doctoral thesis abstract · doctoral thesis abstract doctoral supervisor: prof. danisia haba, md...

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




ii

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




iii

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


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




iv


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




v

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




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.




1

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




2

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




3

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




4

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)




5

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




6

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




7

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




8

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,




9

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).




10

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.


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




11

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




12

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




13

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.




14

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




15

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




16

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).




17

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.


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




18

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.




19

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




20

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.




21

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




22

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




23

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.




24

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.

SELECTIVE BIBLIOGRAPHY

1. Ayusto MI, Gonzalo-Gobernado R, Montaner J.

Neuroprotective diets for stroke. Neurochem Int

2017; 107: 4-10.

2. Esenwa C, Gutierrez J. Secondary stroke prevention:

challenges and solutions. Vasc Health Risk Manag.

2015; 11 :437-50.

3. Fernandes CA, Coelho DB, Martinelli AR, et al. Right

cerebral hemisphere specialization for quiet and

perturbed body balance control: Evidence from

unilateral stroke. Hum Mov Sci 2018; 57: 374-387.

4. Froehler MT, Ovbiagele B. Therapeutic hypothermia

for acute ischemic stroke. Expert Rev Cardiovasc

Ther 2010; 8, 593-603.

5. Consequences for Canadian Stroke Patients. Can J

Neurol Sci 2017; 44(2): 146-151.

6. Genthon N, Vuillerme N, Monnet JP, et al.

Biomechanical assessment of the sitting posture

maintenance in patients with stroke. Clin Biomech

(Bristol, Avon) 2007; 22(9): 1024-9.

https://www.ncbi.nlm.nih.gov/pubmed/?term=Ayusto+MI.%2C+Gonzalo-Gobernado+R.%2C+Montaner+J.%2C+(2017).+Neuroprotective+diets+for+stroke%2C

https://www.ncbi.nlm.nih.gov/pubmed/?term=Ayusto+MI.%2C+Gonzalo-Gobernado+R.%2C+Montaner+J.%2C+(2017).+Neuroprotective+diets+for+stroke%2C




25

7. Ginsberg MD. Neuroprotection for ischemic stroke:

past, present and future. Neuropharmacology 2008;

55(3): 363-89.

8. Handschu R, Babjar E, Reitmayer M, et al. Wissen

und Informationsquellen in der Bevölkerung.

Springer-Verlag 2005; 76: 716–723.

9. Ho E, Cheung SHC, Denton M, et al. The practice and

predictors of early mobilization of patients post-acute

admission to a specialized stroke center.

Top Stroke Rehabil 2018; 15: 1-7.

10. Ing MM, Linton KF, Vento MA, et al. Investigation

of Stroke Needs (INVISION) Study: Stroke

Awareness and Education. Hawaii J Med Public

Health 2015; 74(4): 141-5.

11. Kim AS, Johnston SC. Global variation in the relative

burden of stroke and ischemic heart disease.

Circulation 2011; 124(3): 314-323.

12. Lin GH, Huang YJ, Lee SC, et al. Development of a

Computerized Adaptive Testing System of the

Functional Assessment of Stroke. Arch Phys Med

Rehabil 2018; 99(4): 676-683.

13. Magdon-Ismail Z, Ledneva T, Sun M, et al. Factors

associated with 1-year mortality after discharge for

acute stroke: what matters?. Topics in Stroke

Rehabilitation 2018; 25(8): 576-583.

14. Minnerup J, Sutherland BA, Buchan AM, et al.

Neuroprotection for stroke: current status and future

perspectives. Int J Mol Sci 2012; 13, 11753-11772.




26

15. Neculăeș M, Botez P. Preoperative Analysis of the

Barycentre at the Patients with Total Hip

Endoprosthesis. Sp&Soc 2011; 11(2): 206-221.

16. Rodríguez-Campello A, Jiménez-Conde J, Ois Á, et

al. Dietary habits in patients with ischemic stroke: a

case-control study. PLoS One 2014; 15;9(12).

17. Rongies W, Słomka B, Duczek A, et al. The Role of

Posturography in Assessing the Process of

Rehabilitation in Poststroke Patients—A Case Study.

Journal of Stroke and Cerebrovascular Diseases

2017; 26(2), e34–e37.

18. Sahota P, Savitz SI. Investigational therapies for

ischemic stroke: neuroprotection and neurorecovery.

Neurotherapeutics 2011; 8, 434-451.

19. Schaefer PW, Pulli B, Copen WA, et al. Combining

MRI with NIHSS thresholds to predict outcome in

acute ischemic stroke: value for patient selection.

AJNR Am J Neuroradiol 2015; 36(2): 259-64.

20. Tasseel-Ponche S, Yelnik AP, Bonan IV. Motor

strategies of postural control after hemispheric stroke.

Neurophysiol Clin 2015; 45(4-5): 327-33.

21. Wang W, Jiang B, Sun H, et al. Prevalence, Incidence,

and Mortality of Stroke in China: Results from a

Nationwide Population-Based Survey of 480 687

Adults. Circulation 2017; 135(8): 759-771.

22. Yenary MA, Han HS. Neuroprotective mechanisms of

hypothermia in brain ischaemia. Nat Rev Neurosci

2012; 13, 267-278.




27

23. Yeo LLL, Tan BYQ, Andersson T. Review of Post

Ischemic Stroke Imaging and Its Clinical Relevance.

Eur J Radiol 2017; 96: 145-152.

24. Zaidi SF, Aghaebrahim A, Urra X, et al. Final infarct

volume is a stronger predictor of outcome than

recanalization in patients with proximal middle

cerebral artery occlusion treated with endovascular

therapy. Stroke 2012; 43(12): 3238-44.

doctoral thesis abstract · doctoral thesis abstract doctoral supervisor: prof. danisia haba, md...

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