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DOCTORAL THESIS ABSTRACT
Doctoral supervisor:
PROF. DANISIA HABA, MD
Doctoral candidate:
PAUL LUCACI
2019
CONTRIBUTION OF FUNCTIONAL AND
IMAGING EVALUATION TO THE
REHABILITATION MANAGEMENT OF
PATIENTS WITH POST STROKE
DISABILITIES
DOCTORAL THESIS ABSTRACT
Doctoral supervisor:
PROF. DANISIA HABA, MD
Doctoral candidate:
PAUL LUCACI
2019
CONTRIBUTION OF FUNCTIONAL AND IMAGISTIC EVALUATION
TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
i
TABLE OF CONTENTS
CURRENT STATE OF KNOWLEDGE
CHAPTER 1 .................................................................. 1
IMAGING EXPLORATION TECHNIQUES USED
IN THE DIAGNOSIS OF STROKE ........................... 1
1.1 Introduction to the issue of strokes ........................ 1
1.2 Imaging exploration methods for strokes .............. 2
1.2.1 Computed tomography without contrast ............ 3
1.2.2 Magnetic resonance imaging (MRI) .................. 6
1.2.3 Computed tomography angiography .................. 9
1.2.4 Magnetic resonance angiography ..................... 12
1.3 Perfusion imaging ............................................... 14
1.3.1 NMR and CT perfusion .................................... 15
CHAPTER 2 ................................................................ 17
FUNCTIONAL EVALUATION OF THE PATIENT
WITH STROKE.......................................................... 17
2.1. General considerations regarding functional
evaluation in stroke ................................................... 17
2.2 Functional evaluation of the patient with stroke in
the acute and subacute phase ..................................... 19
2.2.1 The Barthel index ............................................. 20
CONTRIBUTION OF FUNCTIONAL AND IMAGISTIC EVALUATION
TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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2.2.2 The FIM scale (Functional Independence
Measure) .................................................................... 21
2.2.3. The ASHWORTH scale modified................... 22
2.3 Functional evaluation of the patient with stroke in
the chronic phase ....................................................... 23
2.3.1 The Romberg test ............................................. 23
2.3.2 The GPS 400 stabilometric platform ................ 24
2.4 Gait evaluation in the patient with stroke............ 29
2.4.1 The “get up and walk” test ............................... 31
2.4.2 The Tinetti gait test .......................................... 31
2.4.3 The gait evaluation test .................................... 31
2.4.4 Gait evaluation using 3D equipment ................ 31
CHAPTER 3 ................................................................ 32
REHABILITATION MANAGEMENT OF
DISABLED PATIENTS POST STROKE ................ 32
3.1 Aspects of medical recovery of patients post stroke
................................................................................... 32
3.2 Rehabilitation of patients with stroke in the acute
and subacute phase .................................................... 33
3.2.1 Passive mobilisation of the patient with stroke 35
3.2.2 Transfer from clinostatism to sitting on the side
of the bed ................................................................... 36
3.2.3 Recovery of the plaegic upper limb ................. 37
CONTRIBUTION OF FUNCTIONAL AND IMAGISTIC EVALUATION
TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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3.3 Balance re-education ........................................... 38
3.4 Gait re-education ................................................. 40
PERSONAL CONTRIBUTIONS
CHAPTER 4 ................................................................ 42
MOTIVATION AND OBJECTIVES OF THE
DOCTORAL STUDY ................................................. 42
CHAPTER 5 ................................................................ 44
STABILOMETIRC ANALYSIS OF THE
BARYCENTRE PROJECTION AND OF SUPPORT
AT THE LEVEL OF LOWER LIMBS .................... 44
5.1 INTRODUCTION ............................................... 44
5.2 MATERIAL AND METHOD ............................ 44
5.3 RESULTS............................................................ 48
5.3.1. Comparisons by gender and age...................... 48
5.3.2. Comparative analysis of the data recorded at the
initial and final evaluation regarding balance, load
distribution at the level of lower limbs, variations of
the barycentre and barycentre curve length, by gender.
................................................................................... 49
5.3.3. Comparative analysis of the data recorded at the
initial and final evaluation regarding load distribution
at the level of lower limbs, imbalance direction,
variations of the barycentre and barycentre curve
length, by the hemispheric localisation of stroke. ..... 61
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POST STROKE DISABILITIES
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5.3.4. Comparative analysis of the data recorded at the
initial and final evaluation regarding balance of the
subjects by impaired hemibody. ................................ 72
5.3.5. Comparisons between the initial and final
evaluation regarding the load of lower limbs,
imbalance direction, speed of oscillations of the
barycentre and barycentre curve length. ................... 74
5.4. Discussions ......................................................... 86
5.5. Conclusions ........................................................ 99
CHAPTER 6 .............................................................. 100
CORRELATIONS BETWEEN
CRANIOCEREBRAL IMAGING EXAMINATION
USING MAGNETIC RESONANCE AND
FUNCTIONAL EVALUATION WITH THE
STABILOMETRIC PLATFORM .......................... 100
6.1 INTRODUCTION ............................................. 100
6.2 MATERIAL AND METHOD .......................... 100
6.3 RESULTS.......................................................... 106
6.3.3. Comparisons between initial and final
examination using magnetic resonance imaging ..... 108
6.3.4. Comparisons between the patients with stroke in
the superficial and deep area of the middle cerebral
artery........................................................................ 109
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TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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6.3.5. Comparisons of the stabilometric testing
between the patients with significant modifications
and the patients with insignificant modifications of
stroke, at the imaging examination ......................... 120
6.4. Discussions ....................................................... 131
6.5. Conclusions ...................................................... 138
CHAPTER 7 .............................................................. 139
CONTRIBUTION OF THE QUESTIONNAIRE TO
THE IMPROVEMENT OF MEDICAL
EDUCATION OF PATIENTS WITH STROKE .. 139
7.1 INTRODUCTION ............................................. 139
7.2 MATERIAL AND METHOD .......................... 139
7.3 RESULTS.......................................................... 139
7.4 Discussions ........................................................ 159
7.5 Conclusions ....................................................... 164
CHAPTER 8 .............................................................. 165
GENERAL CONCLUSIONS .................................. 165
CHAPTER 9 .............................................................. 167
ORIGINAL ELEMENTS AND PERSPECTIVES OF
THE DOCTORAL STUDY ..................................... 167
BIBLIOGRAPHY ..................................................... 169
APPENDIX
CONTRIBUTION OF FUNCTIONAL AND IMAGISTIC EVALUATION
TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
KEYWORDS: recovery, balance, stabilometry,
imaging, disabilities
The doctoral thesis comprises 183 pages and it is
structured on two parts: the general part called “Current
state of knowledge” including 3 chapters (41 pages) and
the personal part called “Personal contributions”,
including 6 chapters (168 pages).
There are 279 bibliographic references, within
pages 169-183.
The general part of the doctoral thesis comprises 1
table and 26 figures, while the personal part comprises
177 tables and 101 figures.
Throughout the abstract, I referenced certain
chapters and figures, stating the page number within the
doctoral thesis.
The bibliographic references within this abstract
are placed at the end, in the section called “Selective
Bibliography”, from the bibliography of the doctoral
thesis.
CONTRIBUTION OF FUNCTIONAL AND IMAGISTIC EVALUATION
TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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INTRODUCTION
The statistics done for the level of the entire world
show that, in the past years, humankind has faced an
increasing number of strokes, thus representing a major
problem of public health (Kim & Johnston, 2011; Ho et
al. 2018). Unfortunately, the management of stroke
remains suboptimal, despite the years dedicated to the
study and the increased attention on this phenomenon.
Nonetheless, the clinical trials for the evaluation of new
treatments have benefited from improvement and they
become ever more sophisticated. Ongoing trials regard
investigations with a promising potential such as
neuroprotector compounds (Ginsberg, 2008; Sahota &
Savitz, 2011; Minnerup et al. 2012; Sutherland et al.
2012) hypothermia (Froehler & Ovbiagele, 2010; Campos
et al. 2012; Yenari, & Han, 2012), oxygen therapy, brain
stimulation and regenerative therapy.
PERSONAL CONTRIBUTIONS
CHAPTER 4
MOTIVATION AND OBJECTIVES OF THE
DOCTORAL STUDY
My personal practice has shown me that
neuromotor recovery must benefit from rigorous
knowledge and from increased attention for designing the
recovery programs by the particularities of stroke also in
agreement with the functional remain of the patient. The
neurological recovery is a passion for me because I
believe that functional independence and quality of life
represent essential and indispensable elements for daily
living. The increased interest for this branch of medical
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TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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recovery is also due to the fact that, unfortunately, stroke
does not represent only the appanage of old age, which
has become ever more common in the past years and
among young persons, in full professional activity.
The motivation for choosing this study was
confirmed by the possibility of conducting functional
evaluation through state-of-the-art means, like the
stabilometric platform GPS 400 within the complex
posture evaluation equipment called Posturograph.
In this context, I have set the following objectives
of the doctoral study:
- Assessing weight distribution at the level of
lower limbs and balance by using the
stabilometric platform (modern evaluation
method) for a sample of patients during the
acute/subacute stage and six months after
completing the rehabilitation programs in
order to point out the modifications induced by
physical therapy treatment in the study group.
- Correlating the imaging data for a sample of
patients post stroke, with functional outcomes
evaluated with the stabilometric platform, a
research conducted for the first time in
Romania.
- Determining the utility of the stabilometric
platform as an auxiliary method in the
adaptation of physical therapy programs, as
well as in helping the clinician track down the
functional recovery of the patient with stroke.
- Developing a questionnaire by the author of
the doctoral thesis, to identify the medical
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POST STROKE DISABILITIES
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education level and the conditions for
improving the addressability of the patient
with stroke to specialised treatment.
CHAPTER 5
STABILOMETIRC ANALYSIS OF THE
BARYCENTRE PROJECTION AND OF SUPPORT
AT THE LEVEL OF LOWER LIMBS
5.1 INTRODUCTION
The patients with ischaemic stroke require
rehabilitation strategies and usually undergo diverse
specific programs of medical recovery. In the recent
years, the stabilometric platforms were introduced as a
means of assessing balance and of the loading degree of
lower limbs, in Romania, the first stabilometric studies
were carried out in the orthopaedic sphere.
5.2 MATERIAL AND METHOD
The study was prospective and included a sample
comprising 66 subjects (35 men and 31 women) with a
mean age of 61.23 ± 5.21, who suffered an ischaemic
stroke, being in the first six months post stroke.
The research carried out by using the stabilometric
platform within the centre of medical recovery Kinego,
Iași was carried out in two phases: the initial one in the
subacute stage of stroke and the second phase
corresponding to the six-month follow-up, a period when
the subjects carried out specific programs of medical
recovery.
The evaluation was carried out with the purpose of
identifying the balance disorders of the subjects (through
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TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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the left - right and anterior – posterior deviations), of the
speed of barycentre oscillations, of the barycentre curve
length and the weight distribution pattern on the impaired
lower limb as well as on the healthy one, as exemplified
in case of subject 3 (left ischaemic stroke) within the study
sample, at the initial evaluation (fig 5.1) and at the follow-
up (fig 5.2), six months after conducting the recovery
programs.
Fig 5.1. Results of the initial stabilometric evaluation with eyes open,
in subject 3 within the research sample (collection of the medical
recovery practice S.C Kinego S.R.L Iași)
Fig 5.2. Results of the final stabilometric evaluation with eyes open,
in subject 3 within the research sample (collection of the medical
recovery practice S.C Kinego S.R.L Iași)
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Statistical analysis
The comparative analysis of the results obtained at
the initial and final evaluation was carried out using the
software program STATISTICA var.7.0. To highlight the
potential influences, the analysis was also carried out by
gender and age group. I have also compared the initial and
the final data by location of stroke (left or right).
5.3 RESULTS
Within the study conducted, I analysed the effects
induced by the recovery treatment on the body balance of
the subjects, as well as on the loading degree of lower
limbs, of the speed of barycentre oscillations and of the
barycentre curve length. I have also recorded the data of
the initial testing and at the final testing, and then I made
comparisons between results of the subjects by gender,
age, hemispheric location of stroke and impaired
hemibody.
Fig.5.31. Differences between the initial and final evaluation,
regarding the average loading of the lower limbs, at open eyes
evaluation
33.77
66.23
44.62 55.38
15
35
55
75
Paretic Healthy
Initial evaluation Final evaluation
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Fig.5.32. The imbalance direction at open eyes evaluation
Fig. 5.29 Speed of barycenter oscillations depending on
hemiparesis side
0
50
100
150
200
250
300
350Anterior
Right
Posterior
Left
Initial evaluation Final evaluation
0
200
400
600
800
1000
1200
1400Eyes open
Eyes closed
Head to the
right
Head to the
leftHead tilt right
Cu capul
înclinat spre
stânga
Head
retroflexed
Left hemiparesis initial Right hemiparesis initial
Left hemiparesis final Right hemiparesis final
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Fig.5.30. Length of barycentre curve depending on the hemiparesis
side
5.4. DISCUSSIONS
In order to improve the efficiency of assessing the
functional status of the patient with stroke, a set of tests
have been developed, providing a certain precision, but in
the recent years, specialists have focused on computer-
based tests that have been applied successfully, being
viable and efficient in the evaluation of functional
outcomes (Lin et al. 2018).
Hence, through the stabilometric platform GPS
400 – a modern evaluation method – I was able to point
out and synthesise information regarding the
rehabilitation patterns of patients with ischaemic stroke,
in what concerns weight distribution at the level of lower
limbs, the imbalance direction and the barycentre
00.5
11.5
22.5
33.5
44.5Eyes open
Eyes closed
Head to the right
Head to the leftHead tilt right
Head tilt left
Head retroflexed
Left hemiparesis initial Right hemiparesis initial
Left hemiparesis final right hemiparesis final
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POST STROKE DISABILITIES
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projection, oscillation speed and the barycentre curve
length.
After a stroke, the evaluation with the
stabilometric platform is conducted in order to test the
stability surface necessary and its limits, for the patient
tobe able to stand (Tasseel-Ponche et al. 2015).
Within the research sample, I have noticed that the
frequency of stroke is higher in men aged 53-58 years old
and 59-64 years old (31.43%) compared to women
(9.38%, p=0.003), but in the age group 65-70 years old,
the prevalence of ischaemic stroke is higher in women
(43.39% compared to 14.29% in men, p=0.001).
A comprehensive epidemiological study carried
out in China on a sample of 480,687 subjects highlights
that the highest incidence of stroke is around the mean age
of 66.4 years old, the average age in men being 66.2 years
old, in women being discretely higher for 66.6 years old
(Wang, et.al. 2017).
In addition, another study carried out worldwide
in 2017, shows that the incidence of stroke is higher in
men than in women (Thrift et al., 2017).
In what concerns the recovery of patients with
ischaemic stroke by the impaired brain hemisphere, I have
not found statistically significant differences in what
concerns the evolution of results for the parameters tested,
eyes open, eyes closed, face rightward, face leftward,
head tilted rightward, head tilted leftward, head in
extension.
I highlight that for both the subjects with the
ischaemic focus located in the right hemisphere and for
those with the location of the lesion in the left hemisphere,
CONTRIBUTION OF FUNCTIONAL AND IMAGISTIC EVALUATION
TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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the evolution was favourable, the weight distribution at
the level of lower limbs reaching closer to the normal
values, the projection of the barycentre lowering and the
range, variation of the barycentre decreasing with the
reduction of the barycentre curve length.
The difference I have noticed is confirmed by
another study published in 2018 that suggests that the
right brain hemisphere plays a more prominent role in the
processes in charge with the control of balance (Fernandes
et al. 2018). In order to quantify the results obtained
through this study, I can highlight the need to use modern
and objective methods of evaluation of lower limbs
loading, of the imbalance direction, of the speed of
barycentre oscillations and of the barycentre curve length.
I believe that the adaptation of physical therapy
programs and by these parameters of balance, the results
obtained sunt superior, thus reflecting the increased
quality of life of patients who suffered an ischaemic
stroke.
The research conducted using devices such as the
stabilometric platform, underlines that this type of
evaluation should be used in current practice, being a
quick, non-invasive and easy measurement tool (Genthon
et al. 2007).
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TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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CHAPTER 6
CORRELATIONS BETWEEN
CRANIOCEREBRAL IMAGING EXAMINATION
USING MAGNETIC RESONANCE AND
FUNCTIONAL EVALUATION WITH THE
STABILOMETRIC PLATFORM
6.1 INTRODUCTION
Exploration imaging through magnetic resonance
of the patient with ischaemic stroke is rather rare upon the
first admission, but it has become in the recent years a
very effective method of accurate diagnosis for small
ischaemia, which through location in certain areas may
induce physical and mental disabilities.
The purpose of imaging evaluation through
magnetic resonance and the correlation of the data
obtained in functional evaluation with the stabilometric
platform GPS 400 is of identifying the small ischaemic
lesions that were not identified during CT carried out in
the ER, as well as potential limits or possibilities of
recovery by the location of the lesion and by the evolution
of brain morphology as shown through imaging.
6.2 MATERIAL AND METHOD
I have carried out a prospective study on a sample
of 23 de subjects diagnosed through magnetic resonance
with ischaemic stroke, localised in the area of the middle
cerebral artery (deep and superficial): 6 subjects with
location of the lesion in the superficial area of the middle
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cerebral artery on the right side and 2 on the left side, 2
subjects with the location of the lesion in the deep area of
the middle cerebral artery on the right side and 13 on the
left side. In addition the study sample was explored
imagistic through magnetic and functional resonance
through the stabilometric platform GPS 400, both at the
beginning of the study (in the subacute stage), and six
months after the recovery treatment.
The imaging exploration protocol included
specific diffusion sequences (DWI), T1, T2, FLAIR, the
apparent diffusion coefficient (ADC), T2*, TOF, and the
images were analysed 2 experienced neuroradiologists
and a physical therapist who analysed the signal, size and
location of the lesion (fig. 6.1).
Functional evaluation was carried out with the
stabilometric platform GPS 400 through which I analysed
the loading degree of lower limbs, balance, variation of
the barycentre and barycentre curve length.
Fig. 6.1. Exploration MRI with T1, T2, FLAIR, DWI, ADC
sequences of an acute lacunar infarction situated in the deep area of
the left MCA (subject 1 within the research sample)
Statistical analysis
Statistical analysis was carried out using the
software program STATISTICA var.7.0. following the
identification of potential modifications during the MRI
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TO THE REHABILITATION MANAGEMENT OF PATIENTS WITH
POST STROKE DISABILITIES
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or functional stabilometric exam, after the six months of
neuromotor recovery.
In order to conduct the comparative analysis of the
results, I used the t test for correlated samples, keeping as
significant those differences situated at a significance
threshold p<0.05.
6.3 RESULTS
The first phase of my study concerned the analysis
of the aspects of ischaemic lesions revealed through
exploration with magnetic resonance in the patients
included upon admission in the study sample, tracking
down the location of the lesion, the vascular area and the
extension of the ischaemic lesion (fig. 6.3.1).
The second phase of the research carried out,
namely the exploration through magnetic resonance
carried out at the six-month follow-up on the same sample
of patients that carried out the recovery treatment and
stabilometric re-education, and highlighted the mitigation
of the lesion and the modified signal, characteristic for the
sequela of stroke (fig. 6.3.2).
Fig. 6.8. The results of the final imaging evaluation compared to the
initial evaluation
73.9126.09
With significant changes With insignificant changes
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Fig. 6.6. Initial MRI evaluation of subject 14, featuring a small area
of diffusion restriction in the posterior arm of the right internal
capsule, suggesting Subacute lacunar stroke with a diameter of 1.07
cm measured in the sequence T1SE.
Fig. 6.7. MRI evaluation six months after physical therapy of subject
14, featuring a small area of diffusion restriction in the posterior arm
of the right internal capsule, suggesting Subacute lacunar stroke with
a diameter of 5.5 mm measured in the sequence T1SE.
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6.4. DISCUSSIONS
Following the imaging evaluation through
magnetic resonance, initial and six months after
undergoing individualised physical therapy programs,
within the sample of 23 subjects, I have noted that on the
images obtained, the difference between initial
exploration and the final one was represented by the
significant modifications (a percentage of 73.91%) or
insignificant (a percentage of 26.09%), which emerged.
The significant modifications (accounting for
58.82% for the superficial area of the middle cerebral
artery and 41.18% for the deep area of the middle cerebral
artery) involved a reduction of the ischaemic area in the
chronic stage compared to the initial evaluation and the
lack of lesion extension or the emergence of
complications, on the subjects within the research sample.
In what concerns the insignificant modifications,
they referred to maintaining the size of the ischaemic area
or to producing very small modifications, without the
extension of the lesions or the emergence of
complications that accounted for a percentage of 33.33%
for the superficial area of the middle cerebral artery and
66.67% for the deep area of the middle cerebral artery,
within my study sample.
The results of the research hereof have highlighted
the contribution of stabilometric evaluation of of imaging
through magnetic resonance, to rehabilitation
management of the patient with disabilities post stroke,
through the elucidation of modifications in the cerebral
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POST STROKE DISABILITIES
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morphology associated with balance disturbances and
issues of weight distribution at the level of lower limbs.
Hence, within my study sample, I have noted that
the small lesions have favoured an efficient recovery of
balance of patients, of weight distribution at the level of
lower limbs, of oscillation speed and of the barycentre
curve length.
The conducting of follow-up imaging evaluation
through magnetic resonance is important in guiding the
clinician in order to optimise recovery treatment and with
the purpose of increasing the insight into the
manifestations and evolution of stroke (Yeo et al. 2017).
The studies carried out underline that by
correlating the images obtained through magnetic
resonance with the scale for quantifying the gravity of
stroke (National Institutes of Health Stroke Scale), one
can make predictions concerning the clinical results with
positive value (Schaefer et al. 2015).
In the research conducted, I have identified the
presence of significant modifications, more poignantly, in
case of the subjects with location of stroke in the
superficial area of the middle cerebral artery, than in case
of the subjects with the deep area affected, thus obtained
values of 58.82% to re-educate the ischaemic area in case
of the superficial area and 41.18% in case of the deep area
of the middle cerebral artery.
At the final evaluation with eyes open, better
values were obtained also in case of patients with a
vascular event localised in the superficial area of the
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POST STROKE DISABILITIES
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middle cerebral artery (45.60%), the patients with the
ischaemic lesion located in the deep area of the middle
cerebral artery, thus obtaining a final average value of
44.38%.
A study conducted on 201 patients with occlusion
of the middle cerebral artery explored paraclinically using
magnetic resonance, underlines that the final volume of
the infarction is a good predictor of clinical outcomes
(Zaidi, 2012).
This research has proved the efficiency of
combining elements of physical therapy with training on
the stabilometric platform, leading to improved support at
the level of the lower limbs, to a decrease in the
imbalances anteriorly and posteriorly, as well as to the
sides (left-right).
In addition, the personalised neuromotor
rehabilitation programs and the balance parameters
related to the speed of oscillations of the barycentre and
barycentre curve length improved, recording statistically
significant values at the initial evaluation and at the
follow-up with the stabilometric platform GPS 400.
Functional and imaging explorations have a
special importance also in what concerns the prevention
of stroke relapse, despite new evidence supported the
existence of the best management for patients with
cerebral ischaemic lesion, because the relapse risk is still
quite high (Esenwa & Gutierrez, 2017).
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CHAPTER 7 CONTRIBUTION OF THE QUESTIONNAIRE TO
THE IMPROVEMENT OF MEDICAL
EDUCATION OF PATIENTS WITH STROKE
7.1 INTRODUCTION
Questionnaires are used in research to collect date
related to a certain topic, with a purpose and a
multidisciplinary character. The medical education of the
patient with stroke is a little approached subject by the
specialists in order to quantify the level of information
that the patients with cerebral ischaemic lesion hold. To
my knowledge, there are no national studies concerning
this topic; the questionnaires applied in Romania in
general refer to the level patient satisfaction regarding the
medical services received.
The purpose of the study hereof is to identify the
information level of the patient with stroke, in what
concerns the pathology they have to face. I wished to
highlight the level of knowledge related to the
possibilities of recovery, symptomatology, need for a
personalised physical therapy program, adapted and
monitored, after a cerebral ischaemia.
7.2 MATERIAL AND METHOD
I have carried out a prospective study throughout
18 months, on a sample of 153 subjects (80 male subjects
with the average age of 68.47 years old and 73 female
subjects with the average age of 67.97 years old), who
suffered an ischaemic stroke. The sample comprised 73
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urban subjects and 80 rural subjects, who filled out a
questionnaire developed by the author of the study.
Besides data regarding gender, age and residence, the
level of studies and profession of the subjects, there are
10 items referring to a set of information held by subjects
concerning stroke.
7.3 RESULTS
For an effective reveal of the results obtained, I
have carried out the statistical interpretation of the data by
gender, age, profession, and I have analysed the frequency
of answers concerning knowledge related to the locations
when one may undergo the medical recovery after a
stroke, the accession of patients to specific programs of
rehabilitation, the causes of failing to undergo physical
therapy, the information means concerning the production
of a stroke, the specific symptomatology, the time
necessary to call the emergency numbers, the physical
activities necessary, the diet and the prevention of stroke.
In addition, I have carried out statistical analysis for the
frequencies of answers provided by the residence of
patients, in order to disseminate the potential differences
in what concerns the medical education of the rural and
urban patients.
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Fig. 7.7. Frequency of performing physical therapy programs
Fig. 7.10. Causes of non-performance of physical therapy according
to the environment origin
7.4 Discussions
The research I have conducted highlights
that the medical education of the patient with ischaemic
stroke is not a very clear concept or a very well defined
on in Romania. Consequently, the subjects included
within the study managed to mention only some
information related to the pathology they have to face.
The information concerning this disease are very
important for very individual because this may lead to
Performed
60.13%
Did not
performed
39.87%
0
20
40
60
80
100
No causes Distance Lack of
time
Lack of
companion
Transport
issues
Lack of
money
26.03
5.48 4.11
20.55
9.59
69.86
5
11.25 13.75
27.5
37.5
88.75
Urban Rural
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increased neurological rehabilitation, to an optimization
of autonomy and to their treatment compliance.
Other studies report that the medical education of
the patient with stroke may contribute to an increase in
their recovery performances (Dudka et al. 2016). The
same study underlines that the implementation of medical
education had a positive effect on realising the purpose of
the rehabilitation period; the knowledge acquired
contributes to better chances to resume the social and
professional activities.
In what concerns the conducting of long-term
physical therapy programs, I have concluded that rather
many patients, namely 39.87% of the patients did not
undergo medical recovery programs after discharge.
The percentage of the rural subjects who did not
benefit from physical therapy was very high (61.25%,
compared to the urban subjects 38.75%, p<0.00001).
In what concerns the causes preventing the
subjects of the research sample from undergoing
specialised medical gymnastics programs after discharge,
the main impediment was represented by the lack of
money (79,74%), which had a higher frequency of
answers in case of the rural subjects (88.75% compared to
69.86% in case of the urban subjects).
When the subjects were asked what would be the
most adequate means for them, to warn them about the
signs of a stroke, all of them answered that TV would be
the most appropriate information channel; a frequency of
59.48% of the answers concerned the radio, 50.33% the
newspapers, 22.22% medicine promoting magazines in
drugstores, 24.57% schools and 9.8% on the Internet.
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In a similar study conducted in Bavaria on 532
respondents, it has been concluded that the most
important source of information for the subjects was
represented by the personal experience of other patients
(30.01%), TV or radio (22.1%), newspapers (18,4%),
relatives and friends 17.2% (Handschu et al. 2005).
In what concerns the level of information
concerning the symptomatology of a stroke,
unfortunately, most subjects of the research sample were
able to mention only one or two symptoms, very few
managed to mention three (24.18%) or four (4.58%)
symptoms.
In what concerns the information held by
caregivers, sit has been found that they manage to identify
the signs of stroke only in case of severe symptoms such
as losing consciousness (Ing et al. 2015).
To the question related to the physical activity of
the patient post stroke, most answers refereed to simple
chores; very few e answers mentioned physical therapy as
a useful physical activity, though the last represents the
main and most important activity that a patient with stroke
should perform, representing standard care in
rehabilitation (Magdon-Ismail et al. 2018).
The frequency of answers obtained to the question
concerning the diet of the patient with stroke highlights
the very low information level concerning a lifestyle with
a balanced diet.
The researches carried out have shown that the
type of diet may impact the evolution of vascular
pathology (Ayusto et al. 2017), but the patients with
stroke generally have an unhealthy diet, being reluctant to
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change their dietary habits (Rodriguez-Campello et al.
2014).
Unfortunately, after processing the results
concerning the prevention of a stroke, the information of
the subjects concerned mainly stress reduction (92.81%)
and more rest (54.9%). Many of the patients questioned
have incriminated the stressful lifestyle sin the production
of the stroke, without considering that for the human body
it is stressful to consume unhealthy foods and alcohol in
excess.
An alarmingly small number of answers
concerned the conducting of regular medical check-ups
(46.41%) and the monitorization of blood pressure
(34.64%), considering that the respondents were
diagnosed with primary arterial hypertension, too.
Medical education may begin through an efficient
instruction of the patient and the caregivers, who can
convey in their turn the information to their families and
their socio-professional setting. In order to accomplish
this desideratum, a common effort is necessary, which
will impact, over time, the information level of the
population.
CHAPTER 8
GENERAL CONCLUSIONS
1. The evaluation of balance disturbances by using
the stabilometric platform GPS 400, carried out in the first
prospective study provided me with the possibility of
developing for the first time in Romania individualised
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physical therapy programs by the functional parameters of
each subject.
2. Through the analysis of the barycentre, I was
able to observe that when the patient with ischaemic
stroke turns his head towards the healthy hemibody, their
balance improves.
3. The comparative analysis between the initial
results obtained with the stabilometric platform and the
results recorded six months after the physical therapy
highlight the need to develop personalised neuromotor
rehabilitation programs.
4. The imaging exploration through magnetic
resonance, on a sample of patients in the subacute phase
of stroke that had a second MRI examination six months
from the ischaemic stroke has helped me understand the
correlation between the location and the extension of the
cerebral lesion and the possibilities of recovery for the
patient with ischaemic stroke.
5. I have concluded that the evolution is
favourable for all the patients that had a smaller cerebral
ischaemic lesion and that underwent a monitored process
of neuromotor rehabilitation associated with stabilometric
re-education programs.
6. The follow-up exam using magnetic resonance,
carried out six months from the ischaemic stroke, has
enabled me to underline the reduction of the ischaemic
area, with far better results at the stabilometric evaluation,
a finding conclusive with the studies within the literature
in the field.
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7. The use of a questionnaire developed by the
author of the thesis, carried out for the first time in
Romania among the patients who suffered a stroke has
highlighted the insufficient knowledge regarding the
causes leading to a stroke, regarding a healthy lifestyle
and diet, which may prevent a stroke, as well as poor
knowledge of the recovery possibilities.
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