The symmetry of weight bearing at seat-off during SitTS has been extensively studied, as this event is a transition point at which the balance parameters change from a stable three-point base of support to a relatively unstable two-point base of support. Roy found asymmetry index values at seat-off range from 11.1 (20.2) to 25.6 (12.7) for four foot positions among stroke patients (spontaneous, symmetrical, and the 2 asymmetrical foot positions) [16]. By comparison, the average asymmetry index for SitTS at seat-off is 1.017 (0.979–1.054) among healthy subjects [19], and ranged from 12.8 (Fab) to 21.4 (Faf) in our study. This was much higher than in normal subjects even though subjects exhibited relatively high functional performance as measured by FIM.
In terms of the effect of foot position on the asymmetry index, our results were consistent with previous studies in demonstrating the asymmetrical foot position with Fab facilitated more leg load on the affected leg and subsequently resulted in reduced asymmetry index during SitTS tasks [20,21]. The backward foot functioned as a main pivot at the initial phase. To rise up, the affected lower limb must generate sufficient joint moment from the ankle, knee, and hip joints. Thus, adopting this foot position may improve symmetrical leg loading and avoid non-use of the affected leg.
4.5.3 The effect of hand position on the asymmetry of weight bearing
In this study, the position of the hand was found to play an important role in adjusting motor control before the standing event, even when feet were placed asymmetrically. When feet were placed asymmetrically (Fab or Faf), the hands-clasped (Hc) position led to a shorter duration than other hand positions during preparation and ascending phases, but led to increased duration of the stabilization phase, which is the major determinant of the overall duration of the SitTS task. The increase time needed to stabilize the body might result from a lack of hand movement after standing. It may therefore be inferred that the overall duration of SitTS may be shortened when subjects stand up from the chair with hands clasped and then release
the effect of hand position on the asymmetry index, the hands clasped position let to decreased asymmetry at the onset and seat-off events regardless of foot position.
When subjects reach forward in the hands clasped position, the basic kinematics of forward reach includes forward trunk flexion and hip flexion to bring the center of mass (COM) forward. Furthermore, the retraction of scapula and associated reactions in arm is prevented during SitTS with hands held forward. In simulated studies of the whole-body forward reach task, COM has been shown to be the primary stabilizing reference for posture and movement coordination [22, 23]. Forward trunk inclination has been shown in hemiparetic patients to improve stability at seat-off and during the standing process [18]. As the head-arm-trunk (HAT) segment represents about 70% of the body mass, a change in trunk position leads to altered weight bearing during the SitTS task. Their results may indicate the hands clasped position influences COM and lead to symmetrical alignment of the upper body before standing and during the ascending phase [21]. Thus, the effect of hand position appears to act as the initiating events of a kinematic chain-reaction. Correct hand placement before standing up from the chair usually results in a shorter duration of SitTS and greater symmetry of weight bearing. Torso-limb coupling is a complex neural circuit pathway [24–26], and a fundamental concept, often used in clinical practice to train hemiparetic patients.
Torso-limb coupling also enhances activity through alignment of limbs and body segments.
4.5.4 The effect of foot and hand positions on leg load discrepancy
This whole section is unclear and disorganized. There are some good points but none are fully developed or linked to results. Although the asymmetry index has been studied for various events (such as seat-off), this may not have been sufficient in representing the actual muscle activity after each event. Throughout the SitTS task, the Fab position led the lowest degree of leg load discrepancy.
The stroke patients in this study, with mild functional impairment, compensate for increased difficulty in rising from a chair by attempting to increase body momentum.
While increasing their momentum, they also need to maintain postural stability. Thus, the subjects in this study were likely presented with two conflicting situations: the biomechanical result of projecting the COM onto the posterior foot (affected lower extremity); and the natural tendency to put more weight on the unaffected side. The large leg load discrepancy observed asymmetrical foot placement is most likely a compromise in this difficult situation. The findings in this study, regarding reduced weight-bearing asymmetry, are consistent in terms of leg load discrepancy.
Limitations
First, due to the high demands of this study in terms of participant effort and time, only 21 subjects with relatively high functional performance completed all trials.
Though study subjects had only mild impairments, significant differences were observed among postural configurations in this study. It could be inferred that asymmetry of weight bearing may be even more marked in subjects with moderate and severe functional impairments. Second, the kinematic data of the upper
extremities and trunk are not included in this study. Understanding the interaction of the limbs and trunk and changes in COM would be helpful in determining strategies used by, in, hemiparetic patients performing the SitTS task. Further studies utilizing full body markers and electromyographic recordings during SitTS are required to elucidate the neural control of interactions between the trunk and limbs.
Conclusions
The FabHc position leads to shorter movement durations before rising up and increased leg load symmetry during SitTS. Using the FabHc position for rising up and releasing clasped hands for more stability after standing is a useful strategy for stroke patients performing the SitTS task. Using this strategy, to train stroke patients
according to the purpose of training, clinicians can provide more effective therapeutic interventions for specific underlying impairments.
References
[1] Ramnemark A, Nilsson M, Borssén B, Gustafson Y. Stroke, a Major and Increasing Risk Factor for Femoral Neck Fracture. Stroke. 2000 Jul 1;31(7):1572–7.
[2] Hyndman D, Ashburn A, Stack E. Fall events among people with stroke living in the community: Circumstances of falls and characteristics of fallers. Arch Phys Med Rehabil. 2002 Feb;83(2):165–70.
[3] Forster A, Young J. Incidence and consequences of falls due to stroke: a systematic inquiry. BMJ. 1995 Jul 8;311(6997):83–6.
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[5] Sze K, Wong E, Leung HY, Woo J. Falls among chinese stroke patients during rehabilitation. Arch Phys Med Rehabil. 2001 Sep;82(9):1219–25.
[6] Teasell R, McRae M, Foley N, Bhardwaj A. The incidence and consequences of falls in stroke patients during inpatient rehabilitation: Factors associated with high risk. Arch Phys Med Rehabil. 2002 Mar;83(3):329–33.
[7] Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM. Risk Factors for Falling in Home-Dwelling Older Women With Stroke The Women’s Health and Aging Study. Stroke. 2003 Feb 1;34(2):494–501.
[8] Moreland JD, Richardson JA, Goldsmith CH, Clase CM. Muscle Weakness and Falls in Older Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc. 2004 Jul 1;52(7):1121–9.
[9] Wei TS, Hu CH, Wang SH, Hwang KL. Fall characterictics, functional mobility and bone mineral density as risk factors of hip fracture in the community-dwelling ambulatory elderly. Osteoporos Int. 2001;12(12):1050–5.
[10] Yamada T, Demura S. Relationships between ground reaction force parameters during a sit-to-stand movement and physical activity and falling risk of the elderly and a comparison of the movement characteristics between the young and the elderly. Arch Gerontol Geriatr. 2009 Jan;48(1):73–7.
[11] Engardt M, Olsson E. Body weight-bearing while rising and sitting down in patients with stroke. Scand J Rehabil Med. 1992;24(2):67–74.
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[13] Malouin F, Richards CL, Doyon J, Desrosiers J, Belleville S. Training Mobility Tasks after Stroke with Combined Mental and Physical Practice: A Feasibility Study. Neurorehabil Neural Repair. 2004 Jun 1;18(2):66–75.
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[15] Janssen WG, Bussmann HB, Stam HJ. Determinants of the Sit-to-Stand Movement: A Review. Phys Ther. 2002 Sep 1;82(9):866–79.
[16] Roy G, Nadeau S, Gravel D, Malouin F, McFadyen BJ, Piotte F. The effect of foot position and chair height on the asymmetry of vertical forces during sit-to-stand and sit-to-stand-to-sit tasks in individuals with hemiparesis. Clin Biomech. 2006 Jul;21(6):585–93.
[17] Chen HB, Wei TS, Chang LW. Postural influence on Stand-to-Sit leg load sharing strategies and sitting impact forces in stroke patients. Gait Posture.
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[19] Burnett DR, Campbell-Kyureghyan NH, Cerrito PB, Quesada PM. Symmetry of ground reaction forces and muscle activity in asymptomatic subjects during walking, sit-to-stand, and stand-to-sit tasks. J Electromyogr Kinesiol. 2011 Aug;21(4):610–5.
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Multidisciplinary interventions for fall prevention related to the stroke
We had presented the research results that the previous stroke was one of risk factor of fall and fall related injury (OR=2.9, 95% CI. 1.6~6.3).[1] A high sensitivity and specificity multivariate regression model was built to predict risks of fall for community-dwelling stroke patients, and asymmetrical gait pattern [adjusted odds ratio, aOR = 2.2, 95% CI (1.2–3.8)], spasticity of gastrocnemius [aOR = 3.2 (1.4–
7.3)], and depression [aOR = 1.4 (1.2–1.8)]; the accuracy of model is 0.856; Model two: low score of functional independent measure [aOR = 0.9 (0.9–1.0)],
asymmetrical gait pattern [aOR = 3.6 (1.4–9.2)] and postural sway in mediolateral direction [aOR = 1.7 (1.0–2.7)] were identified as independent risk factors.
Furthermore, the leg and hand strategies during the sit-to-stand and stand-to-sit task, which is related to fall risk during the transfer, were investigated. All these
information were useful for making strategies of multidisciplinary interventions for fall prevention related to the stroke. Recently, the ways of intervention for stroke patients is changing toward a biopsychosocial care model, instead of traditional biological model which only focused on physical condition. The International Classification of Functioning, Disability and Health (ICF) model is based on the
environment, and personal factors. This model can be used to gather information from biological, psychological, and social perspectives. Therefore, the ICF model is an appropriate model for comprehensive fall prevention to organize fall-related risk factors in stroke patients.
Fall prevention and management related to the stroke
Among the interventions studied in our publications and conference papers, a multifactorial falls risk assessment and management were list below in Table 5-1. It includes that exercise program (Yuanji-dance), physical therapy (electrical
acupuncture), and Botulinum Toxin Type-A for spasticity reduction. Although multifactorial fall prevention interventions might be effective for individual patients.
However, for community programs for stroke populations still have risks, targeted single intervention is as effective as multifactorial interventions in the beginning of intervention, may be more acceptable and cost effective.
Table 5-1 Publications and conferences related to fall prevention for the stroke.
Items Publications and Conferences Method
Spasticity reduction
1. Early Injection of Botulinum Toxin Type-A and Electrical Stimulation Improve Upper Extremity Motor
Botulinum Toxin Type-A
Function in Stroke Patients(2016 ISPRM)
2. Effect of Electro-acupuncture on
Decreasing Spasticity of Lower Limbs in Stroke Patients. Journal of Chinese Medical Association of Acupuncture, 2004
1. Application of Electroacupuncture for Improving Gait Performance of Stroke Patient. Journal of Rehabilitation Medicine Association, 1992 2. The Immediate Effect of
Electro-acupuncture on Gait in Stroke Patients with Spastic Hemiplegia. Journal of Chinese Medical Association of Acupuncture, 2011
3. The effect of Chinese Yuanji-dance on Dynamic Balance and the Associated Attentional Demands in Elderly Adults. J Sport Sci Med, 2010
Electrical acupuncture
Yuanji-dance
Depression
1. The Influence of Nasogastric Tube to Post-Stroke Depressive Tendency and Functional Outcome. Journal of Rehabilitation Medicine Association,
1. Delphi-Based Assessment of Fall-Related Risk Factors in Acute
Rehabilitation Settings According to the ICF. Archives of Physical Medicine and Rehabilitation,2014
2. Geriatric health promotion Ch 9: Fall prevention in the elderly. Farseeing
ICF model (Core set)
Comprehensive management
Treatments of spasticity improves gait asymmetry
Spasticity is an upper motor neuron syndrome. It may cause a variety of symptoms that interfere with function. Interventions effects of spasticity management in stroke patients are affected by the length of onset, severity, and distribution of the spasticity;
the locations of injury; the presence and severity of co-morbidities; the family support;
and the goals of treatment (Figure 5-1). In stroke patients, inadequate motor unit recruitment and co-contraction attributable to impaired antagonist inhibition play in the movement disorder of the hemiplegic limbs. Electromyographic data could record muscle activities from agonist and antagonist muscles while subjects attempted to do specified tasks. Inadequate recruitment of agonists, not increased activity in the antagonists, was often seen in patients who were unable to carry out the movement tasks. A case study with co-activation of leg muscles in a patient with stroke was shown in Figure 5-2.
Abnormal muscle tone reduction is indicated if spasticity interferes with some level of function, positioning, care, or comfort. Treatment goals should be well defined before treatment. Botulinum toxin may be used to treat focal spasticity as part of an overall treatment plan [4] and early intervention is suggested [5].
Accurate injection is a fundamental prerequisite for the effective and safe treatment of focal spasticity with botulinum toxin type A (Figure 5-3), and the excellent outcome after botulinum toxin injection was shown in Figure 5-4.
Figure 5-1 Management of spasticity algorithm.
Figure 5-2 Muscle co-contraction pattern on upper and lower limbs.
Agonist-antagonist muscle co-contraction in a 70-year-old Right Hemiplegic patient.
Left: raw EMG signal at lower legs.
Right: RMS of EMG signal.
(A)L anterior tibialis (B)L gastrocnemius (C)R anterior tibialis (D)R gastrocnemius
0
Figure 5-3 Ultrasound guided Botox injection for spasticity reduction.
Figure 5-4 Improvement of equino-varus foot and claw toes after Botox injection.
ICF model for fall prevention
In the past, specialists approach fall-related risk assessment and the development of prevention strategies from their own experience. Currently, the International Classification of Functioning, Disability and Health (ICF) provides a model that systematically organizes fall related risk factors into a comprehensive framework to elucidate the multiple domains of items linked to risk and their interrelations provides a holistic framework for describing and classifying diseases and health conditions.[2]
The ICF model is based on the interactions of body functions, body structures, activities and participation, the environment, and personal factors. It can be used to gather information from biological, psychological, and social perspectives. [2]
Therefore, the ICF model is an appropriate model for comprehensively organizing fall-related risk factors. The advantage of an ICF core set of fall-related risk factors is that multiple fall-related risk factors can be systematically organized based on the ICF framework. A total of 88 fall-related risk factors were identified from relevant articles published between March 1987 and July 2012 were identified from the MEDLINE, PubMed, and SCOPUS databases. Among them, 86 were derived from the systematic literature review and 2 were derived from expert opinion, namely, brain structure defects and ankle spasticity (Appendix 1). This model focused on interactions
between falls and functioning, personal attributes, and environmental influences (Figure 5-5). Table 5-2 showed that the ICF core set for falls by Delphi round in acute rehabilitation settings. A total of 34 categories achieved threshold values of
importance after the third round: 18 categories in body functions (53%), 2 categories in body structures (6%), 8 categories in activities and participation (23%), and 4 categories in environmental factors (12%). Two categories in personal factors (6%) were also identified. For the stroke patients, an example for evaluation of a Stroke patient by ICF healthcare model was shown in Table 5-3.
Figure 5-5 ICF core set of risk factors for falls in acute rehabilitation settings.
Table 5-2 ICF categories included in the ICF core set for falls in acute rehabilitation b240 Sensations associated with hearing and
vestibular function 4.5±0.6 4.8±0.4 4.9±0.3 b755 Involuntary movement reaction functions 4.5±0.6 4.5±0.7 4.6±0.6 b760 Control of voluntary movement functions 4.6±0.5 4.8±0.4 4.8±0.3 b765 Involuntary movement functions 4.1±0.9 4.2±0.7 4.1±0.4 b770 Gait pattern functions 4.8±0.3 4.9±0.2 4.9±0.2 Body structures
s750 Structure of lower extremity 4.5±0.6 4.6±0.5 4.7±0.4 s770 Additional musculoskeletal structures
related to movement 4.1±0.9 4.0±0.7 4.0±0.7 Activities and participation
d410 Changing basic body position 4.4±0.7 4.5±0.6 4.6±0.6 d415 Maintaining a body position 4.3±0.8 4.2±0.5 4.2±0.4 d420 Transferring oneself 4.4±0.6 4.5±0.5 4.5±0.5
d450 Walking 4.7±0.9 4.9±0.3 4.9±0.3
d455 Moving around 4.0±1.2 4.1±0.8 4.1±0.7
d460 Moving around in different locations 4.3±1.0 4.4±0.6 4.3±0.6
Products and technology for personal indoor and outdoor mobility and transportation
4.1±1.1 4.1±0.7 4.1±0.4
e150
Design, construction, building products, and technology of buildings for public use
NOTE. Values shown are the group’s (20 experts) mean scores ±SD from a 5-point Likert scale.
* Categories with a mean score <4 in each round.
* The ICD codes with gray mark are consistent with the our findings in chapter 1
Table 5-3 Evaluation of a stroke patient by ICF model.
Name:
Mr. Chuang Age: 80
Medical diagnosis:
Ischemic stroke (I 63) with left hemiplegia and aphasia
Primary goal of rehabilitation:
Enhance independence of daily activity (FIM reach 80)
Prevent fall, reduce shoulder pain (VAS=2)
Inside walking with cane
Patient's perspective
L’t hemiplegia
Marked L’t shoulder pain after assisted flexion (VAS=5)
Sitting independently
Standing for more than 10 minutes under minimal assistance
Slow walking with assistance of quad-cane for 10 meters
Favor to take a walk in the park, but refuse it after stroke event
Disability for engaging the farmer’s work
Poor expression which lead to communication disturbance Body structures/ Functions Activities/ Participation
Health professional's perspective
L't shoulder ROM limited, (ER-60°, Abducted-160°)
Loss of muscle strength (MMT: 1-2) Increased muscle tone (MAS:1-2) Poor coordination
Abnormal gait pattern (drop foot in swing phase)
Moderate assisted in ADLs (FIM=68) Transfer from wheelchair to bed (moderate support)
No active arm movement
Movement around using wheelchair need others assisted
Contextual factors:
Environmental: Lives in a second floor flat, no elevator; good family support; had cane, wheelchair and AFO's, no other assistive products
Personal: a farmer, depression after stroke, lives with son;
comorbidity- HTN, DM
References
[1] T. S. Wei, C. H. Hu, S. H. Wang, and K. L. H. D. Of, “Fall Characterictics,
Functional Mobility and Bone Mineral Density as Risk Factors of Hip Fracture in the Community-Dwelling Ambulatory Elderly,” Osteoporos. Int., vol. 12, no. 12, pp. 1050–1055, Dec. 2001.
[2] World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization Publishing; 2001.
[3] Stucki G, Grimby G. Applying the ICF in medicine. J Rehabil Med 2004;(44 Suppl):5-6.
[4] 1997 John Wiley & Sons, Inc. Spasticity: Etiology, Evaluation, Management, and the Role of Botulinum Toxin Type A, MF Brin, editor. Muscle Nerve
[4] 1997 John Wiley & Sons, Inc. Spasticity: Etiology, Evaluation, Management, and the Role of Botulinum Toxin Type A, MF Brin, editor. Muscle Nerve