Recuperación de la ambulación comunitaria en pacientes con accidente cerebrovascular en fisioterapiacapacidades funcionales pronósticas y su mínimo cambio clínicamente relevante

Abstract

One of the activities frequently limited by stroke is the ability to perform community ambulation which is the ability to walk outside the home in any public or private environment independently. More than half of stroke patients do not achieve satisfactory community ambulation upon completion of their Physiotherapy. Two approaches have been used to measure community ambulation, one based on the level of participation in relevant social activities achieved and measured by self-reported questionnaires, and the other based on measuring elements associated with community ambulation such as walking speed, strength or endurance. Speed, which has been the most studied, has been used to classify community ambulation into household ambulation (speed less than 0.4 m/s), limited ambulation (between 0.4 and 0.8m/s), and full ambulation (more than 0.8m/s). Various cross-sectional studies have been conducted to identify factors associated with the achievement of full community ambulation, but longitudinal studies to identify prognostic factors are scarce. Therefore, the aims of this thesis are, firstly, to estimate the frequency in which stroke patients receiving outpatient physiotherapy treatment regain some level of community ambulation and/or full community ambulation before discharge and also the time in which they do so. Secondly, to identify whether any of the factors associated with community ambulation are also predictors of the likelihood of achieving full community ambulation or improvement from baseline level of ambulation. Thirdly, to determine whether the prognostic tests have sensitivity to change and what their minimum clinically meaningful change is. To achieve the objectives, 111 patients were analysed and classified into three groups according to their walking speed: 44 non-ambulatory, 33 household ambulatory and 32 limited ambulatory. From the start of physiotherapy until discharge, the following were assessed monthly: walking speed using the 4-meter walk test, balance using the balance test from the Short Physical Performance Battery (SPPB), and the 5STS test (sit-to-stand test performed five times). The main findings were that patients starting physiotherapy as non-ambulatory patients do not achieve full community ambulation at discharge, whereas in ambulatory patients (household and limited community) this probability is 40%. Among ambulant patients this probability is higher the better their baseline 5STS skills are. On the other hand, while non-ambulatory patients have a lower than 50% probability of improving their baseline ambulation level, in ambulatory patients the probability is higher than 50%. In non-ambulant patients the probability of improvement is higher the better their baseline abilities in the balance tests. Likewise, limited community ambulant patients were more likely to improve the better their baseline 5STS skills were. Finally, during the first two months in physiotherapy, a monthly reduction of 3 s in the 5STS test represents the minimum change that is clinically relevant for patients starting physiotherapy as limited community ambulant. For the rest, reductions of less than 3 s are clinically relevant. In conclusion, the present study shows that while in non-ambulant patients the tests with prognostic value at discharge are the balance tests, in limited ambulant patients it is the 5STS. In contrast, in household ambulatory patients no test showed prognostic value.