A dissertation submitted to the Faculty of Health Sciences,
University of the Witwatersrand,
in fulfilment of the requirements for the degree of
Master of Science in Physiotherapy
Johannesburg, 2016INTRODUCTION
Stroke is a major cause of mortality and long-term adult disability and has a
significant physical and psychosocial impact on individuals and their Health-Related
Quality of Life (HRQoL). The loss of upper limb function post-stroke directly impacts
on shoulder girdle stability of the affected side. Shoulder girdle stability is essential
for optimal functioning of the upper limb; good shoulder function is a prerequisite for
effective hand function and the execution of the expected tasks with regard to
activities of daily living (ADL). It is well known that the rehabilitation of the upper limb
post-stroke remains challenging.
AIM
The aim of the study was to determine the effect of shoulder stability training using
the Biodex Balance System (BBS) on shoulder girdle stability, upper-limb function,
pain control and HRQoL in patients with hemiplegia post-stroke.
METHODS
The study utilised a quantitative longitudinal randomised control trial design with
single blinding. Participants who met the inclusion criteria and who gave informed
consent were assigned to one of two groups, the experimental or the control group,
using computer-generated random numbers with concealed allocation. Participants
were included in the study if they met the following criteria: were either male or
female patients, who had a stroke, resulting in hemiplegia and/or shoulder instability,
and were between the ages of 18 and 85 years. In addition to usual care, shoulder
girdle stability training using the BBS was given to the participants in the
experimental group. Assessments were done at baseline and one, three and six
month’s post-baseline.
All the participants were assessed by the research assistant using the following: pain
measured by the Wong-Baker FACES Pain Rating Scale, the functionality of the
upper limb measured by the Fugl-Meyer Assessment Upper Extremity, the shoulder
girdle stability measured by the Postural Stability Test on the BBS and HRQoL
measured by the SF-36v2 Health Survey.
RESULTS AND DISCUSSION
A total of 17 participants were included in the main study after screening and, 53%
were males. The median age of the study sample was 53 years. The control group
comprised more female (n=5) than male (n=2) participants, while the experimental
group comprised more male (n=7) than female (n=3) participants. All the participants
in the control group were right-handed implying that more of them had their dominant
hand affected than those in the experimental group. At baseline the two groups were
comparable with regard to shoulder girdle stability, upper limb function and the
HRQoL, but were not comparable regarding pain, as the control group experienced
significantly more pain than the experimental group.
There were no statistically significant differences between the two groups with regard
to shoulder girdle stability on any of the three BBS stability levels neither at the
baseline (p=0.69) nor at one-month follow-up post-baseline (p=0.77).
There was no significant difference in upper limb function (baseline p=0.5, one month
follow-up post-baseline p=0.93) between the control and the experimental groups for
the entire study period. The severity of the impairment of upper limb function for both
the control and the experimental group was comparable at baseline and improved
from moderate (56-79) to mild (>79) during the duration of the study.
At baseline the participants in the control group already expierienced more pain than
the experimental group (p=0.05). Participants in the control group experienced
significantly more shoulder pain than the experimental group at the one-month followup
(p=0.02), but no differences were found at the three- (p=0.17) and sixmonths(
p=0.12) follow-up post-baseline.
At baseline a statistically significant difference was found regarding the impact of
emotional problems on role limitation (p = 0.03) and pain (p = 0.05) between the two
groups, with the control group indicating lower scores than the experimental group. At
one month a statistically significant difference was found between the two groups
regarding the extent of impaired social functioning (p = 0.05).
The participants in the experimental group reported improvement in their health over
time (baseline = 67.5 and six-month follow-up post baseline = 86.11). None of the
factors investigated in this study impacted on HRQoL outcomes over time.
CONCLUSION
Shoulder girdle stability training using the BBS did not result in significant
improvements in shoulder girdle stability, upper limb function, pain relief and HRQoL
post-stroke in this cohort. The findings in this study could have been influenced by
the small sample size (the power calculation was done only for the shoulder girdle
stability) and also by participants in the control and experimental group continuing
with their standard care, which included an intensive rehabilitation programme. This
could have been a confounding factor impacting on the outcome. Further research in
this field is required.MT201
