Increasing age has detrimental effect on balance and functional capacity in patients with stroke
Introduction
The World Health Organization defines stroke as ‘a clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hours or leading to death’ (G13). It is the second most frequent cause of mortality worldwide and a leading cause of disability (2, 3, 4). Stroke is the third most common cause of death, after heart disease and cancer(g8). Stroke incidence and mortality vary by countries and increase with age (makale 5).
Socioeconomic importance of stroke increases in aging populations day by day(G14). Stroke is a common and serious disease which could cause severe disability for patients, particularly in older individuals. (G16). With 65% of all strokes occurs after age of 65 years (makale 4) The prevalence of stroke is 11% between 55 and 64 years of age. This prevalence increases with age and nearly reaches 43% at 85 years of age. (G22).
Stroke is characterised with impairments in sensory, motor, cognitive, and emotional function, speech disorders, aphasia, hemianopsia, dysphagia, ataxia, balance problems. These problems can lead to restrictions in stroke patients’ ability to perform basic activities of daily living (ADLs). Compared to younger adults, older individuals commonly have poorer functional outcomes poststroke, including postural control, balance, gait and functional capacity. (makale 4)
Balance can be defined as the ability to maintain the body’s center of gravity over its base of support with minimal sway or maximal steadiness. (G43) Balance impairment is a common problem that may be caused by various factors, such as deficits in motor, visual and sensory function, cerebellar lesion or vestibular dysfunction in stroke patients. İncreased in body sway during standing and weight bearing on the unaffected limb, decreased muscle power and sensory input from limb causes balance impairments in these patients(makale 1, G40).
Balance problems in patients with stroke are caused by a complex interplay of visual, vestibular, somatosensory, motor, and cognitive impairments. Balance and coordination problems affects more than 80- 90 % of patients post-stroke. Stroke patients commonly bear most of their body weight through their uninvolved limb and this situation causes distinct asymmetrical stance and weight bearing (G39, G45, g46). As a result of changes with aging in the somatosensory, visual and vestibular system affect adversely balance and postural control. (21. KAYNAK).
To improve functional capacity and independence of patient are main goals of stroke rehabilitation. Patients afflicted with stroke commonly experience a constellation of challenges that include a reduced functional capacity, activity intolerance, muscle atrophy, partial paralysis, gait and balance problems. Several variables may influence the magnitude of these deficits. Age is the most important one in these variables. (makale 6).
An advanced age is a factor associated with a poorer functional prognosis following a stroke. Individuals with stroke have more impairment such as motor, sensory and vision deficits resulting from their strokes than the average elderly.These deficits can affect their balance and functional capacity. The purpose of this study was to investigate the role
of age on balance and functional capacity in stroke patients
MATERIALS AND METHODS
All patients admitted to neurologia clinic at Dokuz Eylül University Hospital from January 2015–September 2015. with a diagnosis of stroke were included in this study. Data were collected for 68 patients who were under and over 65 years. The study was approved by the Local Ethics Committee of Dokuz Eylul University, Ethical approval No: 1856-GOA.
Inclusion criteria; Acute and subacute stroke, ability to walk 10 meter (with assistive device, if required), able to communicate, a score of more than 22 on the Mini mental test.
Dışlama ölçütleri: presence of aphasia, the presence of any other neurological diagnosis and a history of surgical procedure in the lower extremities in the prior 6 months, recurrent stroke, orthopedic problem which prevent walking.
Firstly, Mini Mental Test were performed and patients whose score more than 22 were evaluated. 115 patients were excluded from the study for various reasons (Figure 1).
Demographic characteristics and the clinical information about dominant side, affected side
anatomical localization of lesion, stroke type and duration, presence of hemiparesis, comorbid diseases, walking aids, marital status, educational status and working status were recorded. Functional capacity was evaluated with 6 Minute Walk Test and balance was evaluated using Trunk Impairment Test and Timed Up and Go Test.
The participants were instructed to ‘walk as far as possible’ on path in 6 min. The total distance walked in 6 min was recorded. The 6-Minute Walk Test is a reliable method to assess functional capacity in individuals with stroke (B1).
Assessment. TUG is an objective, reliable and simple measurement used to assess balance. Participants are asked to get up from a chair, walk three meters, turn around, walk back and sit in the chair. Scoring is calculated by measuring how many seconds the test took to finish. Use of walking aids during the test is permitted (B1). The TIS measures the motor impairment of the trunk after a stroke through the evaluation of static and dynamic sitting balance as well as co-ordination of trunk movement. Scores range from a minimum of 0 to a maximum of 23. Higher scores show better balance(kaynak 24,25).
Statistical analyses were performed using the SPSS software version 15. The variables were investigated using visual (histograms, probability plots) and analytical methods (Kolmogorov-Simirnov/Shapiro-Wilk’s test) to determine whether or not they are normally distributed. Descriptive analyses were presented using means and standart deviations for normally distributed variables and were presented using medians and interquartile range (IQR) fort he non-normally distributed and ordinal variables. The Mann-Whitney U test was used to compare non-normally distributed variables between the groups. While investigating the associations between non-normally distributed and ordinal variables, the correlation coefficients and their significance were calculated using Kendall test. A p-value of less than 0,05 was considered to show a statistcally significant result (26. Kaynak).
RESULTS
Elucidating the effect of age, patients were divided two groups as geriatric group (Group 1:aged 65 and over) and non- geriatric group (Group 2: aged under 65) and then statistical comparisons were done. 32 geriatric, 36 non-geriatric patients included this study.
Mean age of geriatric stroke group (Group 1) was 74,21±7,43, mean age of non-geriatric group (Group 2) was 54,25±9,40 year. Group 1 included 10(31.3%),females, 22(68,8%) males, and 18(50%) females, 18(50%) males for Group 2. The mean body length was1,66±0,08 m in Group 1 and 1,68±0,09 m for Group 2. The mean body weight of Group 1 was 72,71±10,28 kg , mean body weight of Group 2 was 78,62±13,81 kg. Body Mass Index (BMI) in Group 1 was 26,35±4,4 kg/m² and 27,82±4,11 kg/m² in Group 2. While there was no statistically significant difference between groups in terms of sex and body length, there was a significant difference between groups for BMI and body weight (p<0.05).
When patients analyzed for stroke type, 31’patients (96,9%) had ischemic stroke, 1 patient (3,1%) had hemorrhagic stroke in Group 1 and 35 patients (97,2%) had ischemic stroke, 1 patient (2,8%) had hemorrhagic stroke in Group 2. Time after stroke was 41,62±66,02 month in Group 1, 44,88±51,25 month in Group 2.
Analyzing the results of functional capacity and balance tests; there were statistically significant differences between groups for 6MWT, TUG and TIS ((p<0,05,Table 1).
Table 1: Comparison of Functional Capacity and Balance Parameters Between Groups
ICF
domain Grup 1
Ortanca (minimum-maksimum) Grup 2
Ortanca (minimum-maksimum) P
6MWT (meter) (activity) 367,0 (88,8-515,7) m 441,6 (138,0-627,0) m 0,03*
TIS (activity, body structure, body function) 18,50 (12,0-23,0) 21,0 (13,0-23,0) 0,01*
TUG (second) (activity) 10,15 (6,10-33,70) s 7,95 (5,35-22,0) s 0,001*
A significant weak negative correlation was found between age and functional capacity (6MWT, r=-0,245, p=0,004). Similarly, there was a significant weak negative correlation between age and TIS (r=-0,0242, p=0,006). And there was a significant positive weak correlation between age and balance measurement (TUG, r=0,318, p=0,00).
Table 2: Correlation Between Age and Measurements
YAŞ 6DYT GBÖ SKYT
YAŞ
r
P —
-0,245
0,004* -,0242
0,006* 0,318
0,000*
6DYT r
P —
—
0,395
0,000* -0,719
0,000*
GBÖ r
P —
—
—
-0,423
0,000*
SKYT r
P —
— —
— —
— —
—
DISCUSSION
The incidence of stroke is increasing once again, primarily in relation to the aging population and age is a primary risk factor for stroke..(t16) Older people have a greater incidence and prevalence of ischemic stroke compared to younger individuals and 65% of all strokes occur in individuals older than 65 years (t9,t10). Stroke is one of the major causes of disability in the elderly population. (t17) Advanced age is associated with lower functional outcome because of a limited physical capacity or slower functional recovery(t16)
Age of all patients was ranged from 25 to 90 year and mean value was 63,6 ± 13,1 year. The mean age of our patients was similar age range of stroke incidence.
Balance is an ability to maintain the line of gravity of a body within the base of support with minimal postural sway. Balance is required to be able to demonstrate the optimum function of manifold system, Stroke survivors present with deficits that increase with age in different systems, including sensory, musculoskeletal, perceptual, and cognitive, which decrease postural stability(makale 3, (t32).)Balance functions need sufficiently to carry out social activity, continue safely, activities of daily life for stroke patients. (makale 2,t22). In our study, balane scores of non-geriatric patients were better than geriatric patients.
Differential clinic test has been developed to evaluate balance after stroke. In this study, we evaluated balance with TUG and TIS in stroke patients. Similarly Sawacha et al. used TUG to assess the balance after stroke, and they found that mean time for TUG was 24,75 s.(t28). Additionaly Shamay et al. found mean time for TUG test as 22,60±8,60 s in chronic stroke patients(t21). In our study mean time measured by the TUG test was 12,33±6,32 in geriatric group and 8,72±3,12 in non-geriatric group and there was a significant difference between groups. In our consideration, TUG score of patients in this study was so different other studies in order that only 48,5% of our patients had hemiparesis.
Trunk function includes various components. Stabilization and selective movements of the trunk in flexion, extension, lateral flexion and rotation are some of those components.. To allow efficient walking, counter rotation between the shoulder and pelvic girdle is needed. (t22). Verheyden et al. show that trunk control was associatiated with balance, walking and functional ability in stroke patients (t24). We found that there was a association between trunk control and functional capacity and balance.
Increasing of functional capacity after stroke enhance activity of daily life after stroke. The most frequently used test to assess functional capacity is 6MWT. (t29). The 6MWT was a clinically reliable measure to determine walking ability in stroke survivors. The 6MWT distances of healthy subjects range between 400 and 700 meters. The stroke literature highlights the significant walking impairment in stroke survivors with documented 6MW distances ranging from 116 to 341 meters(t31).
Sibley et al. evaluated funcyional capacity with 6MWT and they found that mean distance of walking in 6MWT was 283,3±136,8 mt30). In our study we found that mean distance for 6MWT was 400,44±276,37m in geriatric group and 435,36±102,0m in non-geriatric group. Since functional levels of our patients are good, mean distance is more than the other studies.
CONCLUSIONS
In this study, geriatric patients had worse trunk control and balance scores than non-geriatric patients because of this reason their functional capacity and paticipation of activity of daily life were decreased. In stroke patients balance and functional was decresed with increasing age.
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