BAOJ Orthopedics

BAOJ Orthopedics Enas Elsayed, et al, BAOJ Ortho 2016 1: 1 1: 001

Research Article

Effect of Shoe Insert on Weight Bearing Symmetry in Stroke Patients Enas Elsayed1,2*, Ashraf Darweesh2, Rasha Hegazy2, Saja Basharahil1 and Abrar Al Beladi1 Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdulaziz University, KSA

1

Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Egypt

2

Abstract Backgruond There is evidence that patient with stroke exhibits asymmetry in standing position as well as during functional activities. Objective The study aimed at investigating the effect of shoe insert on the symmetry of weight bearing in stroke. Subjects Twenty subjects with stroke were selected from King Abdulaziz University hospital in Jeddah and were randomly assigned into two equal groups, study and control. Methods All patients were evaluated regarding balance by Berg Balance scale (BBS), motor function of the lower limb by Fugl-Meyer assessment scale (FMA), weight bearing symmetry by weighting scales, gait velocity by stop watch and finally step length for both lower limbs by tape measurement. Both groups received traditional physical therapy exercise program but the study group was instructed to wear a shoe insert in the non-affected limb for 35 min during which the weight bearing exercises were practiced. The study continued for four weeks, two times /week, every session lasted for 60 min. Results The findings revealed remarkable improvement in weight bearing symmetry, significant improvement in the BBS scores (p= 0.03). Also, there was mild improvement in the motor functions of the lower limb regarding FMA scores, gait velocity and step length symmetry after treatment in study group. Conclusion Use of shoe insert in the non-affected lower extremity, in addition to the conventional physical therapy program, is effective in improving weight bearing symmetry and motor functions in patients with stroke. Key Words: Stroke; Shoe Insert; Weight Bearing Symmetry; Berg Balance Scale; Fugl-Meyer Assessment; Gait Velocity

Introduction Stroke is one of the most common neurological disorders that represent a major cause of disability [1]. It is an enormous and serious public health problem and the third leading cause of death, BAOJ Ortho, an open access journal

after ischemic heart disease and cancer. Most of deaths from stroke occurred in the less developed countries [2]. A stroke has a major effect on individual’s life. It results in longterm disability and necessitates prolonged treatment. Patients present healthcare professionals with a variety of complex physical, psychological and social problems. The sudden loss of any capacity causes severe stress not only to the patient but also to the family. The resultant neurological deficit can have a devastating outcome [3]. One of these disabling outcomes is the impaired balance where the standing posture is characterized by three patterns. An increase in centre of gravity (COG) shifting, which reflects postural instability and attributed to musculskeletal, sensorimotor, and cognitive abnormalities; the presence of a limited area of stability beyond which the COG cannot shift without causing loss of balance which results from either an inability to control a stressed equilibrium system or from affected co-ordination between posture and movement; and finally, weight bearing asymmetry with more weight bearing on the unaffected limb [4,5]. Asymmetric steps are a characteristic of hemiparetic gait, with the paretic limb having a shorter stance time and step length than that of the non-paretic limb. It has been reported that the degree of asymmetry is related to the degree of motor recovery and spasticity of the affected ankle plantar flexors [6]. Gait asymmetry leads to increased energy consumption and liability to fall. So, enhancement of symmetry can be considered a clinical marker of functional recovery [7-9]. The goal of stroke rehabilitation is to obtain maximum independence and functioning. Rehabilitation involves relearning *Corresponding author: Enas Elsayed, Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia, P.O. Box 80200, Jeddah21589, E-mail: [email protected] Sub Date: October 5, 2016, Acc Date: October 18, 2016, Pub Date: October 19, 2016. Citation: Enas Elsayed, Ashraf Darweesh, Rasha Hegazy, Saja Basharahil and Abrar Al Beladi (2016) Effect of Shoe Insert on Weight Bearing Symmetry in Stroke Patients. BAOJ Ortho 1: 001. Copyright: © 2016 Enas Elsayed, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Volume 1; Issue 1; 001

Citation: Enas Elsayed, Ashraf Darweesh, Rasha Hegazy, Saja Basharahil and Abrar Al Beladi (2016) Effect of Shoe Insert on Weight Bearing Symmetry in Stroke Patients. BAOJ Ortho 1: 001.

skills that might be lost such as walking and communication. Several different approaches of physiotherapy are recommended after stroke. These approaches are based on different ideas about motor recovery [10]. Rehabilitation should be directed at specific training of skills and functional movements. Physical therapy should be given with sufficient intensity to improve skill acquisition [11]. The application of therapeutic exercise can be effective in the reeducation of specific movement and learning the discriminative control of the muscle that are lost after stroke [12]. Many physical rehabilitation approaches were used to improve weight symmetry, balance and gait pattern. Jung et al [13] reported that single-leg stance on the affected lower extremity with knee flexion and extension increased symmetry in weight bearing during stance phase time. Thus, it augments improved gait function through sufficient weight bearing in the stance phase of the affected side. Other rehabilitation approach was the use of postural audiovisual feedback that reduced weight loading asymmetry of the lower limbs in stroke [14]. Furthermore, Mudie et al. [15] compared task-related reach, Bobath and balance performance monitor feedback approaches for training symmetry of weight distribution after stroke. They reported that the Bobath approach was the most effective treatment for retraining sitting symmetry in the short term however, some generalization of symmetry training in sitting to standing was noted in the balance performance monitor feedback training group which appeared to persist long term. One of the potential clinical applications for motor skill rehabilitation is the induced body weight shift therapy. It involves a forced shift of body weight towards the affected lower limb by means of a shoe insert which may give a sustained lift of the nonaffected lower extremity during treatment and daily activities thus helping in overcoming learned disuse of affected lower limb [16]. There is lack in studies reporting which treatment approach is most effective in improving weight bearing symmetry and balance in stroke patients. Aim of the Study The objective of research was to examine the effect shoe insert wearing in the unaffected side on weight symmetry in patients with stroke.

Subjects, Materials and Methods Subjects Twenty stroke patients were selected from Physical Medicine department, KAU hospital in Jeddah. Inclusion Criteria: Patient’s age ranged from 50-70 years-old, the duration of illness was up to 24 month, muscle tone ranged from grade 1+ to 2 according to modified Ashworth scale [17]. Patients were able to maintain balance from sitting and standing and could walk independently. Exclusion Criteria: Cognitive and perceptual deficits and other neuromuscular or orthopedic disorders that might interfere with BAOJ Ortho, an open access journal

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walking. The participants were randomly divided into two equal groups: Study and control. Procedures Assessment Procedures Weight Bearing: Each patient was asked to stand vertically on two digital weighing scales in such a way that his affected leg was on the platform of the scale and the non-affected leg on the other platform to measure the difference of the weight bearing between both lower limbs. Gait Velocity :Patients were instructed to walk, under supervision, six meters at a customary speed and the total consumed time was recorded using a stopwatch. The velocity was then calculated by dividing the distance (m)/time (sec). Step Length: A pen was attached for each foot’s heel and the patient was instructed to walk over a sheet to detect the mark of foot contact with the ground. The step length was the measured distance between the heel of one foot and that of the other foot. Six step lengths mean was calculated for each foot to detect the difference between the affected limb and non-affected limb Balance: Berg balance scale [18] was used to evaluate patients’ balance through 14 items. Each item have five points which indicate the score ranging from 0 to 4, “0” indicates the lowest level of function while “4” the highest level of function and the total Score = 56. Motor functions: Five items from the Fugl-Meyer scalewere selected for the lower limb: Lower extremity motor function including reflex activity; volitional movement within synergies; volitional movement mixing synergies; volitional movement with little or no synergies, sensation (light touch and position), passive joint motion, and joint pain during passive joint motion. Each item was rated on a three-point ordinal scale [19]. Treatment Procedures Control Group: Patients of the control group received traditional physical therapy program for 60 min per session, two sessions per week for four successive weeks. The program included prolonged stretching of affected lower limb for 10 minutes through the full flexion of the hip and knee with ankle dorsiflexion aiming to inhibit spasticity muscles as well as to control the spastic pattern during walking, strengthening exercises for both flexors and extensor muscle groups of the knee and ankle joints in the form of manual or mechanical isometric exercises and graduated resistive exercises according to patients tolerance for five minutes. A-twenty minutes walking on the treadmill were practiced while speed was adjusted to each patient tolerance to gain normal walking and to avoid falling, a 10 minutes walking up and down stairs. In addition, faradic stimulation (Physiomed-Elektromedizin, Hz=50/60, made in Germany) was applied for ankle dorsiflexors to increase sensory input and decrease spasticity as well as increasing the ROM. Intermittent current less than 100 Hz frequency, one ms Volume 1; Issue 1; 001


pulse width, one second contraction and three seconds for rest was used. A final five minutes of balance exercises aiming to improve patients balance and stability as well as decreasing the risk of falling with safely precautions to prevent the patient from falling. The patient was asked to stand feet together, hands beside body with open eyes and instructed to keep this position 10-30 seconds, as a progression a patient was instructed to elevate his arm laterally 90 degree and keep this position 10-30 seconds starting with non-affected arm then the affected arm and finally elevate both of them together, as a progression the patient asked to elevate his arm in front of him 90 degree in the same sequence and a therapist can assist the patient to elevate the affected arm. For the lower limbs, the patient, from the previous starting position, was asked to glide his affected leg side away keeping this position 1030 seconds, then to glide the non-affected limb side away keeping this position 10-30 seconds, as a progression he was asked to take a step side away by the affected limb keeping the position 10-30 seconds and follow the same sequence for non-affected limb, then progress it to glide his leg in front of him and take a step forward and follow the same sequence. Study Group: Patients in the study group received the previously mentioned physiotherapy program and according to the compelled body weight approach, the patients’ body weight was shifted toward affected side using a shoe insert of 0.6 cm height fabricated from medium hardness foam material made of ethylene vinyl acetate [16]. It was available with different sizes according to every patient’s feet size. It was inserted in the non-affected side. Data Analysis: Means and standard deviations (SD) were calculated for all quantitative data. Data were treated by the test of normality prior to analysis. Paired and unpaired t-tests were used for comparison. The p-value was 0.05. Software SPSS version 16 and Microsoft excel program 2007 were used for data analysis and presentation.

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Results Patients’ Characteristics The results showed non-significant difference between the study and control groups regarding mean values of patients’ age (mean= 55.2±14.4 and 51.2±12.5 respectively) (p=0.7). Also, there was non-significant difference between the study and control groups regarding mean values of patients duration of illness (mean= 11±7.7 and 18.4±3.5 respectively) (p=.09) (figure 1). Weight Bearing Symmetry (Wbs) The findings also showed non-significant difference between the study and control groups regarding mean values of affected limb WB neither before (mean=36.6± 11.4 and 33.4± 6.8 kgm respectively) nor after treatment (mean= 42.6± 15.7 and 34±7.1 kgm respectively) (p= 0.6 and 0.3 respectively). Also, there was non-significant difference in the mean values before and after treatment neither in the study group (p=0.07) nor in the control group (p=0.5) (table 1 and figure 2). Moreover, there was nonsignificant difference in the WBS mean values between affected and non-affected limb neither before (p=0.2) nor after treatment (p=0.7). Fugl-Meyer Assessment The results showed a non-significant difference between the study and control groups regarding mean values of FMA scores neither before (mean= 64.6± 2.6 and 63.2 ± 1.9 respectively) nor after treatment (mean= 63.2±1.9 and 64± 2 respectively) (p= 0.4 and 0.6 respectively). Also, there was non-significant difference in the mean values before and after treatment neither in the study group (p=0.3) nor in the control group (p= .09) (Table 2 and figure 3). Berg Balance Scale The results showed a non-significant difference between the study and control groups regarding mean values before treatment (mean= 49.2 ± 4.7 and 45.2± 3.7 respectively) (p= 0.2). In contrast, a significant increase in BBS mean values was shown in the study

Fig 1: Mean values of A-patients’ age B-duration of illness in the study and control groups. BAOJ Ortho, an open access journal

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Table 1: Comparison between study and control groups regarding weight bearing symmetry mean values before and after treatment. WBS (kgm)

Study group

Control group

(Mean ± SD)

(Mean ± SD)

p

pre

36.6± 11.4

33.4± 6.8

0.6

Post

42.6± 15.7

34± 7.1

0.3

p

0.07

0.5

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Table 3: Comparison between study and control groups regarding BBs mean values before and after treatment. Study group

Control group

(Mean ± SD)

(Mean ± SD)

Pre

49.2 ± 4.7

45.2± 3.7

0.2

Post

52± 3.9

47± 4.2

0.05*

p

0.03*

0.009*

BBs

p

Fig 4: Mean values of BBs score before and after treatment in the study and control groups. Fig 2: Mean values of weight bearing symmetry before and after treatment in the study and control groups. Table 2: Comparison between the study and control groups regarding FMA scores mean values before and after treatment. FMA scores

Study group

Control group

(Mean ± SD)

(Mean ± SD)

p

Pre

64.6± 2.6

63.2 ± 1.9

0.4

Post

63.2±1.9

64± 2

0.6

p

0.3

0.09

Gait Velocity The findings showed non-significant difference between the study and control groups regarding mean values of gait velocity before treatment (mean= 0.16± 0.12 and 0.23 ± 0.11m/sec respectively). In contrast, a post treatment results showed a significant difference (mean= 0.08 ± 0.06 and 0.25 ±0.13 respectively) (p= 0.4 and 0.03 respectively). Also, there was no significant difference in the mean values before and after treatment in both the study (p= 0.12) and control groups (p= 0.11) (table 4 and figure 5). Table (4): Comparison between the study and control groups as regards gait velocity before and after treatment. Gait velocity

Study group

Control group

(m/sec)

Mean ± SD

Mean ± SD

p

Pre

0.16± 0.12

0.23 ± 0.11

0.4

Post

0.08 ± 0.06

0.25 ±0.13

0.03

p

0.12

0.11

Fig 3: Mean values of FMA scores before and after treatment in the study and control groups.

group compared to that of the control group after treatment (mean= 52± 3.9 and 46.6± 3.7 respectively) (p= 0.05). Also, there was significant difference in the mean values before and after treatment in both study group (p= 0.03) and control group (p= 0.005) (table 3 and figure 4). BAOJ Ortho, an open access journal

Fig 5: Mean values of gait velocity before and after treatment in the study and control groups. Volume 1; Issue 1; 001


Step Length Additionally, there was a non-significant difference between the study and control groups regarding mean difference values of affected limb step length neither before (mean= 5.38± 3.41 and 5.6± 1.9 respectively) nor after treatment (mean= 3.82± 2.4 and 4.9± 2.32 respectively) (p= 0.9 and 0.49 respectively). Also, there was non-significant difference in the mean difference values before and after treatment neither in study group (p= 0.12) nor in the control group (p= 0.11) (Table 5 and figure 6) as well as there was nonsignificant difference in mean values between affected and nonaffected limb neither before (p=0.5) nor after treatment (p=0.6). Table 5: Comparison between the study and control groups as regards step length before and after treatment. Step length

Study group

Control group

(cm)

Mean ± SD

Mean ± SD

p

Pre

5.38± 3.41

5.6± 1.9

0.9

Post

3.82± 2.4

4.9± 2.32

0.49

p

0.12

0.11

Fig 6: Mean values of step length of the affected limb before and after treatment in the study and control groups.

Discussion Stroke patient may be unable to bear much weight through the paretic limb. However, a continued weight-bearing asymmetry fosters further disuse of the affected side despite the probability that improved motor function in the lower limb may occur. Such a learned disuse of the affected limb may contribute to the lack of progress in recovery of some individuals with stroke. Several treatment approaches are used to improve weight-bearing symmetry in individuals with stroke. The current study was conducted to investigate the effect of shoe insert on weight bearing symmetry in patients with stroke. The results of the present work revealed significant improvement in balance regarding BBS scores after treatment in the study group. This agreed with the findings Mohapatra et al. [16] who found improvement (46% increase) in BBS after CBWS treatment. In the same line, Aruin et al. [20] found significant improvement in BBS scores by the end of intervention that involved compelled loading of the affected limb during daily activities and elements BAOJ Ortho, an open access journal

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of compelled weight bearing during physical therapy sessions and self-performed exercises at home. In accordance, Chitra and Mishra [21] concluded that compelled body weight shift therapy can be easily administrated in the daily rehabilitation protocol, while treating stroke patients with balance problems due to asymmetrical weight bearing. With more symmetrical weight bearing, balance can be improved for better ambulation and reduced risk of falls. Moreover, mild improvement in the motor functions of the affected lower limb was revealed regarding FMA scores after treatment in both study and control groups. This could be explained by the short duration of the intervention because it is expected that motor recovery continues after the initial two-week period. These findings comes also in accordance with Aruin et al. [21] who found significant improvement in FMA scores after treatment involving use of a shoe lift consisting of a three-layer inner sole that was positioned into the shoe of the subject during daily activities as well as during physical therapy sessions. In addition, there was an observable improvement in the weight bearing on the affected side in the study group after treatment. This is agreed with Mohapatra and associates [16] who reported an improvement in the symmetry of weight bearing. They explained their result by that a simple shoe lift during physical therapy session would compel the patient to shift more weight to the affected side and helped those individuals avoid the development of learned disuse of the affected limb. Similarly, Mishra and Chitra [22] concluded that compelled body weight shift therapy and modified constraint induced movement therapy are both effective in improving weight bearing symmetry and balance in post stroke patients. However, modified constraint induced movement therapy has showed more significant improvement compared to compelled body weight shift therapy in terms of weight bearing symmetry. The findings also revealed that gait velocity and step length were improved in the study group after treatment. It is important to note that the improvement of gait velocity was achieved in parallel with the improvement in weight-bearing symmetry. In accordance, previous studies [20,23,24] found improvement in three parameters: stride length, gait velocity and weight bearing symmetry at the end of the intervention, which involved compelled loading of the affected extremity during functional movements and elements of compelled weight bearing during physical therapy sessions and exercises at home. This result is in contrast with the previously published data on the lack of observed improvement of walking function after the use of a feedback device that provided visual information about relative weight distribution over the paretic and non-paretic limb. The improvement in motor function, gait velocity and step length in control group as well as the study one could be explained by that the conventional physical therapy program was effective as it included different exercises, balance training, treadmill walking and faradic stimulation treadmill training. This is supported by Volume 1; Issue 1; 001


Lehmann et al(6) and Tyson et al. [9] who reported that walking on the treadmill has many benefits, it improves ambulatory functions and cardiovascular fitness, improves symmetry and weight bearing on the paretic side, and restore normal movements of the trunk, pelvis, and lower extremities. Also, the improvement in both groups could be attributed to faradic stimulation. This type of stimulation achieves desired muscle contraction, reduces spasticity immediately following treatment, increases sensory inputs into the central nervous system and so accelerates nervous plasticity and leads to faster motor learning.

Conclusion The use of shoe insert on the non-affected lower extremity, in addition to traditional physical therapy program, is effective in improving balance, motor function, weight bearing symmetry, gait velocity and step length of individuals with stroke.

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