Physical Therapy following Stroke
The purpose of this paper is to review a study by Kim, Kim, and Kim1 on the topic of physical therapy following cerebrovascular accident (stroke). The paper will summarize the study, comment on the relevance of the article to the field of physical therapy, and the importance of the study to other stakeholders. Finally, the paper will add recommendations for future research based on the results of the study.
1. Summary of the study
The aim of the study was to determine if there was a relationship between stroke survivors’ quality of life and their ability to accomplish daily living activities. The design of the study was to conduct two questionnaires with stroke survivors, activities of daily living and quality of life, and to perform statistical analyses in order to determine if there is an association between the two variables. The participants were 68 individuals who had been diagnosed with stroke and were attending a disability welfare center or a health care facility. The exclusionary criteria were severe aphasia or a score < 20 on the Mini Mental State Examination, both of which would likely interfere with the participants’ ability to respond accurately to the test instruments.
The survey instruments were the Stroke Specific Quality of Life (SS-QOL) and the Functional Independence Measure (FIM). The SS-QOL encompassed 12 domains related to quality of life and consisted of: mobility, language, mood, thinking, family role, work or productivity, social role, energy, self-care, personality, upper-extremity function, and vision. The FIM assessed the level of independence across a range of activities: sphincter control, locomotion, social cognition, self-care, and mobility in terms of transfers. The questionnaires were conducted by three physiotherapists and one nurse in face-to-face interview with the participants.
Correlations between test results of the different raters indicated an acceptable interrater reliability. The test results were analyzed by conducting correlations among the items on the FIM and the total FIM score, and between the FMI scores and the SS-QOL scores. A multiple regression analysis was used to determine the most important factors of the FMI that led to higher quality of life levels. The results showed statistically significant positive correlations between each item of the FIM and the total SS-QOL score and the total FIM score and the total SS-QOL score. The two items on the FIM questionnaire that were most associated with high levels of SS-QOL were mobility and social cognition.
2. Analysis of the study
The study has value to the field of physical therapy because the assessments of activities of daily living and quality of life provide the information needed to prepare a therapy plan. An appropriate physical therapy plan enhances the ability of the stroke survivor to re-integrate into the community and to avoid institutionalization. The finding that quality of life is associated with mobility is important because previous research indicated that lack of mobility is related to a greater risk of mortality and loss of independence.2
Although the study demonstrated significant results, the findings would have a greater weight if a control group had been used, for example, a group age and sex matched with a comparable disability such as hip fracture or osteoporosis. A control group would have allowed a greater analysis of the impact of cognitive deficits, which common among stroke survivors but not among other disabilities, on quality of life. Also, it would have been helpful for the reader to have details on the validity and reliability of the FIM and the SS-QOL.
3. Beneficiaries of the study results
Stroke is the biggest cause of adult disability in the U.S.3 About one-quarter of stroke survivors sustain a marked functional disability at the point they are ready to be discharged from the hospital and hence can benefit from physical therapy.4 The field of physical therapy, hospital administrators, the Ministry of Health, and of course the stroke survivor and his or her caregivers, are all stakeholders in the results of the study. The finding of Kim, Kim and Kim1 on the relationship between mobility and quality of life highlights the importance of the field of physical therapy in the wellbeing of stroke survivors. A good inpatient physical therapy program will ultimately lead to a better quality of life for stroke survivors. This is an important finding because other research has demonstrated that, internationally, guidelines on the length and intensity of physical therapy post stroke frequently are not being met.5
Post stroke care is one of the most rapidly growing expenditure for Medicare.3 Also, close to 70% of primary caregivers will spend more than 40 hours a week providing physical and psychosocial support to stroke survivors.6 Both the Ministry of Health and caregivers are stakeholders in the functional status of stroke survivors and benefit by their achieving as great an independence as quickly as possible. A further cost savings is that functional independence reduces the chance that stoke survivors will be institutionalized.2
The primary beneficiaries of the results of the study are the caregivers and the stroke survivors. In addition to increasing the burden on the caregiver, limited capabilities in activities of daily living exacerbate post-stroke depression7, which in turn leads to the loss of social contact and valued social roles.8 Therefore, it is important to understand the aspects of activities of daily living that provide the best outcome in terms of quality of life.
4. Significance of the paper for physical therapy
Promoting the quality of life through better mobility and function is central to physical therapy practice. The Kim, Kim and Kim1 study has value to the physical therapy literature as it extends the information on the relationship between quality of life and activities of daily living. Stroke is more prevalent among the elderly. As the population ages, the role of physical therapy in the health care delivery system will expand. Further, isolating mobility as the factor most related to quality of life allows physical therapists to place more emphasis on the specifics of mobility, such as transfers, in their treatment plans.
Much of the research in physical therapy focusses on inpatient interventions and the early rehabilitation phase of chronic disabilities. The Kim, Kim and Kim1 study participants are on average eight years post stroke, which provides information on the status of activities of daily living and the quality of life at a later stage of recovery. Specifically, the study allows physical therapists to plan interventions today with a view to the stroke survivor’s quality of living in the years to come.
5. Implications for future research
Although the findings were statistically robust, the study had a small number of participants given the complex factors that intersect with quality of life. An increased number of subjects and a control group would provide more convincing evidence for the relationship between activities of daily living and quality of life and clarify other confounding factors. A longitudinal study with an assessment of activities of daily living and quality of life at different stages would give a better picture of the factors that lead to quality of life in the long run.
Co-morbidities, drug regimens, and gender could have implications for long term rehabilitation studies in community living stroke survivors. Based on the Kim, Kim and Kim1 study results, another direction for research that would provide useful information for physical therapists, would be controlling for these factors.
References
1. Kim K, Kim YM, Kim EK. Correlation between the activities of daily living of stroke patients in a community setting and their quality of life. J. Phys. Ther. Sci. 2014; 26: 417-419.
2. von Bonsdorff M, Rantanen T, Laukkanen P, Suutama T, Heikkinen E. Mobility limitations and cognitive deficits as predictors of institutionalization among community-dwelling older people. Gerontology. 2006; 52(6): 359-65.
3. Dobkin BH. Rehabilitation after stroke. N Engl J Med. 2005; 352(16): 1677–1684. doi:10.1056/NEJMcp043511.
4. Knecht S, Hess S, Oster P. Rehabilitation after stroke. Dtsch Arztebl Int 2011; 108(36): 600–606. DOI: 10.3238/arztebl.2011.0600
5. Clark DJ, Tyson S, Rodgers H, et al. Why do patients with stroke not receive the recommended amount of active therapy (ReAcT): Study protocol for a multisite case study investigation. BMJ Open 2015. DOI: 10.1136/bmjopen-2015-008443
6. Luker JA, Bernhardsson S, Lynch E, Murray C, Hill OP. Carers’ experiences, needs and preferences during inpatient stroke rehabilitation: a protocol for a systematic review of qualitative studies Systematic Reviews 2015; 4:108. DOI 10.1186/s13643-015-0097-0
7. Ouimet M, Primeau F, Cole M. Psychosocial risk factors in poststroke depression: A systematic review. Can J Psychiatry 2001; 46: 819-828.
8. Pound P, Gompertz P, Ebrahim S. A patient-centred study of the consequences of stroke. Clin Rehabil 1998; 12:338–347.
