Stroke Rehabilitation for Early Physical Activities among Patients Ongoing Rehabilitation: A Meta-Analysis

Zohaib Shahid1,2*, Regidor III Dioso1, Muhammad Zahid Latif2, Hira Tariq2, Ayesha Anwar2

1Lincoln University College, Wisma Lincoln, No. 12-18, Jalan SS 6/12, 47301 Petaling Jaya, Selangor Darul Ehsan, Malaysia

2Superior University, Kot Araian, Lahore, 54590 Pakistan

*Corresponding Author’s Email: zshahid@lincoln.edu.pk

ABSTRACT

Background: A report from the World Health Organisation says that stroke is the second largest cause of death and the primary reason for impairment in the world. Stroke is a worldwide well- being problem with an incidence of 0.2 to 2.5 per 1000 population. Stroke patients lead to paralysis on one or both sides of the body, causing difficulty in Activities of Daily Living (ADLS) and ambulation. Methods: A search for published materials was conducted from 1990 until 2023 through online sources such as Google Scholar, PubMed, Medline, Cochrane Library, and Embase. The following keywords were combined collectively to identify appropriate study papers. A total of seven studies were included in this study. Results: Higher heterogeneity was evident in the present meta-analysis (p=0.06, I squared=0.59). Prognosis- based outcome analysis showed a substantial difference in the online management system for early physical activity of stroke patients’ continuous rehabilitation. Conclusion: Prognosis- based outcome analysis revealed that there was a significant difference in the online management system for early physical activity of stroke patients in rehabilitation.

Keywords: Functional Ambulation Category (FAC); Health-Related Quality of Life (HRQoL); High-Intensity Resistance Training (HBR); Spasticity; Stroke Rehabilitation

INTRODUCTION

Stroke is one of the most common causes of mortality and disability worldwide (Braakhuis et al., 2022; Li et al., 2023). Stroke is a significant public health issue, accounting for 10% of global fatalities and 5% of years of life lost due to disability. Even in individuals who have received treatment, stroke causes substantial rates of morbidity and death (Wu et al., 2018). Similarly, stroke-related disability is the main cause of disability (Wu et al., 2023). Stroke accounts for one-third of all fatalities globally and it is the second most common cause of death in China (Wang et al., 2017). Low- and middle-income nations account for 87% of stroke- related disability (Kayola et al., 2023). Stroke is a widespread, dangerous, and incapacitating health issue that affects the entire world. Stroke is typically the second or third primary cause for death worldwide and one of the primary contributors to impairments. The prevalence of stroke-related disability will probably increase during the next 20 years (Langhorne, Sandercock, & Prasad, 2009). Stroke is the most common cause of complicated disability. Almost half of all stroke survivors experience some level of disability. It affects a person's capacity to function more severely than any other chronic disease (Adamson, Beswick, & Ebrahim, 2004). Less than 50% of stroke victims will regain arm function, but the majority will be able to walk on their own again. When compared to lower extremity function, the recovery

period for the upper extremities is frequently slower (Aoyagi & Tsubahara, 2004). The first 12 weeks following a stroke are crucial for recovery, when neuroplasticity is at its peak (Janssen et al., 2022). Adults with stroke experience a variety of issues, such as restrictions on their ability to participate in activities (Mayo et al., 2002). Physical activity is indicated for secondary prevention and rehabilitation (Nindorera et al., 2023). Physical activity, regardless of intensity, is crucial for stroke recovery and reducing the risk of future vascular events such as high blood pressure (Simpson et al., 2022). According to one study, even three years after a stroke, 62% of stroke victims need assistance with daily tasks like washing, using the restroom, and getting dressed (Pettersen, Dahl & Wyller, 2002). Between 55% and 75% of stroke survivors consistently struggle to conduct their ADLs (Thrasher et al., 2008). In addition, despite receiving standard therapy, the majority of patients do not attain fully functional and community ambulation (Bogey & George Hornby, 2007). Physical inactivity is the second leading risk factor for stroke, and it is both independent and modifiable (Sammut et al., 2022).

After a stroke, being active physically and exercising may be helpful in several physical and psychosocial areas. Exercise is a type of physical fitness that is repetitive, scheduled, and whose primary or secondary goal is the maintenance or improvement of physical fitness. Physical activity is defined as "Energy is expended during every skeletal muscle-driven physiological motion". Exercise after a stroke can enhance cardiovascular health, according to substantial data. Different online intervention strategies have been created for stroke rehabilitation, which focus on getting the patient back to an active way of life (Neil, 2023; Pang et al., 2006). The primary goal of stroke rehabilitation is to improve participation in ADLs (Kuppuswamy et al., 2024; Slenders et al., 2024). Understanding the complicated relationships between physical activity, a multidimensional idea, and physical capacity may provide strategies to improve rehabilitation interventions (Braakhuis et al., 2022).

The WHO defines rehabilitation as “a set of measures that assist individuals who experience or are likely to experience disability to achieve and maintain optimal functioning in interaction with their environments” (Kwakkel et al., 2023; Wang et al., 2022). In the medical history of individuals impacted by a moderate nerve case, rehabilitation is difficult. Particularly in terms of the quality of regaining and affordability, it has been established that physical therapy should be initiated as soon as possible following a stroke (Paolucci et al., 2000). But there are many different kinds of challenges (Lin et al., 2022). The challenge of obtaining a spot in a rehabilitation facility is just one of them (Kylén et al., 2022). Motivating the patient, who is frequently suffering from post-traumatic stress disorder, is important, (Polopalli et al., 2022) as they are often detained in the acute ward until a seat in a post-acute rehabilitation centre becomes available; lengthy waiting lists also drain resources (Chang et al., 2022). This happens when patients are unable to return home (for instance, if they were living alone) (Quaglini et al., 2004). This is expensive since the patient spends more time than necessary in the costly acute ward. Thus, there is a need for solutions that increase patients' autonomy in their recovery process.

The Stroke Prevention and Educational Awareness Diffusion (SPREAD) guideline is one example of current stroke prevention and treatment guidelines that suggest the prospective value of programs that might encourage a quicker and more thorough recovery, both in the hospital and at home (Tormene et al., 2009). The basic idea of this is to provide sufferers with their own rehabilitation technology, which can offer immediate feedback and motivate performance improvement. By enabling patients to attend more rehabilitation sessions than those that are regularly scheduled in the hospital, these systems could improve the traditional rehabilitation practice at home and enable therapy to be continued, possibly with remote supervision, implementing crucial continuity of care. Nurses are the largest professional group dealing with stroke survivors (Clarke & Holt, 2015). Nursing practice in stroke rehabilitation care varies and may be influenced by changes in stroke therapy, cultural norms, and ideology. Nurses help patients acquire problem-solving and stress management skills while also improving their quality of life by monitoring physiological and psychological changes. A rehabilitation nurse specialises in caring for those who are dependent or semi-dependent. They offer direct care, educate patients and families, and coordinate treatment. A rehabilitation nurse creates a dynamic process that promotes an individual's "functional capacity," including their engagement with the environment. This helps patients reach their full potential (Meng et al., 2020). The APEASE criteria for building scaled interventions are Affordability, Practicality, Effectiveness, cost-effectiveness, Acceptability, Safety, and Equity, which may be met by an online intervention as a strategy to overcome these barriers (Michie, Van Stralen & West, 2011). More than 86% of Australians reported having access to the Internet at home (Clancy et al., 2022). Up to 80% of patients, according to surveys, are interested in receiving information online in addition to support from a clinician, and studies have repeatedly shown that online interventions for co-morbid populations for anxiety, depression, easing pain, and disability reduction are effective (Monnier, Laken & Carter, 2002). Information technologies are ideal for realising rehabilitative assistance and can be utilised locally or with therapists’ support. In addition to financial and organisational reasons, computerised interventions are attractive as they make it possible to collect quantitative data on how the therapy is going (a lack of quantification is additional issue in the rehabilitation field). The therapy could be easily tracked, and a systematic record of its success could be provided via a computer-based rehabilitation tool. After a stroke, being active physically and exercising may be helpful in several physical and psychosocial areas. Exercise is a type of physical movement that is frequent or scheduled, and its primary or secondary aim is the maintenance or improvement of physical fitness. Physical activity is defined as "Energy is expended during every skeletal muscle-driven physiological motion".

METHODOLOGY

Data Mining and Search Strategy

A search for published material was conducted from 1990 until 2023 through online sources such as Google Scholar, PubMed, Medline, Cochrane Library, and Embase. The following keywords were combined collectively to identify an appropriate study paper.

Eligibility Criteria

The study's inclusion criteria for patients required a diagnosis of stroke, including ischemic, hemorrhagic, or critical subcortical involvement, with a recovery period of more than 6 months. Patients also had to present clinical symptoms of hemiplegia or hemiparesis, be over 18 years of age, have the ability to understand basic instructions, and possess access to smartphones or a reliable internet connection. The exclusion criteria included the presence of other neuromuscular or neurological conditions, fractures, or significant structural abnormalities (Salgueiro, Urrútia & Cabanas-Valdés, 2022).

Intervention

The treatment strategy includes the following approaches: Early rehabilitation (mobilisation, chest physiotherapy, counselling of patient, weight-bearing activities, and stretching) The mode of exercise includes self-care activities, intermittent standing and sitting, low-level walking, seated activities, range-of-motion exercises, and motor challenges, all of which are suggested for stroke patients during a hospital stay and early convalescence (acute phase). Exercise therapy for patients and outpatients includes endurance and strengthening exercises for the muscles (resisted training of the lower and upper extremities, circuit training, trunk partial weight-bearing tasks, pulleys, elastic bands, spring coils, functional mobility), flexibility exercises for the trunk and upper and lower extremities, and neuromuscular activities (balance and coordination exercises, yoga, active video gaming).

Main Measurements Examined

The described data showed that for the results, different outcome measures were used; the most commonly used outcome was the Barthel Index, along with a stroke-specific quality of life scale.

The interpretation for the Barthel scores is:

1. Total independence indicated by a 0-20 score

2. Severe dependence indicated by a 21-60 score

3. Moderate independence indicated by a 61-90 score

4. Slight dependence indicated by a 91-99 score

Source: Williams et al. (1999)

Figure 1: Interpretation of Stroke-Specific Quality of Life Scale

Quality and Risk of Bias Assessment

The quality of the study was assessed by using the Cochrane criteria, which consist of four aspects:

1. Random sequence generation

2. Allocation of concealment

3. Blinding of outcome assessment

4. Incomplete outcome data

The first three aspects were scored as follows: "No = 0," "Unclear = 1," and "Yes = 2." The fourth aspect was scored as "No = 0" and "Yes = 1." Studies that received a score of two or more were considered to be of low quality and were included in the data synthesis. All studies were conducted based on the authors' assessments of the inclusion and exclusion criteria.

Statistical analysis was performed using Review Manager software. The incidence rates across studies were combined using a fixed-effects meta-analysis. I² statistics were used to assess the heterogeneity of the research, and a funnel plot was used to detect potential publication bias.

Figure 2: Flow Chart of Study Selection (PRISMA)

RESULTS

Table 1: Summary of the Studies on Stroke Rehabilitation Interventions

Figure 3: Forest Plot Showing an Acceptable Intervention Based on the Pooled Evidence from the 7 Studies

This foster plot graph showed that the overall p-value was 0.37 while heterogeneity: Tau- squared=0.06.

Figure 4: Funnel Plot Showing No Biases on the Studies Selected

DISCUSSION

Seven publications were involved in the present meta-analysis, none of which had controversial conflicts or conclusions. The purpose of the study was to develop a stroke rehabilitation algorithm as an online management system for the early physical activity of stroke patients during ongoing rehabilitation. To measure physical activity, the Barthel Index, a stroke-specific quality of life scale, was used. The outcomes of the recent meta-analysis were consistent with the included research and demonstrated significant differences in online management systems for the early physical activity of stroke patients' ongoing rehabilitation. However, only a few randomised controlled trials have focused on online management systems for early physical activity in stroke patients.

Guillaumier et al. (2022) conducted a trial focusing on the effectiveness of an accessible health behavior change intervention aimed at preventing second strokes. Within the six-month follow- up, the study found improvements in health-related quality of life (HRQoL) among stroke survivors. According to the study's conclusions, stroke survivors' self-reported global HRQoL scores (as measured by EQ-VAS) improved at the six-month mark due to the P2S online healthy living program.

Results for patients with stroke fighters between 6 and 36 months after the stroke were evaluated for patients involving just stroke survivors. Moreover, specific data on online management for the physical activity of stroke survivors is lacking. However, different studies have developed different online management tools (smartwatches and others).

The recent meta-analysis presented higher heterogeneity (p=0.06, I²=0.59). Prognosis-based conclusion analysis showed there was a significant difference in the online management system for early physical activity of stroke patients' ongoing rehabilitation. Guillaumier et al. (2019) conducted a randomised controlled open-label trial in which a total of 530 stroke adults were selected according to block randomization and divided into a control group and an interventional group. The EuroQol-5D questionnaire was used to measure the primary outcome HRQoL. In the secondary outcome, cost-effectiveness was measured using Client Service Receipt Inventory along with MBS and PBS data. Vegetable and fruit intake was measured using the Australian Recommended Food Score, while physical activity was measured with the Godin Leisure Time Exercise Questionnaire (GLTEQ). Anxiety and depression were measured using the Patient Health Questionnaire four-item (PHQ-4). Instrumental Activities of Daily Living (IADL) scores and the Barthel Index were used to assess physical functioning and independence. According to the study's findings, P2S, a low-cost per-user alternative to augment existing treatment, may help stroke survivors’ HRQoL and reduce their chance of having another stroke (Guillaumier et al., 2019).

The result of the current study may also change if different online interventional tools are separately considered, but there is little literature review on algorithm development for the online management of stroke survivors. However, different online management tools, such as P2P and others, may prove beneficial for stroke survivors, but different trials on this may be required.

Other research on physical therapy (which included exercises for range of motion, strengthening of muscles, posture balance, transferring, and walking) and an Independent Mobility-related Physical Activity (IMPACT) Program were contrasted with a standard physical therapy treatment plan. Because the included studies employed various statistical methods, care was taken in the analyses.

Limitations

The limitations of the study include:

Variability in intervention design: Differences in online platforms, exercise protocols, and engagement strategies may affect results.

Small sample sizes: Limited sample sizes may impact the generalizability of findings.

Inconsistent outcome measures: Varied outcome measures complicate direct comparisons across studies.

Short follow-up periods: Limited follow-up may not capture long-term effects. Publication bias: Potential bias as positive results are more likely to be published. CONCLUSION

According to the meta-analysis, online management solutions for early physical activity during stroke rehabilitation have been shown to considerably improve patient outcomes. According to the analysed research, stroke patients who used these online platforms saw significant increases in their Barthel Index scores, indicating more autonomy with everyday tasks. Furthermore, according to the Stroke-Specific Quality of Life Scale, these patients reported a higher quality of life. Even though the results were generally positive, there was a lot of variation in each study's effectiveness, which suggests that program design and patient participation are two important aspects that may affect how well these online interventions work. This variation highlights the need for additional studies to evaluate the long-term advantages of online rehabilitation techniques and standardize them.

Recommendation

Further recommendations of the study include:

Implementation of targeted treatments: To reduce the risk of falls in chronic stroke patients, health practitioners should consider into normal care.

Further research: Conduct longitudinal studies with bigger and more varied populations to evaluate the therapies' efficacy and investigate their long-term effects.

Enhanced training: Create and deliver training programs for healthcare personnel that focus on fall risk assessment and treatment in patients with chronic stroke.

Policy development: Evidence-based fall prevention methods should be included into public health guidelines and stroke treatment standards

Conflict of Interest

The authors certify that they have no conflicting personal or financial interests.

ACKNOWLEDGEMENT

The authors are thankful to the institutional authority for completion of the work.

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