it was determined whether the heel, foot flat or the toes made initial contact with the floor. Additionally, it was registered if heel contact occurred at all and if there was knee hyperextension. In swing phase it was noted if the foot in relation to the tibia was dorsally flexed to or above neutral position or all the time in relative equinus/drop foot.

Muscle tone in the calf muscle on the affected side was registered [24]. Dorsiflexion strength of the foot at the ankle on the affected side was assessed by a “5 point scale” - normal strength=5, good=4, fair=3, poor=2, trace=1 and no trace of contraction=0 [25]. Active and passive range of motion from the hip, knee and ankle joints was measured.

Walking aid and braces

The type and design of walking aids and braces was noted as well as if the devices were used outdoor and/or indoors. How well the equipment fitted was evaluated.

Statistical Analysis

In order to evaluate the strength of associations between quality-of-life variables and variables for observational gait analysis and walking speed Spearman’s correlations coefficients was calculated. The correlations coefficients were based on bivariate correlation tests. All calculations were done using SPSS version 15.

Results

Of the 141 patients that met the inclusion criteria 60 were females and 81 men. The median age was 74 years, range 29103 years. The Computed Tomography scan (CT) performed at admission in all patients but one, revealed cerebral infarction in 123 patients and cerebral hemorrhage in 17 patients. The mean hospital stay was 10 days. The majority, 112 patients returned directly to their previous independent private living, 22 were discharged to homes for elderly and 7 to other hospitals.

Quality of life questionnaires

In the quality-of-life questionnaire the stroke patients scored worse in all domains compared to age and gender matched controls. The higher score the worse reported quality of life. (Figure1).

Figure 1: Quality of life and age groups after stroke

Functional assessments

The Barthel´s index of activities of daily life showed most patients on a high score meaning good ability. Of 141 patients, 106 scored above 90 points where 100 were considered normal. Similarly in the Timed Up and Go test 104 patients scored normal or nearly normal. Also, in the Scandinavian Stroke Scale the majority of patients scored high.

Observational gait analysis and clinical assessment

In 68 patients (48%) the observational gait analysis and the clinical assessment revealed one or more pathological findings with deviation from normal. Twenty-seven patients had drop foot in swing, 35 heel not down at initial contact, 14 hyperextension of the knee during stance and 51 decreased dorsiflexion strength (less than 3 on the “5 point scale”). Fourteen had decreased ankle dorsiflexion in passive motion (less than 5 degrees over neutral). Finally, 16 had an increased muscle tone in the calf muscle plantar flexors (triceps surae) on the affected side. (Table 1).

Table 1: Variables from the observational gait analysis and clinical examination in the 68 patients (of 141) with one or more pathological findings.

The mean time for 5 meters walking with shoes was 7, 7 seconds and barefoot 8, 2 seconds.

The correlation between walking speed and the observational gait and clinical variables were statistically significant but the strength of associations was only fair. There was a moderate to good correlation between walking speed and quality of life, NHP 1. (Table 2). The other variables were not correlated.

Table 2: Correlation coefficients between walking speed 5 meters and variables from observational gait analysis and strength and quality of life.

Walking aid and orthosis/braces:

Walking aid was prior to stroke used by 23 patients (16%) and after stroke by 69 patients (49%). Before stroke no patients had walking aid indoor but after stroke 38 (27%) did. (Figure 2).

Figure 2: Walking aid before and after stroke.

In the group with pathological findings on the observational gait analysis and the clinical examination there was a marked increase in frequency of walking aid from 15 patients (22%) to 47 patients (70%). In the group without pathological findings 8 patients (11%) had walking aid before stroke and 22 patients (30%) after stroke.

Of 8 patients that had a brace 5 used it. Three were used outdoor, 1 always when walking and in one patient once in a while. These five braces were considered to fit well. In three patients the brace was not used and did not fit. Three braces were toe-off and five were premade pp-braces made of polypropylene.