Abstract
Walking at a functional level is a requirement for walking safely in the community. Walking at a functional level requires good balance control and the ability to perform functional tasks while walking in challenging situations such as walking across a busy road. This thesis attempts to answer a number of questions regarding assessment of walking at a functional level in older people at risk of falls and in stroke survivors. The first part of the work involves a systematic review.The aim of the systematic review is to identify the available clinical OM used in clinical physiotherapy to assess walking at a functional level for stroke rehabilitation and to evaluate their psychometric properties. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The Consensus-based Standards for the selection of health status Measurement Instruments (COSMIN) tool was used to assess the risk of bias in the quality of the methodological design and statistical methods in reliability, validity, and responsiveness in the included studies. Fifty-four studies were included in the review, six OM were identified for dynamic balance, twenty-one OM for functional gait, and three studies including five tests each for motor and cognitive tests to assess dual task while walking. The most tested psychometric properties were reliability and construct validity. Studies on responsiveness were limited.
The aim of the first experimental study (Chapter 5) is to identify the associations between walking at a functional level and subjective visual verticality (SVV), cognitive function, psychosocial aspects, and physical activity (PA) levels. Twenty chronic stroke survivors capable of independently walking at least 6 metres and twenty healthy controls were recruited in this study. Assessment of functional-level walking included the Mini-Balance Evaluation Test (Mini-BESTest), and the Functional Gait Assessment (FGA). The Rod and Disc test was used to assess the SVV, the Cambridge Neuropsychological Test Automated Battery (CANTAB) tests for the cognitive functions, a set of questionnaires were used to assess psychosocial aspects and the AX3 monitor to determine the PA levels. The difference was significant between the groups in the Mini-BESTest and the FGA (p<0.001), lower (i.e., worse) Mini-BESTest and FGA scores were observed for ambulatory chronic stroke survivors. Balance confidence emerged as a key factor associated with both the Mini-BESTest and the FGA in ambulatory chronic stroke survivors. The Spearman’s rank-order correlations between the balance confidence scale and the Mini-Best, and the FGA were (rs = 0.72 and 0.75) respectively in ambulatory chronic stroke survivors. The results suggest that there is a need for rehabilitation for walking at a functional level for ambulatory stroke survivors and balance confidence should be considered in their assessment and treatment.
Difficulties in balance control and limited walking functions are also common in older adults and increase their risk of falls. Both populations (older adults at risk of falls and stroke survivors) need balance training rehabilitation based on a multifactorial approach, which current rehabilitation programmes do not incorporate. Current rehabilitation programmes are limited to simple physical exercises. In addition, previous studies have shown that adherence rates to exercise rehabilitation programmes are low. Using telerehabilitation can enhance adherence rates and adds enjoyment to the exercise rehabilitation programmes.
The aim of the next experimental work presented in this thesis was to assess the feasibility and acceptability of a novel telerehabilitation system in older adults at risk of falls and ambulatory chronic stroke survivors: the HOLOBalance system. This is a platform that uses a hologram to deliver the exercise instructions for balance training and uses wearable sensors to detect simultaneous body movements. The training addresses all components relevant to balance using multisensory rehabilitation exercises, exergames, and cognitive training. In addition to assessment of feasibility and acceptability, trends of improvement in balance and functional gait were also investigated. This was undertaken in both older adults at risk of falls and stroke survivors. For older adults at risk of falls (n=54) the participants were randomised to HOLOBalance intervention home-based (HOLOBalance), clinic based (HOLOBox) or control groups. In a second study, the HOLOBalance system (clinic based HOLOBox) was assessed for feasibility and acceptability in stroke survivors (n=8).
The main finding from both feasibility studies was that the HOLOBalance system was feasible and acceptable for older adults at risk of falls and ambulatory stroke survivors, as assessed by drop-out, adherence rates, exit interviews, and usability scales. The preliminary data showed that there were trends of improvement in balance and functional gait measures in the intervention groups (HOLOBalance and HOLOBox) in the older adults, and in the stroke survivors who had received the clinic based HOLOBox intervention.
| Date of Award | 1 Oct 2024 |
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| Original language | English |
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| Supervisor | Marousa Pavlou (Supervisor), Stephen Harridge (Supervisor) & Isaac Sorinola (Supervisor) |