Abstract
Introduction
Stroke is a major cause of disability and represents a very high cost in developing countries. Self-rehabilitation programs represent a new and original treatment for stroke patients, likely to reduce upper limb impairments and improve activity and participation. The goal of this study is to evaluate the feasibility of a self-rehabilitation protocol in Benin.
Methods
Twelve chronic stroke patients carried out the upper limb self-rehabilitation program (3 hours/day, 5 days/week for 2 weeks). The performance of these patients was evaluated before and after the self-rehabilitation program, by measuring the number of exercises that patients were able to achieve during a three-hour session, and by assessing their gross manual dexterity.
Results
Twelve patients were effectively able to complete the entire program. The number of unimanual exercises and self-mobilizations performed during a three-hour session as well as the score of the Box and Block test were improved by the self-rehabilitation program ( P < 0.05).
Discussion and conclusion
Self-rehabilitation programs are feasible and inexpensive as they do not involve a therapist. It is then a promising approach in stroke rehabilitation, particularly in developing countries, where rehabilitation costs are usually supported by patients.
1
Introduction
Stroke is a major cause of morbidity and mortality, in developed and developing countries alike . It leads to major financial burden in terms of healthcare costs for the acute and chronic management of the pathology . In developing countries, the socio-economic environment remains a limiting factor in the healthcare system support . The number of existing rehabilitation structures is limited, and costs of this rehabilitation care are most often supported by patients themselves . Very few patients are financially able to benefit from this rehabilitation care. Alternative rehabilitation methods are thus necessary to answer growing rehabilitation needs in developing countries.
Community-based rehabilitation (CBR) was initiated by the World Health Organization (WHO) in 1978. It has been defined as “a strategy to improve the access to rehabilitation care for disabled persons in low-income countries, by optimizing the use of local resources” . Its main objective is to ensure that “disabled persons can develop to the maximum their physical and mental capacities, in order to achieve a full social integration in their community and society” . Among CBR programs, self-rehabilitation programs are part of the “ability for a person to manage his or her symptoms, treatment, physical and psychosocial consequences of his or her disease” . They can be administered individually, or in groups, at the hospital or the patient’s home, or in a community hall . They could help increase the number of rehabilitation sessions for patients without further implication from professional rehabilitation therapists .
In developing countries and especially Benin, patients benefit from very few rehabilitation sessions due to the absence of a social security system, high cost of sessions, as well as the limited number of professionals and rehabilitation structures.
In Benin, CBR structures, directed by community agents who did not receive specific rehabilitation training, provide rehabilitation services and support for community re-insertion for patients with various disabilities. These structures may be used in this context to guide the self-rehabilitation of patients with post-stroke hemiparesis.
To our knowledge, no study has specifically evaluated self-rehabilitation programs in developing countries. Our objective was to demonstrate the feasibility of an upper limb self-rehabilitation program in chronic stroke patients in a developing country, like Benin.
2
Method
2.1
Patients
Twelve patients were recruited in the Physical Medicine and Rehabilitation (PM&R) department of the National University Hospital of Cotonou, Benin.
They met the following inclusion criteria: time since stroke > 6 months, presence of motor impairments on one side after stroke, obtaining a score of at least 5 out of 7 on the items “toilet transfer” and “locomotion” of the Functional Independence Measure (FIM) scale , obtaining a score of 2 or 3 for the distal and proximal motor function of the paretic upper limb on the Stroke Impairment Assessment Set (SIAS) , living in their home in the city of Cotonou or its suburbs, having given their written consent for participating in the study. Patients were excluded if they had a Mini Mental Scale Evaluation score below 20 , and if they benefited from rehabilitation care in the past two months prior to inclusion.
The study was approved and authorized by the management of the National University Hospital of Cotonou.
2.2
Self-rehabilitation protocol
The self-rehabilitation protocol was described in a guide handed out to the patients. This guide included an introduction explaining the relevance of the self-rehabilitation program, a list of the necessary material and the description of the self-rehabilitation protocol.
The self-rehabilitation protocol was described in common French, it required easily-available material and included three groups of exercises. Its duration: 3 hours.
The first part included passive self-mobilization exercises with the healthy upper limb or active self-mobilizations when possible (exercises A), for 15 minutes. Its objective was to mobilize the paretic upper limb to improve and promote passive joint motion of the shoulder, wrist and paretic fingers.
The second part (exercises B) included unimanual functional exercises performed with the paretic upper limb for 90 minutes. The exercises consisted of bringing a glass to the mouth, stacking up 10 plastic cups, grabbing water-filled bottles, moving cutlery around, moving coins around on a table, and returning each card in a deck of 52 cards.
A 20-minute rest period was observed after exercises B.
The third part included bimanual functional exercises (exercises C) and lasted 40 minutes. The patient had to fold a napkin, button and unbutton a shirt, grab a water bottle with one hand and open it with the other hand.
The description of each exercise included a picture of a person performing the task, to facilitate the patients’ comprehension of the required tasks.
The materials necessary for performing exercises B and C were the following:
- •
ten forks and tablespoons, twelve paper cups (11 empty ones and one filled with water) and ten 0.5 L water-filled bottles, which the patient needs to grab and move around;
- •
a comb to groom oneself;
- •
a deck of 52 cards and ten 50fr CFA coins, to perform fine motor skills exercises;
- •
a shirt, with at least 5 buttons, and a handkerchief, for bimanual exercises of folding and fine motor dexterity;
- •
a stop watch or a watch, to monitor the time needed to perform the exercises.
To carry out these exercises, the patient had to sit on a chair facing a table where the material was laid out.
2.3
Study protocol
Along with a family member, patients were invited to attend a session where the self-rehabilitation protocol was explained. A demonstration by a physiotherapy student and a patient was also part of this introductory session. All patients were also handed out the self-rehabilitation protocol as a written document detailing the execution of the exercise and the duration of each exercise.
After this introductory session, patients had a week to collect the necessary material for the exercises. Then, the self-rehabilitation protocol was performed at home, if necessary with the help of the person who came to the introductory session with the patient. Patients were asked to perform the exercises 3 hours per day, 5 days/week for a 2-week period. Patients were advised to do the exercises for 3 hours during each session. They were contacted by phone every two days, in order to enquire about eventual difficulties and to encourage them to continue the treatment. They were also asked to note each day the difficulties encountered in a notebook. Evaluations took place twice. The first one in the two days before the start of the program, and the second one in the two days following the end of the program.
2.4
Assessed variables
The patient had to carry out the entire protocol during the two evaluation sessions. Repeat exercises consisted of the number of times the patient was able to perform each group of exercises during the given time period. The patient’s performance was evaluated as the difference between the numbers of repetitions in the two evaluation sessions.
The “Box and Blocks” test was also performed. This test assesses gross manual dexterity. It consists in moving around as many blocks as possible from one compartment to another. Norms are available for adults according to age, sex and upper limb laterality .
A 13-item questionnaire ( Table 1 ) was designed and handed out to patients at the end of the rehabilitation program to look for the presence or absence of material, temporal, motivational and family barriers to performing the self-rehabilitation protocol, as well as assessing fatigue and patients’ satisfaction in participating in such a program.
| Parameters | n |
|---|---|
| Duration of the protocol | |
| Insufficient | 2 |
| Sufficient | 8 |
| Very long | 2 |
| Feeling the exercise-related fatigue | |
| No fatigue | 2 |
| Acceptable (not leading to exercise interruption) | 10 |
| Unacceptable (leading to exercise interruption) | 0 |
| Understanding instructions | |
| Yes | 12 |
| No | 0 |
| Dropping-out of the exercises | |
| Yes | 0 |
| No | 12 |
| Protocol satisfaction | |
| Satisfied | 12 |
| Dissatisfied | 0 |
| Acquiring exercise-related material | |
| Yes | 12 |
| No | 0 |
| Obtaining human help | |
| Yes | 4 |
| No | 8 |
2.5
Statistical analysis
A descriptive analysis of patients’ characteristics was performed. A paired samples t -test was done to compare results pre- and post-treatment. P ≤ 0.05 was considered significant. Statistics were conducted with Excel 2010 and Sigmastat 3.5.
2
Method
2.1
Patients
Twelve patients were recruited in the Physical Medicine and Rehabilitation (PM&R) department of the National University Hospital of Cotonou, Benin.
They met the following inclusion criteria: time since stroke > 6 months, presence of motor impairments on one side after stroke, obtaining a score of at least 5 out of 7 on the items “toilet transfer” and “locomotion” of the Functional Independence Measure (FIM) scale , obtaining a score of 2 or 3 for the distal and proximal motor function of the paretic upper limb on the Stroke Impairment Assessment Set (SIAS) , living in their home in the city of Cotonou or its suburbs, having given their written consent for participating in the study. Patients were excluded if they had a Mini Mental Scale Evaluation score below 20 , and if they benefited from rehabilitation care in the past two months prior to inclusion.
The study was approved and authorized by the management of the National University Hospital of Cotonou.
2.2
Self-rehabilitation protocol
The self-rehabilitation protocol was described in a guide handed out to the patients. This guide included an introduction explaining the relevance of the self-rehabilitation program, a list of the necessary material and the description of the self-rehabilitation protocol.
The self-rehabilitation protocol was described in common French, it required easily-available material and included three groups of exercises. Its duration: 3 hours.
The first part included passive self-mobilization exercises with the healthy upper limb or active self-mobilizations when possible (exercises A), for 15 minutes. Its objective was to mobilize the paretic upper limb to improve and promote passive joint motion of the shoulder, wrist and paretic fingers.
The second part (exercises B) included unimanual functional exercises performed with the paretic upper limb for 90 minutes. The exercises consisted of bringing a glass to the mouth, stacking up 10 plastic cups, grabbing water-filled bottles, moving cutlery around, moving coins around on a table, and returning each card in a deck of 52 cards.
A 20-minute rest period was observed after exercises B.
The third part included bimanual functional exercises (exercises C) and lasted 40 minutes. The patient had to fold a napkin, button and unbutton a shirt, grab a water bottle with one hand and open it with the other hand.
The description of each exercise included a picture of a person performing the task, to facilitate the patients’ comprehension of the required tasks.
The materials necessary for performing exercises B and C were the following:
- •
ten forks and tablespoons, twelve paper cups (11 empty ones and one filled with water) and ten 0.5 L water-filled bottles, which the patient needs to grab and move around;
- •
a comb to groom oneself;
- •
a deck of 52 cards and ten 50fr CFA coins, to perform fine motor skills exercises;
- •
a shirt, with at least 5 buttons, and a handkerchief, for bimanual exercises of folding and fine motor dexterity;
- •
a stop watch or a watch, to monitor the time needed to perform the exercises.
To carry out these exercises, the patient had to sit on a chair facing a table where the material was laid out.
2.3
Study protocol
Along with a family member, patients were invited to attend a session where the self-rehabilitation protocol was explained. A demonstration by a physiotherapy student and a patient was also part of this introductory session. All patients were also handed out the self-rehabilitation protocol as a written document detailing the execution of the exercise and the duration of each exercise.
After this introductory session, patients had a week to collect the necessary material for the exercises. Then, the self-rehabilitation protocol was performed at home, if necessary with the help of the person who came to the introductory session with the patient. Patients were asked to perform the exercises 3 hours per day, 5 days/week for a 2-week period. Patients were advised to do the exercises for 3 hours during each session. They were contacted by phone every two days, in order to enquire about eventual difficulties and to encourage them to continue the treatment. They were also asked to note each day the difficulties encountered in a notebook. Evaluations took place twice. The first one in the two days before the start of the program, and the second one in the two days following the end of the program.
2.4
Assessed variables
The patient had to carry out the entire protocol during the two evaluation sessions. Repeat exercises consisted of the number of times the patient was able to perform each group of exercises during the given time period. The patient’s performance was evaluated as the difference between the numbers of repetitions in the two evaluation sessions.
The “Box and Blocks” test was also performed. This test assesses gross manual dexterity. It consists in moving around as many blocks as possible from one compartment to another. Norms are available for adults according to age, sex and upper limb laterality .
A 13-item questionnaire ( Table 1 ) was designed and handed out to patients at the end of the rehabilitation program to look for the presence or absence of material, temporal, motivational and family barriers to performing the self-rehabilitation protocol, as well as assessing fatigue and patients’ satisfaction in participating in such a program.
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