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Restoration of weight-shifting capacity in patients with postacute stroke: A rehabilitation cohort study

https://doi.org/10.1016/j.apmr.2004.10.010Get rights and content

Abstract

de Haart M, Geurts AC, Dault MC, Nienhuis B, Duysens J. Restoration of weight-shifting capacity in patients with postacute stroke: a rehabilitation cohort study. Arch Phys Med Rehabil 2005;86:755-62.

Objectives

To identify and interrelate recovery characteristics of voluntary weight shifting after stroke and to examine whether the assessment of weight shifting adds information about balance recovery compared with the assessment of quiet standing.

Design

Exploratory study using an inception cohort with findings related to reference values from healthy elderly persons.

Setting

Dutch rehabilitation center.

Participants

Thirty-six inpatients (mean age, 61.8y; mean time poststroke, 10wk) with a first hemispheric intracerebral infarction or hematoma who were admitted to retrain standing balance and walking.

Intervention

Individualized therapy.

Main outcome measures

Center of pressure (COP) displacements were registered during voluntary frontal-plane weight shifting guided by visual COP feedback using a dual-plate force platform. Besides the speed (number of weight shifts) and imprecision (normalized average lateral COP displacement per weight shift), the weight-transfer time asymmetry and the spatiotemporal distribution were determined. Assessments took place as soon as patients could stand unassisted for at least 30 seconds and at 2, 4, 8, and 12 weeks later.

Results

During the 12-week training period, the stroke patients increased both their speed (2.3 hits/30s; 95% confidence interval [CI], 1.1–3.4) and precision (37.7mm/hit; 95% CI, 10.4–65.0) of weight shifting. Although the speed appeared to stabilize at a suboptimal level after 8 weeks, precision reached normal reference values after 12 weeks. Both older age (≥65y) and the presence of visuospatial hemineglect negatively affected weight-shifting speed but not its relative improvement in time. During the training period, a small degree of weight-transfer time asymmetry persisted (mean change, .07; 95% CI, –.21 to .36), with an average of 23% slower weight shifts toward the paretic leg, but the spatiotemporal distribution remained symmetrical. The correlations between weight-shifting and quiet-standing control at the end of training were moderate (Spearman ρ range, .50–.77).

Conclusions

Even subjects with severe stroke who are selected for inpatient rehabilitation are able to improve their speed and precision of weight shifting by reducing the weight-transfer time toward both legs in a proportionate manner. The observed correlations between weight shifting and quiet standing indicate that the assessment of weight-shifting capacity provides unique information about balance recovery after stroke.

Section snippets

Participants

All patients with a first hemispheric intracerebral infarction or hematoma, who were admitted to our rehabilitation clinic for retraining motor skills and self-care abilities during a period of 2 years were eligible. Patients who, on admission, already walked safely and those with medication- or nonstroke-related sensory or motor impairments that could interfere with their postural regulation were excluded. Based on practical assessment, patients with concomitant cognitive or psychiatric

Cohort

Five follow-up assessments were completed in 36 stroke patients, whose main biologic and clinical characteristics are listed in table 1. As for their functional capacity, the median Brunnstrom stage was IV (range, II-VI) at the start of the balance training and improved to V (range, III-VI) after 12 weeks (P<.001). The median FAC score improved by 2 points from 2 (range, 1–4) at the start to 4 (range, 1–5) at the end of the 12-week period (P<.001). Eleven patients failed to make a minimum of 5

Discussion

The primary goal of this study was to provide insight into several characteristics of the restoration of weight-shifting control in first-ever postacute hemispheric stroke survivors during 12 weeks of inpatient rehabilitation, irrespective of the causal mechanisms. For this purpose, an instrumented dynamic balance task was used that required patients to make voluntary well-controlled weight shifts in the frontal plane while using real-time and real-size visual COP feedback. This task was

Conclusions

Even severe stroke patients who are selected for inpatient rehabilitation to retrain gross motor skills can substantially improve their weight-shifting capacity in the frontal plane during a 12-week training period, in terms of both speed and precision. Unlike the speed of weight shifting, precision may even reach the performance level of the healthy elderly. An advanced age (>65y) and the presence of visuospatial hemineglect primarily affect the absolute weight-shifting speed but not its

Acknowledgment

We thank the staff of the Department of Physical Therapy for their help during the posturographic assessments.

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