Section 1 Rehabilitation

## **Chapter 1**

## Post-Stroke Rehabilitation: A Necessary Step

*Iria Beltrán-Rodríguez, Laura García-Talavera Casado, Óscar Durán-Borrella, Patricia González-Feito, Irene Sánchez-Serrano and Rebeca de la Fuente Blanco*

## **Abstract**

A stroke is defined by the abrupt and sudden onset of neurological signs and symptoms that occur due to a disorder in cerebral blood circulation. Cerebrovascular diseases are a well-known cause of morbidity and mortality, being the second cause of mortality and disability throughout the world. Stroke treatment has improved substantially in recent years with the implementation of stroke units and revascularization therapies. The role of rehabilitation is to help improve deficits to regain functionality and to define the needs and care in patients with permanent disabilities. Stroke rehabilitation must start early and intensively and it must be carried out by a multidisciplinary team made up of neurologists, rehabilitation doctors, nurses, physiotherapists, occupational therapists, speech therapists, neuropsychologists, neurophysiologists, and social workers. Patients and families should be actively involved with this team, if possible, from the beginning and throughout the rehabilitation process. Functional recovery through comprehensive rehabilitation allows patients to remain in their usual environment, perform their work duties and carry out activities of daily life by themselves, reducing the need for institutionalization in long-term care facilities.

**Keywords:** stroke, rehabilitation, disability, skills, recovery

## **1. Introduction**

A stroke is defined by the abrupt and sudden onset of neurological signs and symptoms that occur due to a disorder in cerebral blood circulation. It can be due to an excess of blood in the cranial cavity, which is in expansible, called hemorrhagic stroke; or due to insufficient blood supply of oxygen and nutrients to the parenchyma: an ischemic stroke. Strokes usually have symptoms related to a focal brain lesion, an abrupt onset followed by stabilization with a tendency to regress, and predisposing risk factors.

We should suspect it when the following symptoms suddenly appear: weakness or numbness of a half body; difficulty speaking or understanding language; vision difficulty in one or both eyes having ruled out ophthalmological pathology, vertigo, or instability associated with other neurological symptoms or signs.

Cerebrovascular diseases are the second cause of morbidity and mortality in the world [1].

There is an estimated prevalence of about 80 million people with stroke worldwide. In 2016, of the 80.1 million affected, 41.1 were women and 39 were men [1].

The highest risk of stroke is found in populations in East Asia, Central Europe, and Eastern Europe. In terms of race, the incidence per 100.000 inhabitants of ischemic stroke is higher in black than in Hispanic, and higher in Hispanic than in white; being all the etiologies of stroke more frequent in black, except cardioembolic [2, 3].

In the last 30 years, a decrease in the incidence and mortality from stroke has been observed due to the better control of vascular risk factors, health education, and advances in the treatment of the acute phase of stroke. This improvement, unfortunately, is not universal and is highly influenced by the economic situation and the educational background of the population in each geographic area. In recent years, a decrease in the incidence of stroke has been observed in whites, remaining constant in blacks [4].

Hand in hand with the global decrease in incidence and mortality rates is the increase in the prevalence of stroke and its social health impact, due to a longer life expectancy and increased survival rate of patients suffering from cerebrovascular events.

Stroke patients have a high risk of poor prognosis during the first year after the event, including rehospitalization (33%), recurrence (7–13%), dementia (7–23%), mild cognitive disorder (35–47%), depression (30–50%) and fatigue (35–92%), all contributing to affect health-related quality of life [5, 6].

Stroke units and revascularization therapies have changed the stroke prognosis [7]. The role of rehabilitation is to help improve deficits, regain functionality and define the needs and care in patients with permanent disabilities. Disability in stroke varies according to the initial severity, the location of the injury, the patient's pre-morbid state, the degree of neurological recovery, and the support system that surrounds the patient [7, 8].

It is evidenced that comprehensive rehabilitation after stroke has a prognostic impact that is maintained in the long term, in the form of a better functional situation for the patients who access it. Functional recovery through comprehensive rehabilitation allows patients to remain in their usual environment, perform their work duties and carry out activities of daily life autonomously, reducing the need for institutionalization in long-term care facilities [9].

The recommendations of the King's College research team, in collaboration with the European Alliance Against Stroke, which presented the document "*The impact of stroke in Europe to the European Parliament*", indicate that multidisciplinary evaluations should be carried out in the stroke unit and the rehabilitation should start as soon as the patient is medically stable. People who start rehabilitation within the first week after admission have better long-term results than those who start their rehabilitation later [10].

## **2. Stroke rhabilitation**

## **2.1 Pathophysiology and principles of neurological rehabilitation**

The cells of the nervous system and the endothelial cells are continuously interacting with each other and with the extracellular matrix in order to maintain continuous cerebral homeostasis, forming a functional unit called the neurovascular unit. It is made up of neurons, interneurons, astrocytes, basal lamina lined with smooth

### *Post-Stroke Rehabilitation: A Necessary Step DOI: http://dx.doi.org/10.5772/intechopen.102971*

muscle cells and pericytes, endothelial cells, and an extracellular matrix [11]. All these elements, interconnected with each other, constitute a highly efficient system for regulating cerebral blood flow [11]. Cerebrovascular events alter the correct molecular communication between each of the elements of the neurovascular unit, generating a functional dysregulation that leads to the damage of the tissue. In the functional recovery phase after an ischemic stroke, compensatory neurovascular signaling at this level favors the repair mechanisms that involve angiogenesis and neurogenesis, thus intervening in achieving the most complete functional recovery possible [12].

Astrocytes play a fundamental role in cerebrovascular events, both in the establishment of the definitive lesion and in the process of tissue repair. During ischemia, the first morphological change observed is the edema of astrocytes, being one of the responsible factors for the decrease in glutamate reuptake. The edema may be surrounding the lesion up to 8 weeks after the stroke, which may alter the functioning of nearby neurons by blocking neuronal conduction [10].

Glial cells that survive the ischemic episode undergo a process of hypertrophy and proliferation, known as reactive gliosis, which has been related to mechanisms of neuroprotection and repair of ischemic injuries [13].

Recovery after stroke is associated with cortical reorganization [8]. After a cerebrovascular event, the tissue recovery that takes place during weeks, months, or years after the acute event is related to different physiological phenomena: dendritic growth, formation of new synapses (synaptogenesis), functional reorganization in the injured area or participation of other neighboring or homologous areas of the contralateral hemisphere in the process. These phenomena can occur spontaneously and they can be facilitated and directed by rehabilitative therapeutic interventions [13].

In ischemic stroke, the obstruction of a cerebral artery generates local changes in cerebral blood flow (CBF). Under normal conditions, CBF through adult brain tissue is >50 ml/100 g of brain parenchyma/minute. When the CBF is reduced in a certain area of the brain below 10 ml/100 g/min, a severe cerebral dysfunction is produced. This leads to a complete neuronal, structural and functional loss in that location in a short time; it is called the core of the infarction. Between this nucleus of ischemic infarction and the normally perfused brain parenchyma, there is a moderately vascularized region, the extent of which depends on the functioning of the collateral circulation, called the penumbra zone, in which two zones with different prognosis are differentiated: oligohemia zone (22–0 ml/100 g/min) and ischemic penumbra zone (10–22 ml/100 g/min) [14, 15]. The oligohemia zone is a hypoperfused zone that still maintains its functionality, while the ischemic penumbra is a hypoperfused and functionally inactive zone that limits the edges of the infarcted area but is still viable if CBF is recovered early [11]. Current strategies for acute reperfusion in ischemic stroke are aimed at restoring cerebral perfusion in the ischemic penumbra [11]. The therapeutic window in ischemic stroke is the time that elapses between the onset of ischemia and the moment in which the neuron located in the ischemic penumbra loses its ability to survive. After this time, reperfusion of the ischemic zone will be useless [13].

The tissue that survives a cerebrovascular event has the ability to adapt and reorganize itself anatomically and functionally to rebuild or replace synaptic connections that have been injured and reinforce neural networks that have remained after injury. This phenomenon is known as neuroplasticity [15], and neurological rehabilitation therapies play a fundamental role in its enhancement [16]. The key to activating neuronal plasticity is the repetition of the affected function, so all those treatment techniques that favor the performance of a function and its repetition will promote brain plasticity and the recovery of patients [9, 10].

The functional reassignment of the different healthy cortical areas to supply the deficit in the damaged area is called brain remapping [12].

The neuroanatomical, neurochemical, and functional changes that occur during the reorganization by neuroplasticity will facilitate, in some cases, the recovery of the affected functions (adaptive neuroplasticity). On other occasions, as a consequence of this reorganization in favor of some functions, the development of others may be hindered (maladaptive neuroplasticity) [17].

The most important cortical functions are not linked to specific anatomical regions, but rather depend on neural networks made up of neurons of diverse cortical locations interconnected with each other and distributed throughout the cerebral cortex [15, 18].

Although some functions of a neural network are specifically ascribed to a region of the same (e.g.: the execution of language to Broca's area), the lesion in that specific area may have little clinical translation if the remaining structures that makeup that network take over functional relief and thus compensate for the defect.

If the damage to a functional system is partial, recovery within the system itself is possible. On the other hand, if the damage is complete, replacement by a functionally related system is the only alternative for the functional recovery of the injured area. Each of the mechanisms involved in the post-injury functional recovery process will depend on the magnitude of the brain damage [16].

Although the basic mechanisms of neuroplasticity are common to the entire cerebral cortex, the pattern of cortical reorganization in the functional recovery of the different capacities is not the same, and the peculiarities in these patterns support the different modalities of therapeutic intervention for the different deficits: motor, sensory and cognitive (**Table 1**) [17, 19].

Motor recovery is a complex process that combines intrinsic or spontaneous neurological recovery and functional recovery. Intrinsic neurological recovery is the recovery of normal movement patterns, being the severity of the initial deficit inversely proportional to the recovery prognosis. It occurs generally within the first 1–3 months after the event. Functional recovery is the regaining of basic tasks or activities of daily life through learned compensatory movements (new movement patterns), which depends on motivation, learning capacity, family support, and the quality and intensity of the rehabilitative therapy [8].

The structures that help restore motor activity and function after a brain injury can be gathered into three groups: intact perilesional areas of the ipsilateral


#### **Table 1.** *Mechanisms of neuroplasticity [19].*

*Post-Stroke Rehabilitation: A Necessary Step DOI: http://dx.doi.org/10.5772/intechopen.102971*

primary motor cortex, ipsilateral and contralesionally auxiliary motor systems together with the structures responsible for executive control and contralateral motor system [20].

In addition to neuroplasticity phenomena, the post-injury recovery process involves mechanisms of regeneration, differentiation, and maturation of new neurons and support cells that facilitate the creation of new neural networks, thus allowing the replacement of damaged ones [16]. Neurogenesis, gliogenesis, and angiogenesis refer to the development and formation of new neurons, supporting glial cells, and blood vessels respectively [14, 15]. Neurogenesis takes place throughout life, although it is attenuated with age. In adults, it is discrete and basically restricted to two neurogenic areas: the subventricular zone close to the third ventricle and the infragranular area of the dentate gyrus of the hippocampus [15]. Several studies have shown that ischemic lesions of the central nervous system lead to an increase in the proliferation of neural stem cells located in the subventricular zone, which will subsequently differentiate into mature cells that will travel to the damaged brain areas through different biochemical mechanisms and molecular cell signaling. Neuronal death is a strong stimulus for neurogenesis after ischemic stroke, even when it occurs in brain territories that are located at a distance from neurogenic niches. However, the vast majority of these newly generated cells have low survival once they reach the damaged area, a fact that could be favored by detrimental factors in the perilesional environment, lack of neurotrophic support, and molecular signaling which is necessary for proper development [16].

Both in the phenomena of neuroplasticity and cell regeneration, epigenetic regulation through mechanisms that include DNA methylation, histone modification and the action of micro-RNAs (miRNA) play a fundamental role [16].

#### **2.2 Disability measurement scales**

### *2.2.1 Disability of basic activities of daily living*

### *2.2.1.1 Barthel scale*

The most widely used and the fastest index of functional independence. Its completion time is 5 min. The maximum score is 100 points (complete functional independence for activities of daily living) and a score below 20 points will show a great dependency level. It rates the level of dependency with feeding, movement, personal grooming, getting on and off the toilet, bathing, walking on a level surface, ascend and descend stairs, dressing and undressing, and bowel and bladder continence [21].

## *2.2.1.2 Functional Independence Measure (FIM)*

Assesses physical and cognitive disability according to the level of assistance required to carry out activities of daily life. Its completion time is 30–40 min. It consists of 18 items that assess 6 areas of function that are summarized in 2 basic domains: physical and cognitive. Each item scores on a scale of 1–7 (1 = total dependence and 7 = total independence), with a maximum score of 126 points. An unfavorable prognostic factor of function is considered a score less than 40 or a score less than 60 in people older than 75 years [9].

## *2.2.2 Motor disability*

### *2.2.2.1 Motor index*

It is a simple, fast scale: its completion time is 5 min and it is useful to assess voluntary motor activity in three basic movements of the upper limb (shoulder abduction, elbow flexion, and handgrip) and another three in the lower limb (hip flexion, knee extension, and foot dorsiflexion). 0 represents total paralysis and 100 represents normality [9].

## *2.2.2.2 Fugl-Meyer scale*

It is used to assess the function and control of the musculoskeletal system, including balance, sensitivity, and joint pain in patients who have suffered a stroke. It has the disadvantage that it requires training for the evaluators, and its application is very slow, taking about 30–40 min. It consists of 155 items, each of which is scored on a three-point ordinal scale. The maximum motor performance score is 66 points for the upper limb, 34 points for the lower limb, 14 points for balance, 24 points for sensitivity, and 44 points each for passive joint movement and joint pain. A maximum of 266 points can be reached [9, 10].

## *2.2.3 Cognitive disability*

## *2.2.3.1 Mini Mental State Examination (MMSE)*

It is a brief test for the detection and quantitative evaluation of cognitive impairment. Its maximum score is 30 and the threshold value for cognitive impairment is 23. It consists of 11 questions that assess orientation in time and space, fixation, attention and calculation, memory, nomination, repetition, understanding, reading, writing, and replication of a drawing. The test is valid as a screening tool and is sensitive to detect moderate/severe impairment, but not mild impairment [10].

## *2.2.3.2 Montreal Cognitive Assessment (MoCA)*

It is a short test that can be performed in 12 min to detect mild cognitive impairment. It consists of 30 questions, the score ranges from 0 to 30. A score above 26 is considered normal. It evaluates different types of cognitive abilities, including orientation, short-term memory, delayed recovery, executive function, visuospatial ability, language skills, abstraction, object naming, and attention [22].

## *2.2.4 Disability for communication*

#### *2.2.4.1 Boston aphasia test*

It requires 1–4 h to do and consists of 16 slides for the diagnosis of aphasia and 60 graphic elements for the vocabulary test. 1 point is awarded for each correct answer, the maximum score being 60. A score above 50 is considered normal [23].

## *2.2.5 Walking disability*

## *2.2.5.1 Sagunto Hospital Functional Gait Categories*

Sagunto Hospital Functional Gait Categories (FACHS) allows a quick, valid, sensitive, and reliable assessment of ambulation, allowing to determine the walking speed of stroke patients. It has 6 self-exclusive and self-explanatory function levels. Level 0: impossible; 1: completely dependent; 2: dependent hand; 3: free; 4: prolonged and 5: normal [10].

## *2.2.6 Stroke severity*

## *2.2.6.1 Modified Rankin scale*

It is a scale to measure functional outcomes in post-stroke patients. Assigns a score of 1–5 based on the level of independence from pre-stroke activities. 0: Asymptomatic; 1: No significant disability, able to carry out all usual duties and activities; 2: Mild disability, unable to carry out all previous activities but able to look after own activities without assistance; 3: Moderate disability, requiring some help, but able to walk without assistance; 4: Moderately severe disability, unable to walk and to attend to own bodily needs without assistance; 5: Severe disability: bedridden, incontinent, and requiring constant nursing care and attention [24].

## *2.2.6.2 National Institutes of Health Stroke Scale (NIHSS)*

It is a measure of somatosensory function used in the acute phase with patients who have suffered a stroke. It is made up of 11 items: level of consciousness, conjugate look, visual fields, facial paresis, paresis of upper extremities, lower extremity paresis, limb ataxia, sensitivity, language, dysarthria, extinction/neglect/inattention. It determines the severity of the stroke: Mild <4, Moderate <16, Severe <25, Very severe ≥25 [10].

## *2.2.6.3 Canadian Neurological Scale (CNS)*

It is also used in the acute phase to assess the neurological status of stroke patients. Ten clinical domains are measured, including mental state: level of consciousness, orientation, language, and motor functions: face, proximal arm, distal arm, leg [10].

## **2.3 Upper and lower limb motor rehabilitation**

Stroke is one of the main causes of disability in adults, and the demand for rehabilitation services after suffering a cerebrovascular event is very high.

Motor deficit is the main cause of physical disability in stroke and the area in which rehabilitation works as a priority. It is usually unilateral, although in more severe patients bilaterally innervated muscle functions, such as trunk control, may be affected [25, 26].

Hemiparesis or hemiplegia is the most prevalent deficit in stroke, being the symptom that is more worrying for the patient and their relatives, and the main indicator of treatment expectations [27]. The rehabilitation program consists of different phases.

### *2.3.1 Rehabilitation in the acute phase*

It covers the first 2 weeks after a stroke and it must be started soon when they are still in the stroke unit [25, 27]. All patients with acute stroke should be evaluated by the rehabilitation physician in the first 24–48 h to assess the deficit and initiate measures to prevent future complications, grade of recommendation A [27].

It is necessary to correctly align the patient in bed, make frequent postural changes, and place the joints in a functional position, with the help of orthoses and pillows. Adduction and internal rotation of the shoulder and flexion of the wrist and hands, as well as hips, knees, and ankles, which tend to extension and varus should be avoided [27].

The immobilization of the muscles in a shortened position is the initial mechanism for the development of contractures, which are objectified as an increase in resistance to passive movement, a situation that, if maintained, will decrease the joint range [26].

Therefore, once the patient is hemodynamically stable, passive kinesitherapy of the affected hemi body will be started [27], performing passive exercises of the full joint arch on a daily basis in the routes susceptible to muscle shortening. Prolonged muscle stretching is more effective than a brief passive exercise. It is also necessary to stimulate the mobility of the unaffected side since immobility weakens its strength [26].

Likewise, the patient will receive instruction to perform functional tasks, such as getting up in the bed and recovering adequate trunk control, which later allows sitting, self-mobilization, and transfers, as well as standing and walking depending on the degree of involvement [27].

In addition, respiratory physiotherapy treatment and global stimulation of the patient should be started [25].

Early mobilization and immediate rehabilitation appear to be the main variables associated with getting the best results in stroke units, by reducing bed-ridden complications (such as aspiration pneumonia, deep vein thrombosis, and pulmonary embolism as a consequence of immobility, contractures and pressure ulcers, potentially avoidable through frequent postural changes) [26].

Current evidence confirms that the more intensive the stroke rehabilitation treatment after the first 24 h, the better the functional results [27].

#### *2.3.2 Rehabilitation in the subacute phase*

From 2 weeks to 4 months after the stroke. Patients should be treated both during their hospital stay and after discharge, by units that are specialized in stroke rehabilitation treatment, recommendation grade A [27].

The objective during this phase is to gain the maximum degree of functionality possible by adapting to the deficits [25]. Recovery of motor activity usually follows a proximal to distal order. In cases of partial motor recovery, synergistic mobility patterns may develop. Proximal muscle contraction may induce distal contraction with the mass movement of the limb. The predominant synergies are antigravity: flexor in the upper limb and extensor in the lower [26].

The patient will learn new motor skills through experience and training for the phenomenon that constitutes brain plasticity. This brain reorganization substrate can be modulated by different rehabilitation therapies [26]. These therapies are very varied, and each physiotherapist applies them according to their knowledge and experience. There is no evidence that any type of physiotherapy shows superior results to the others [25].

## *2.3.2.1 Compensation techniques*

They seek to reeducate residual capacities, especially of the unaffected hemi body, to improve function [26]. They are indicated in severe patients with a poor prognosis or in the stabilization phase [25].

## *2.3.2.2 Neuromotor techniques or facilitating techniques*

Their objective is to improve the quality of movement on the affected side. There are different methods [26, 27]:

Bobath method: inhibition techniques (which reduce spasticity, synergies, and abnormal patterns), facilitation techniques (favor the development of normal posture patterns) are applied and the incorporation of the plegic side in therapeutic activities is promoted [25].

Brunnstrom method: It is based on the stimulation of synergies for the performance of analytical movements that the patient does not perform voluntarily [26].

Proprioceptive neuromuscular facilitation (Kabat): its main objective is to improve muscle weakness. It uses peripheral stimuli of superficial (touch) or deep origin (joint position, stretching) to improve muscle strength and coordination. It is based on movement patterns in which weak muscles are aided by stronger agonists [25].

## *2.3.2.3 Motor relearning techniques or task-oriented rehabilitation*

It aimed at improving the execution of specific tasks that have a practical meaning in the patient's life [27]. Learning requires repetitive and intense training, progressive in its difficulty, with feedback on what is being done and motivation strategies [26].

## *2.3.2.4 Therapy of movement induced by restraint of the healthy side*

It is based on experimental studies carried out by Taub in 1977 with monkeys that had undergone a dorsal rhizotomy, showing that they were able to use the affected limb by immobilizing the healthy side [27].

## *2.3.2.5 Technology applied to task-oriented rehabilitation programs*

For example, functional electrical stimulation (FES) applied to the lower extremity as an alternative to an antiequine orthosis or biofeedback to the patient (FES-EMG). Technology can facilitate the automation of the activity to be trained [26].

In this phase, the assessment and treatment of spasticity are also important, and the prescription of drugs or the application of botulinum toxin on the spastic muscles and/or orthoses that maintain muscle stretching may be necessary [25].

**Rehabilitative treatment of the upper extremity**: Unlike the lower limb, only a minority of patients achieve satisfactory functional use of the upper limb. The purpose of the rehabilitation treatment will be to reach the maximum possible functionality of the affected upper limb [25]. The specific techniques used for its treatment are [27]:

*Assisted passive and active kinesitherapy* of the affected upper limb, as well as muscle strengthening.

*Mental imagery*: Mental practice of movements and activities helps the functional recovery of the affected side.

*Induced movement therapy with suppression of the healthy side*: The best results with this therapy have been obtained when applied 3–9 months after cerebrovascular disease and it has been shown to be superior to conventional therapies in the motor recovery of the paretic upper limb, improving grip and speed of movement in carrying out activities of daily living.

*Mirror therapy*: It is effective in the motor recovery of the affected limb as well as in the reduction of pain. Visual feedback is used through a mirror, mobilizing both extremities, but observing the healthy side reflected.

*Virtual reality*: A simulation of the real environment is produced, generating human-computer feedback, while the patient performs the programmed exercises. Currently, it has been shown to be superior to conventional occupational therapy in improving the disability of the affected limb, also enhancing the effects of the latter.

*Functional electrical stimulation and simultaneous performance of task-oriented exercises*:The synchronization between the increase in sensory inputs to the CNS and muscle contraction stimulates motor recovery.

*Robot-assisted therapy in the upper limb*: It is used when the patient lacks sufficient strength. As an adjuvant therapy to physiotherapy, it makes it possible to increase the intensity of treatment, improving motor function in the shoulder, elbow and wrist, although it has not been shown to improve ADL performance.

*Transcranial stimulation*: It favors neuroplasticity phenomena, interfering with the patient's learning and motor function in a noninvasive and safe way.

**Rehabilitative treatment of the lower extremity**: It should start in the first days. A good mastery of orthostasis and some motor coordination should be achieved as soon as possible [25]. The main objective is to improve mobility and restore motor control of standing and walking (recommendation grade A) [26], to achieve greater independence and reduce energy costs [25]. In general, patients who are capable of performing transfers and standing safely in the subacute phase recover ambulation, in some cases requiring the use of technical aids such as anti-equine orthoses, canes, or a walker [26].

Normally the following phases are followed: initiation of standing, balance reeducation, parallel standing, and walking [25]. The following techniques are used [27]:

*Passive, assisted and active kinesitherapy*, as well as muscle strength training, being the strength of the quadriceps essential for dynamic stability during the support phase of walking.

*Re-education of balance*: Affected in patients with stroke due to impaired motor control in the trunk and lower extremity, as well as the sensitivity of the corresponding hemibody and a perception disorder, which makes it difficult for the patient to achieve correct maintenance of balance. Its treatment is essential since it can reduce the risk of falls.

*Physical reconditioning*: It is necessary to carry out an individualized aerobic training program that involves large muscle groups, to combat fatigue and increase cardiovascular resistance. Monitoring of heart rate and blood pressure is recommended during the performance of the same.

*Treadmill gait training with or without body weight offloading*: It improves gait parameters, increasing monopodal support on the affected side and step alternation, as well as physiological activation of the spinal erectors [25].

*FES of the affected lower limb*: It improves strength and deformity, but the effect is not maintained over time [25].

*Mental imagery* [26]. *Virtual reality* [26].

## *2.3.3 Rehabilitation in the chronic phase*

Rehabilitation is a time-limited process. Beyond the sixth month after the stroke, there is a stabilization phase in functional recovery. To indicate additional intervention in the chronic phase, it is necessary to set a realistic goal, have a rehabilitation technique with evidence of being effective in achieving that goal, and objectify progress towards the planned goal on a practical scale [26].

There are different studies about motor limb rehabilitation.

The AMOBES trial [28] found that additional physical therapy aimed at reducing complications of immobility had similar benefits at a lower dose of physical therapy. Studies performed in the early subacute stage of stroke, treating patients with neuromuscular electrical stimulation, functional stretch training, and task-oriented training, showed similar benefits to routine care for upper extremity functional capacity [29].

The EXPLICIT trial [30] found that restricted movement therapy led to an increase in upper limb capacity in the first 12 weeks after stroke, without maintaining this benefit at 26 weeks.

The VIRTUES [31] and EVREST [32] studies carried out an investigation on the effects of virtual reality and video games on the motor capacity of the upper extremities during the subacute stage of stroke.

The RATULS trial [33] investigated the effects of robot-assisted therapy on upper limb motor ability in the chronic stage of stroke. All of these trials illustrate the feasibility of using these technologies on a large scale and report benefits similar to those produced by an equivalent dose of recreational activities or conventional therapies [29].

## **2.4 Aphasia and apraxia rehabilitation**

Aphasia is an alteration of oral (comprehension and/or expression) or written (reading/writing) language as a consequence of a brain injury. 21–38% of stroke patients will present with some type of aphasia.

Dysarthria is the alteration that occurs in speech as a consequence of muscular dyscontrol in the buccophonatory organs due to the lesion, affecting its clarity.

It is necessary to differentiate it from apraxia, which is the decrease in the ability to voluntarily plan and execute the appropriate movements for the articulation of speech, without affecting the muscles involved in speech [34].

In the subacute and chronic phases, recovery from language and speech disabilities will depend on neuroplasticity processes, so specific assessment by specialized professionals and the start of speech therapy treatment during the subacute phase will be essential [27].

The period of recovery is variable, it is considered that during the first 6 months the speed of recovery is much higher and later it slows down, until almost stabilizing after the first year [26].

The treatment of these patients aims to increase the patient's linguistic capacity, providing them with tools to deal with the situation and make up for the deficit. It should be individualized, early (as soon as the patient is stable, able to cooperate with an acceptable level of care, and not excessively fatigued), and intensive [34]. There is an inverse relationship between the time elapsed from the onset of the deficit to the start of treatment and the magnitude of its effect. The magnitude of the effect is directly related to the frequency and intensity of treatment. The therapies usually offered in our environment, which are usually 2 h/week in the best of cases, have

effects that are barely superior to those of spontaneous recovery [27]. Its efficacy has been demonstrated with RCTs with frequencies of 3 h/week or 5 h/week [26].

The speech therapist can opt for three treatment strategies, not mutually exclusive, and that depends on the severity, the evolutionary moment, and the characteristics of each patient [26]:

## *2.4.1 Recovery of specific linguistic deficits*

Recovering the norm, the function is recovered. For example, in Wernicke's aphasia, working on phonological discrimination with specific exercises to differentiate phonemes [26].

## *2.4.2 Reorganization of the function*

Starting from the intact skills. It would be applied to the same patient trying to improve oral comprehension by promoting the use of more preserved semantic comprehension. The important thing is that he understands the messages, not that he maintains certain linguistic skills. It is usually the most used and effective strategy, especially in moderate or severe aphasia [26].

## *2.4.3 Substitution of lost linguistic abilities by any other mechanism that ensures communication*

In the same patient, his or her close environment is taught to increase expressiveness and to increase the gestural code used. It is usually necessary for patients with global or very severe aphasia, in addition to technical aids and augmentative or alternative communication [26].

As long as identifiable goals exist and progress persists, the aphasic patient should continue to receive treatment with regular and objective assessment of progress [25].

## **2.5 Cognitive and perceptual rehabilitation**

Cognitive impairment secondary to stroke is a frequent complication, with a prevalence ranging between 20 and 80%. The risk of cognitive impairment is related to demographic factors (age, education, or occupation of the patient) and vascular factors, although it can be stated in general terms that this risk is increased between 5 and 8 times more after suffering a stroke [35, 36]. Its presence is associated with a lower quality of life 12 months after the stroke, an increased risk of dementia (vascular dementia), mortality and institutionalization rates, as well as an augmented burden on the caregiver and bigger health expenses [37]. However, despite being a common and serious complication that carries a poor prognosis in the medium and long term, it is an underdiagnosed entity [38]. Assessment of cognitive functions should always be done routinely in the clinical care of stroke patients prior to discharge home [39]. To reduce cognitive consequences after stroke, the cognitive impairment must be properly characterized, the underlying causes of cognitive decline understood, and the efficacy of different treatment and rehabilitation approaches determined [40].

Cognition is an aggregate of different cognitive domains that are not independent of each other but are interrelated through neural networks. These cognitive

## *Post-Stroke Rehabilitation: A Necessary Step DOI: http://dx.doi.org/10.5772/intechopen.102971*

domains could be outlined as follows [40]: attention (focusing, shifting, dividing, or maintaining attention on a particular stimulus or task); executive functions (work planning, organization of thoughts, capacity for inhibition, control, and monitoring of responses, instrumental adaptation); visuospatial skills (visual search, drawing, construction); praxic function and perceptual/recognition skills (gnosis); memory (recall and recognition of visual and verbal information) and language (expressive and receptive, verbal and non-verbal, reading and writing).

A common finding in patients with cognitive impairment secondary to cerebrovascular lesions, and one that appears to be a consistent pattern, it is deficits in attention, executive functions, and processing speed [41]. Memory impairment, highly compromised in patients with Alzheimer's Disease, is not usually the most obvious cognitive deficit after a stroke; only about half of the people with vascular cognitive impairment present amnesic signs, and approximately 30% of patients with vascular cognitive impairment will progress to a phase of dementia [42].

The location of the lesion constitutes a determining factor in the clinic of cognitive deterioration after stroke [43]. Strategic infarcts in specific locations in the brain are capable of causing a postictal cognitive deficit, sometimes of acute/subacute onset. The first evidence in this regard was obtained after observing symptoms of cognitive impairment in the context of acute vascular thalamic lesions.

Some typical locations of strategic infarcts and their most characteristic clinical manifestations are described below (**Table 2**) [44].

The most widely recognized neuropathological substrates include infarcts, hemorrhages, and global hypoxic-ischemic brain injury. White matter injury, including demyelination with or without axonal loss, is also common in people with vascular dementia, but is nonspecific and can also occur in the setting of neurodegenerative dementia, such as in AD. Similarly, cortical atrophy and hippocampal sclerosis may be related to both focal and diffuse hypoxic brain injury, but are also not specific to VD, and are also seen in neurodegenerative diseases [41].

Cognitive rehabilitation plays a fundamental role in multidisciplinary stroke rehabilitation and should be started as soon as possible in order to obtain the best functional results. It should not be done in isolation, but rather combined with physical measures and training in activities of daily living. Furthermore, physical activity by itself protects against cognitive decline by increasing cerebral blood flow and the expression of neurotrophic factors [45]. Interventions carried out in cognitive rehabilitation are broadly classified as direct repair/cognitive skills training to restore previously learned behavior patterns and training of compensatory strategies establishing new patterns of cognitive activity through internal compensatory cognitive


**Table 2.** *Cognitive disorders after strategic strokes.* mechanisms, or establishing new patterns of activity through external compensatory mechanisms such as external aids, environmental structuring, and support [45].

The objectives of cognitive rehabilitation are to reinforce previously learned behavior patterns, establish new patterns of cognitive activity through internal compensatory cognitive mechanisms for impaired neurological systems, establish new patterns of activity through external compensatory mechanisms such as external aid, or structuring and environmental support and to allow people to adapt to their cognitive disability [45].

## *2.5.1 Rehabilitation in attention, working memory, and processing speed*

Rehabilitation in attention, working memory, and processing speed are three cognitive domains that constitute the cognitive triad that must be addressed first for the rehabilitation to be successful. Most exercises are based on the stimulus–response paradigm. The repeated activation and stimulation of the attentional systems facilitate changes in cognitive capacity, progressively increasing the attentional demand. Transcranial magnetic stimulation over the left dorsolateral prefrontal cortex can improve attention [46, 47].

### *2.5.2 Memory rehabilitation*

In mild memory problems, compensatory strategies may be considered [45]. The use of internal strategies (visual images, semantic organization, and spaced practice) is an option for patients with a high degree of functional independence. Non-electronic external strategies (use of notebooks, wall calendars, notes, to-do lists) will be another valid option in patients with preserved executive functions. In more serious deficits, the use of external compensations through assisted technology (e.g., tablets, laptops) is recommended, as well as specific interventions aimed at facilitating the acquisition of specific skills (e.g., error-free learning). Virtual reality games could improve attention and visuospatial memory, while music therapy improves verbal memory.

## *2.5.3 Rehabilitation of executive functions*

Executive dysfunction is the main component of neurobehavioral disorders in these patients [45]. It causes disruptive behaviors that have a great impact on the autonomy, functional independence, and social interaction of the patient. Intervention in groups constitutes a work tool of great value in these cases. It represents an opportunity to observe and work on cognitive and behavioral functioning and interpersonal interaction. The great variety of frontal symptoms (cognitive and behavioral) and the theoretical complexity of the exercises constitute some obstacles to which the designs of executive functional rehabilitation programs are exposed, which is why it is necessary to use different non-exclusive techniques such as modifications of the environment, restoration techniques, compensatory strategies, and educational interventions.

## *2.5.4 Dual-task training*

Dual-task training requires subjects to perform complex cognitive and motor activities simultaneously, improving the coordination of various tasks. Dual tasks are important for different daily activities, such as walking while having a conversation [46].

## *2.5.5 Pharmacological treatments*

Pharmacological treatments (acetylcholinesterase inhibitors, antidepressants, atomoxetine, methylphenidate, and modafinil) have not been shown to improve cognitive impairment in patients with cognitive impairment secondary to stroke, so their use must always be individualized [45].

## *2.5.6 Rehabilitation of perceptual and constructive abilities*

Cortical perceptual abilities are defined as the ability to organize, process and interpret visual, tactile, or kinesthetic afferent information or both, and the capacity to act appropriately on the information received [47]. Some symptoms in relation to the compromise of perceptual activities are unilateral spatial neglect (the lack of information, response, or orientation to sensory stimuli presented on the contralateral side of the lesion, usually related to right parietal lesions. These patients can ignore food on one side of the plate, or attend only to stimuli on one side of the body) [48] and anosognosia (lack of awareness of the loss of an important bodily function, mainly hemiplegia. It is also more common in right parietal lesions) [49]. The left hemisphere is responsible for modulating arousal and attention in the right visual field, while the right hemisphere controls these processes in the left and right visual fields. Rehabilitative interventions must be implemented repeatedly, training the patient to voluntarily compensate for its deficits: seeking adaptation to the external environment with strategies that do not require the patient to be aware of the deficit [49], modifying behavioral conditions to affect the execution of observable tasks, trying to correct hemineglect without the conscious participation of the patient, or with the top-down strategies, in which the voluntary effort of the patient seeks to reduce or compensate the negligent side, following the indications given by the rehabilitator [50].

## **2.6 Behavior and psychological rehabilitation**

The psychological and behavioral changes due to stroke are in most cases devastating, causing a marked decline in quality of life, which can be improved with neurorehabilitation. Anxiety is common during the first year after stroke, with one in three experiencing it, and it gets significantly less attention compared to other psychological problems after stroke. Anxiety significantly influences the quality of life and could be a predictor of depression [51]. Post-stroke depression occurs in 1 in 3 stroke patients and more than half of all cases are neither diagnosed nor treated. Symptoms usually occur within the first three months after the event [52]. These patients experience sleep disturbances, vegetative symptoms, and social withdrawal. In some patients, depression can be accompanied by suicidal thoughts or tendencies. Irritability is a very common symptom after stroke and a source of a great deal of distress to patients and caretakers [53]. All these psychological and behavioral problems can be tackled with group rehabilitation, psychological therapy, and drugs such as selective serotonin reuptake inhibitors.

There are other techniques that can help in mental health recovery and psychological rehabilitation after strokes, such as yoga and meditation. Both are known to reduce anxiety, fear, anger, stress, and depression in patients and caregivers, promote cardio-respiratory health, and reduce stroke-related risk factors such as carotid atherosclerosis, dyslipidemia, hypertension, diabetes, and coronary artery disease. Also, it was demonstrated that following practice of yoga and meditation made significant

improvement in muscle power and range of movements in hemiplegic limbs and some positive effects in the Berg Balance Scale, Timed Movement Battery, and quality of life as assessed with the Stroke Impact Scale [54].

## **2.7 Rehabilitation technologies and remote rehabilitation**

Rehabilitation technologies are defined as 'those whose primary purpose is to maintain or improve an individual's functioning and independence, to facilitate participation and to enhance overall well-being' [54]. Such devices are quite helpful in engaging patient's interests and motivation. A wide range of such applications are available:

## *2.7.1 Robotic devices and virtual reality*

Robotic devices are machines capable of carrying out a series of complex actions automatically. Virtual reality consists of machines that produce interactive simulations to allow users to engage in environments that closely resemble the real world. Both techniques use visual and multisensory stimuli and facilitate joint movements, walking, improving muscle strength and motor function. Electromechanically assisted gait training combined with conventional physiotherapy is more effective than training without these devices [54].

To regain motor function after stroke, rehabilitation robots are increasingly integrated into clinics. The devices fall into two main classes: robots developed to train lost motor function after stroke: therapy devices, and robots designed to compensate for lost skills: assistive devices [55].

## *2.7.2 Electrical stimulation*

Electrical stimulation is one of the most widely used therapy and its reported benefits include spasticity reductions, improvements in range of motion, improved sensation, and reduced pain, but its benefit in stroke rehabilitation has not been adequately demonstrated [54].

Remote rehabilitation is very useful after a stroke. Tele-rehabilitation, also known as e-rehabilitation, is the delivery of rehabilitation services over telecommunication networks and the internet, which provides access to rehabilitation services in a remote area using communication technology, minimizing the problem of living far away from these centers where rehabilitation can be offered.

Wearable sensor technology can also address many of these limitations, being able to offer home-based therapies which can be monitored remotely. Brain-computer interface or brain-machine interface is an upcoming technology in stroke rehabilitation, in which brain signals are recorded through a sensor, transmitted to a computer processor to decode it, and formulate a signal for intended actions with a robotic limb or wheelchair [54].

## **2.8 Predictive factors of recovery**

The factors with the greatest weight in the functional prognosis after a stroke are the initial severity, the functionality before the event, the time between the stroke and the

### *Post-Stroke Rehabilitation: A Necessary Step DOI: http://dx.doi.org/10.5772/intechopen.102971*

start of rehabilitation, and the cognitive status. The two most important predictors of functional recovery are initial stroke severity and age.

The patients who benefit the most from a rehabilitation program are usually those with better baseline functionality. Classification of patients can be made based on the severity of the stroke [8, 10].

### *2.8.1 Mild stroke*

Mild deficits: FIM score > 80. NIHSS <5. There are no assessable cognitive deficits. Barthel >80.

## *2.8.2 Moderate stroke*

Moderate deficits: FIM score 40–80. FIM engine 38–62. NIHSS 5–9. Normal level of consciousness with significant hemiparesis. Barthel 60–80.

## *2.8.3 Severe stroke*

Severe deficits: FIM < 40 or motor FIM < 37. NIHSS >9. It is usually associated with severe motor deficits, impaired level of consciousness, and/or medical comorbidities. Barthel <60.

#### **2.9 Community reintegration**

Hospital discharge should never lead to an interruption in rehabilitation, and it is the responsibility of the healthcare organization and the professionals of the rehabilitation teams to ensure the continuity of the process. Hospital discharge planning should be approached from the initial stages of admission and should involve the professionals, the patients themselves, and their families or caregivers. Knowing possible problems and needs in advance facilitates reintegration into the community [51].

The perception of health among people with stroke sequelae 2 years after the stroke is lower than the general population. The factors that determine a lower quality of life are depression, having to depend on a third person, and the need for social help.

Rehabilitation programs are most effective when carried out at an early stage. Late rehabilitation is the one performed when most of the deficits have stabilized and the objective is to maintain recovered functionality, continue the adaptation process, and improve the performance of basic activities of daily life [51].

In patients undergoing rehabilitation programs, improvements in deficits, social participation, and quality of life can be seen even years after the event that generated the initial injury. It is important to make a selection of the appropriate approach to continue the rehabilitation treatment according to the type of patient [9].

#### *2.9.1 Long term care facilities*

Patients who continue to need hospitalization and have a moderate or severe disability in more than two functional areas such as mobility, swallowing, or communication, but whose medical and cognitive conditions do not allow them to participate in therapies of high intensity, and without sufficient social and family support to foresee a return home in the medium term.

## *2.9.2 Outpatient rehabilitation*

If patients have a mild or moderate disability and meet the medical and cognitive conditions that allow them to travel to a rehabilitation center, and have good social and family support, they will continue with high-intensity treatment (1–3 h daily) in outpatient rehabilitation centers or by going to the referral hospital on an outpatient basis.

## *2.9.3 Home rehabilitation*

In those patients who continue with a moderate or severe disability and good cognitive conditions but whose medical or social situation does not allow them to travel to a rehabilitation center. For patients with very severe disabilities in the chronic phase, as long as there are functional objectives to be achieved, home rehabilitation can help to avoid long-term complications, readmissions and moderate the impact of the disability on the quality of life of patients and caregivers.

Regarding social support after the stroke, it will be necessary to report on aspects such as labor reintegration, changes, and strategies to minimize sexual dysfunction, the possibility of driving vehicles again, or the access to adapted transport systems that would make it possible to increase the level of occupational, social and leisure activities, improving the quality of life of the patients. In addition, after a stroke, family training and emotional support are highly important, especially for those who are going to become caregivers [51].

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Iria Beltrán-Rodríguez1 \*, Laura García-Talavera Casado2 , Óscar Durán-Borrella1 , Patricia González-Feito1 , Irene Sánchez-Serrano1 and Rebeca de la Fuente Blanco1

1 Complejo Asistencial Universitario de León, León, Spain

2 St. Vincent's University Hospital, Dublin, Ireland

\*Address all correspondence to: iriabeltranrodriguez@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 2**

## Stroke and Healthcare Facilities in Bangladesh and Other Developing Countries

*Mohammad Shaikhul Hasan, Kanida Narattharaksha, Md. Sazzad Hossain and Nahar Afrin*

## **Abstract**

Globally, healthcare systems are struggling to make a healthier citizen by dropping infectious and non-infectious diseases. South-east Asian countries have achieved several Millennium Development Goals (MDG) with the efforts of better health system management. For instance, in the year 2015, the healthcare system of Bangladesh has achieved the MDG-Four in reducing the infant mortality rate and growth rate. Even then, the life-threatening diseases still remain as a major challenge to the healthcare systems in Bangladesh. Among those, non-communicable diseases (NCDs) are the major cause of death, and stroke is the second leading NCD in accordance with causes of death and long-term disability in Bangladesh. The majority as 80% of stroke survivors are living with either minor or major physical, emotional, and cognitive disabilities. They could get back to their functional life through comprehensive rehabilitation services. Nevertheless, information on the availability of rehabilitation services is not visible to all citizens of Bangladesh. That's why more than half of all stroke survivors are dying on their way to the hospital to seek health care facilities. Therefore, the aim of this literature review was to present a clear vision of the healthcare system and the path of care to all citizens of Bangladesh.

**Keywords:** post-stroke, rehabilitation, non-communicable diseases (NCDs), Bangladesh healthcare service systems

## **1. Introduction**

Stroke is the leading non-communicable disease worldwide and in the Southeast Asia (SEA) region [1]. In Bangladesh, stroke is the second leading non-communicable disease in terms of the cause of death and long-term disability. Those who survived from stroke attack need quality rehabilitation services to maintain their health and prevent them from death due to the second episode of stroke attack [2]. The quality of services can be viewed from many perspectives. However, the patient perspective is now given more importance because it can lead to the effectiveness of healthcare services and better health outcomes. Therefore, this study aims to examine the level

of patient expectations and perceptions and the factors relating to the patient expectations and perceptions of outpatient post-stroke rehabilitation services delivery management in Bangladesh.

This chapter includes an overview of Bangladesh, health status and challenges, stroke definition and situation, post-stroke situation and how Bangladesh healthcare service systems respond to the post-stroke, stroke, and post-stroke care pathway and quality of post-stroke rehabilitation services as well as the methodology to examine the quality of post-stroke rehabilitation services and conceptual framework of this research study.

## **2. Overview of Bangladesh**

Bangladesh is one of the smallest and most densely populated countries in the world. It is a developing country and a founding member of the South Asian Association of Regional Cooperation (SAARC) to promote regional connectivity and cooperation. Additionally, it is a member of the Commonwealth of Nations [3].

## **2.1 Geography**

Bangladesh is a country in the South Asia Region [3]. According to the Ministry of Health and Family Welfare [4], geographically it is divided into eight divisions/ provinces, and the total land area of this country is 147,570 sq. km. Dhaka division is the central division, and Dhaka city is the capital city of Bangladesh followed by Rajshahi, Barishal, Chittagong, Sylhet, Mymensingh, Khulna, and Rangpur divisions. Bangladesh National Portal [5] reported that the divisions/provinces are

## **Figure 1.**

*The administrative geography of the Government of Bangladesh. Adopted from: Bangladesh National Portal [5].*

divided into 64 districts and 11 metropolises. Under the districts, there are 491 subdistricts. The sub-districts contain 4553 union councils in the rural areas and 323 municipalities in the urban areas. Consequently, a ward is under the municipality and the municipality is under the metropolis. There is no specific number of wards and villages. **Figure 1** demonstrates the overall administrative geography of the government of Bangladesh.

## **3. Socio-demographic and economic**

The World Bank [6] reported that approximately 162 million people are living in this country. The World Bank [6] also claimed that in 2016, there are nearly 1253 people per sq. km. However, nearly 35% of the total population are living in urban areas for their employment.

The economic status of the citizens is improving, but still, possibly 25% of the total population are living under the poverty line [7]. In the year 2016, the growth domestic product (GDP) per capita was 1358.78 US\$, and in the same year, the annual growth rate was 7.11 US\$ [6].

## **4. Health status and challenges**

According to Muhammad et al. [8], the healthcare system of Bangladesh has achieved the Millennium Development Goal Four (MDG-4) by reducing infant mortality rate and growth rate, and maternal and child health improvement. Consequently, life expectancy at birth has increased. As an example, the World Bank [9] reported that in 2005, the life expectancy at birth was 67.94 years and in the year 2015, it reached 72.22 years (i.e. male 70.59 years and female 73.94 years). It is comparatively higher than other state members in SAARC. As evidence, the Bhutanese life expectancy was 69.8 years; Indian was 68.3 years, and Myanmar was 66.3 years in the year 2015 data. However, Ahmed et al. [10] claimed that the health system of Bangladesh had achieved MDG-4 and better life expectancy, though several lifethreatening diseases still remain.

The top five causes of death in Bangladesh are heart disease, stroke, Chronic Obstetric Pulmonary Diseases (COPD), lower respiratory infections, and diabetes [11]. The mortality rate of infectious diseases, maternal, prenatal, and nutritional conditions gradually went down from 30.9% in the year 2010 to 25.3% of total death in the year 2015 [12]. Relatively, the mortality rate of noncommunicable diseases is now rising and going to be a major health challenge and life-threatening diseases in Bangladesh [8]. NCDs caused almost 67% of the total death [9]. Significantly, stroke caused more than half of the total NCD fatalities in Bangladesh [13]. And due to the shortage of the health workforce and inefficient management, it was difficult to provide proper services for people who had strokes [4]. **Table 1** demonstrated all related data by selecting the major geographical, socio-demographic, economic, and health status of the citizens of Bangladesh.

## **4.1 Stroke definition and situation**

According to the American Stroke Association [15], stroke is one of the NCDs which is a medical emergency characterized by a neurological deficit attributed to an


#### **Table 1.**

*Major selected geography, socio-demographic, economic, and health status of Bangladesh in the years 2015 and 2016.*

acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) and it is a major cause of disability and death worldwide.

Nearly 4.46 million people have died due to stroke per year; 1.2 million in developed countries and nearly 3.2 million in developing countries [16]. For example, stroke was the 4th leading cause of death for US citizens in the year 2010 [17]. In every 40 seconds, someone was attacked by a stroke, and in every 4 minutes, someone died because of the stroke. It was also the leading cause of long-term disability in the United States. Similarly, in the year 2012 Australia projected that 377,000 people had a stroke sometime in their lives; and in 2013, the estimated deaths due to stroke were 8100 people [18]. Additionally, the stroke prevalence in European countries was also more similar to that in other countries. In 2015, it was found that, in the Netherlands, 0.2% of the total population had suffered from stroke each year [19]. Moreover, in 2008, around 3.7 million Southeast Asian people died from stroke. Islam et al. [20] reported that in Bangladesh, approximately 48,951 people had died due to stroke.

According to mortality, morbidity, and long-term disability rate, stroke is the second leading NCD in Bangladesh [11]. Nearly 113.9 persons per 100,000 had died due to stroke in the year 2013, and the increasing rate per year was 4.9% [21]. A total of 20% stroke patients died immediately in the acute phase, and 80% of the stroke survivors lived with minor or major disabilities [22]. Moreover, Centre for Injury Prevention Health Development and Research Bangladesh (CIPRB) [23] reported that approximately 15 out of 1000 Bangladeshi people were affected by stroke. Additionally, Islam et al. [20] found that the prevalence of stroke is 0.03% and it is snowballing. Nearly 485 out of 10,000 people died suffering from stroke disability [20]. Mamin et al. [24] found that nearly 82.5% Bangladeshi stroke survivors' age ranged between 41 and 60 years. Consequently, the big proportions of working people have lost their functional ability and it greatly impacts the economy of Bangladesh.

## **4.2 Stroke impact**

The American Stroke Association [25] claimed that the stroke effects depend on the lesion of the area of the brain cell. Different areas of the brain cell are responsible for different activities. Due to the lesion of the brain cell, the stroke effects can be physical paralysis, memory loss, speech loss, emotional, and behavioral problems. Wolfe [26] claimed that the stroke impacts could be explained from the perspectives of the government, society, family, and patient. From there, the socio-economic impact of stroke is more common in developing countries. Similarly, Institute for Health Metrics and Evaluation [11] reported that a stroke is a great economic burden for a developing country like Bangladesh.

According to Mamin et al. [24], nearly 77% of stroke survivors were public or private or self-employed in Bangladesh. Similarly, Global Health Statistics [21] reported that a big proportion of the working-age group and healthy life had been lost due to stroke in Bangladesh. For example, an estimated 1259.1 people at the age range of 30–34, 9102.9 people at the age range of 50–54, and 21695.5 people at the age range of 60–64 were affected by stroke and lost their functional life in the year 2014. Therefore, the government of Bangladesh has lost a big proportion of its workforce, and it greatly impacts the government and the economy.

Besides, Mohammad [22] claimed that the physical limitation of the patients greatly impacted the patients' participation in the social programs or activities in society. They need long-term hospitalization and rehabilitation services, and the family has to look after them. However, Disability in Bangladesh (2004) reported that it is difficult to bear the whole treatment cost and the health system of Bangladesh has no health insurance package for their citizens. Therefore, it is also an economic burden for their families [11]. According to Mohammad [22], the burden of stroke is not only for their families, but it is also a burden for the patient because of their post-stroke disabilities and impairments.

## **4.3 Post-stroke**

The post-stroke means a group of conditions including physical disability, emotional disturbance, and loss of cognition [27]. At the post-stroke phase, patients suffered from several complications; such as pressure sores, urinary tract infections (UTI), joint contraction, aspiration pneumonia, and recurrent stroke due to lack of proper healthcare services [2]. Consequently, these complications could be a leading reason for readmission and also for excruciating death. Gordon et al. [28] reported that daily activity or daily routine exercise helps the post-stroke patients' to reduce immobility and make them as functional as possible. Therefore, the post-stroke phase is more crucial. Additionally, Runa [29] found that post-stroke complication is a very common problem in Bangladesh.

Accordingly, Mohammad [22] claimed that better care and rehabilitation services could get them back to their independent life. The better quality of healthcare services means a better patient experience, and it is associated with better health outcomes with a higher level of loyalty to follow preventive and treatment strategies of the hospital personnel [30]. Therefore, the healthcare system needs to ensure better and sustainable healthcare services to reduce post-stroke patients' complications by increasing the better patient experience and patient participation in healthcare [31].

#### **4.4 Healthcare service delivery systems**

The health system is a dynamic and enduring obligation to peoples' health throughout their lifespan [32]. The primary purpose of the health system is to provide healthcare services to promote, restore or maintain the health of the nation [33]. According to the healthcare policy and *Constitution Act 18* cited in Ministry of Law [34], the fundamental principle of the health system of Bangladesh is to ensure better healthcare services for their citizens. The healthcare system of Bangladesh has been providing a comprehensive healthcare service by following multilevel healthcare service delivery processes [35]. The comprehensive healthcare service includes curative, rehabilitative, promotive, and preventive services. In accordance with service delivery processes, the three levels of health care services are being considered in the health systems of Bangladesh. Such as tertiary, secondary, and primary care levels of healthcare services.

#### **4.5 Tertiary care level**

All the national specialized and medical college hospitals are providing the tertiary level of healthcare services [10]. According to the Ministry of Health and Family Welfare [4], there are numerous condition-based specialized hospitals and 14 medical college hospitals that provide the tertiary level of healthcare services, and these are the highest level of referral hospitals in the health system of Bangladesh. Ahmad [36] reported that this tertiary care concentrated more on curative and intensive healthcare services along with rehabilitative care services and ignored the promotive and preventive care services. Besides, Mamin et al. [24] claimed that the public hospitals also wanted to avoid these rehabilitation services in the health systems of Bangladesh.

In regard to stroke care, all public and private hospitals are serving their in-patient intensive curative care and treatment services [4]. However, only a few of them are providing after-stroke rehabilitation services at the physical rehabilitation department on an out-patient basis [37]. Separately, the non-profit organization as the Centre for the Rehabilitation of the Paralyzed (CRP) is providing after-stroke rehabilitation services in both ways (i.e. in-patient and out-patient basis) [38]. The CRP also extended its branches and services across the six divisions in the health systems of Bangladesh [39].

## **4.6 Secondary care level**

According to the Ministry of Health and Family Welfare [4], secondary care or less intensive care is being provided at the district general hospitals. There are 62 district general hospitals to serve their secondary care services throughout the districts of the country. Secondary care includes curative, promotive, and preventive services. The promotive and preventive care services are being provided only for infectious diseases (i.e. Tuberculosis, Malaria, influenza, etc.) [40]. These secondary care hospitals are the first referral hospital in the health system of Bangladesh, and it does not provide rehabilitation services.

### **4.7 Primary care level**

According to the Ministry of Health and Family Welfare [4], primary care includes curative, promotive, and preventive treatment facilities along with rehabilitative

## *Stroke and Healthcare Facilities in Bangladesh and Other Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.101915*

services. The primary care services are being provided at the sub-district or Upazila level, union level, and community level. At this primary care level, the public sector provided the services free of charge. The Upazila health complex and Union subcenters are committed to providing curative, promotive, and preventive services only. There are 491 Upazila health complex hospitals and 3134 Union Sub-centers at the primary care level to provide in-patient and out-patient services. There are 13,336 community clinics serving maternal and child-related outdoor primary care services with basic medicines. Besides, Biswas et al. [40] reported that the Upazila health complex with the cooperation of NGOs has been running an NCD corner (i.e. fast-track corner) at the primary care level of Bangladesh to prevent the risk factors of NCDs. Consequently, due to the lack of healthcare personnel of the public sector, the NGOs are providing community-based rehabilitation services at this primary care level free of charge.

**Table 2** lists all the hospitals and other healthcare facilities beneath the Directorate General of Health Services (DGHS) of the Ministry of Health and Family Welfare of Bangladesh. There is no list of private hospitals; thus, only public hospitals' information is listed in the table. In this table, the type of hospital services includes inpatient and outpatient types of services.

## **4.8 Human resources**

The Ministry of Health and Family Welfare [41] reported that there were 74,099 physicians, 6,481 dental surgeons, almost 46,000 registered nurses, 775 pharmacists, 6,029 medical technologists, and 66,623 community health workers. The number of physicians and population ratio was 4.5 per 10,000 populations. There was no more data on the rehabilitation professionals, only a little information available about the physical therapist. The Ministry of Health and Family Welfare [4] reported that in the public sector, nearly 117 physiotherapists are working. Separately, World Confederation for Physical Therapy (WCPT) [42] reported that approximately 1,600 physiotherapists are working in the whole Bangladesh healthcare service sectors. According to a 2016 report of the Bangladesh Health Professionals Institute (BHPI), 241 occupational therapists have graduated and are working in various national and international organizations and hospitals in the country and abroad [43]. The Society of Speech and Language Therapists (SSLTs) reports that speech and language therapy is a relatively new profession in comparing with other rehabilitation professions in Bangladesh and as of 2016, there are 104 graduate speech and language therapists those are working in various national and international healthcare organizations in Bangladesh [44]. Approximately, 25 to 30 students from each department of BHPI (the academic institute of CRP) (Occupational Therapy and Speech and Language Therapy) completing their graduate program each year and initiate clinical practices [39]. **Table 3** demonstrated the healthcare personnel and population ratio of serving healthcare services healthcare services in Bangladesh. Therefore, the availability of rehabilitation services and the fee for the services are the greatest challenge for the person with rehabilitation service needs.

## **4.9 Financial challenges**

According to Bangladesh National Health Accounts [45], the total health expenditure was only 3.5% of the total GDP. It is relatively low, and according to per capita, the health expenditure was 27 US\$. However, from this expenditure, the


#### **Table 2.**

*The hospitals and other healthcare facilities under the DGHS of Bangladesh.*


#### **Table 3.**

*The healthcare professional and population ratio in the years 2015 and 2016.*

government invested only 23%, and the rest of the amount came from out-of-pocket payments. According to Ahmed et al. [10], this out-of-pocket payment was almost 63% of total healthcare cost. Besides, there was no specific budget for stroke and post-stroke patients and their healthcare services. Moreover, the Ministry of Health and Family Welfare [4] reported that they invested only 2714 million BDT taka (32 million US\$) for overall NCDs surveillance. This was a very small expenditure compared to the expenditures on communicable and maternal diseases (i.e. 579 million US\$) in the healthcare service system of Bangladesh. Therefore, financial challenge is a big challenge to provide NCD-related healthcare programs in the healthcare system of Bangladesh.

## **4.10 Policy and programs**

Since the liberation, the health system of Bangladesh has been concentrating on controlling communicable and maternal and child-related diseases [10]. Global Health Statistics [21] reported that within the last decade the burden of NCDs is snowballing and has become a major health challenge for Bangladeshi citizens. Furthermore, the Ministry of Health and Family Welfare concentrated on this issue, and with the cooperation of NGOs and private organizations, they developed different policies and had been implementing these to strengthen the healthcare system of Bangladesh [40].

There is no specific policy and program for after-stroke disability. All the policies are focused on preventive and promotive health care services to control the risk factors of NCDs including stroke. However, these services are also important to reduce the second episode of stroke attack [46] such as the Health, Nutrition and Population Strategic Investment Plan (HNPSI) for six years (2016–2021) to inter-organization collaborative work and improve healthy lifestyles [4]; *The Smoking and Tobacco Products Usages (control) Act, 2013* to reduce smoking [5]. Furthermore, the governance, non-governance, and private organizations are working collaboratively to implement these policies and programs [40]. One example is the NCDs intervention corner at the primary care level of Bangladesh.

## **4.11 Governance and organizations**

The health system of Bangladesh has been following a pluralistic healthcare system. The Ministry of Health and Family Welfare is the main government organization of the health system of Bangladesh [4]. This ministry is responsible for providing curative, promotive, and preventive services through tertiary care, secondary care, and primary care organizations. For rehabilitation services, the Ministry of Social Welfare is the responsible government organization, but at present both ministries (i.e. Ministry of Health and Family Welfare and Ministry of Social Welfare) are working collaboratively to serve rehabilitation services at the different levels of healthcare services [47].

The public sector in the health systems of Bangladesh did not concentrate more on rehabilitation services [24]. Thus, the private sectors (for-profit organizations) and NGOs (not-for-profit organizations) extended their healthcare services including rehabilitation services [20]. A few of the private hospitals are providing post-stroke rehabilitation services at tertiary care level hospitals on an inpatient and outpatient basis.

### **Figure 2.**

*Health service systems structure in Bangladesh health systems. Adopted from: Ministry of Health and Family Welfare [4]; Ahmed et al. [10]; Biswas et al. [40].*

*Stroke and Healthcare Facilities in Bangladesh and Other Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.101915*

Along with the private sectors, several NGOs under the Ministry of Social Welfare have been offering post-stroke rehabilitation services within the community and hospital [40]. These NGOs are the Bangladesh Rehabilitation Assistance Committee (BRAC), Handicap International (HI), International Committee of the Red Cross (ICRC), and the CRP (Handicap International (HI) [48] and Islam et al. [20]). The International Committee of the Red Cross (ICRC) with the collaboration of CRP has been providing rehabilitation services in the community [49]. While only the CRP provides hospitalbased stroke rehabilitation services besides community-based rehabilitation services.

The CRP is offering rehabilitation services throughout the six divisions of the administrative geography of Bangladesh [39]. The CRP is also committed to provide Multi-Disciplinary Team (MDT) based rehabilitation services. According to Gresham et al. [50], the rehabilitation services by a multidisciplinary team provide better health outcomes after-stroke disabilities. The MDT approach consists of different specialists or professionals, those working in a team according to the needs of the patient [51]. In this approach, all professionals are offering their highest potential skills to change the patients' condition as much as possible. **Figure 2** demonstrates the overall service structures of the Bangladesh healthcare system.

## **5. The Centre for the Rehabilitation of the Paralyzed (CRP)**

According to CRP [39], the CRP is a not-for-profit NGO to serve rehabilitation services for person with disabilities. CRP's vision is "to ensure the inclusion of girls and boys, women and men with disabilities into mainstream society." To achieve this vision, CRP worked with several missions such as "to promote an environment where all girls and boys, women and men with disabilities have equal access to health, rehabilitation, education, employment, the physical environment, and information." The CRP is coordinated by a committee, and it is committed to serving quality services.

Trust for Rehabilitation of the Paralyzed (TRP) is the central committee and all the decisions such as policy, programs, and implementation are being addressed by the recommendation of this committee. The executive director coordinates all the CRP services throughout the CRP branches. The program manager helps the executive director to coordinate all the programs. The program manager divides all the CRP activities into various programs or services. Every wing is being coordinated by the head of the wing along with several heads of the departments. Additionally, there is the academic wing to provide the skillful rehabilitation professionals to serve the quality services toward the patients. It has ten branches, and the medical service wing is responsible for serving all healthcare services.

In this context, the physical therapy department is responsible for recovering physical functions, the occupational therapy department for recovering daily activities, and the speech and language therapy department for recovering communication and swallowing difficulties. According to CRP policy, all medical professionals have to wear hospital uniform during therapy services. Only the five CRP divisional hospital branches (i.e. Rajshahi, Chittagong, Barisal, Sylhet- Moulvibazar, and Mymensingh branches) along with the main branch of Dhaka division has been providing the out-patient medical services and rehabilitation services. The rest of the branches are responsible for providing Community-Based Rehabilitation (CBR) services and health promotion and prevention activities beneath the rehabilitation wing. CBR is offering these services five full days a week, from 8 am to 5 pm.

### **Figure 3.**

*The organogram of the CRP activities in Bangladesh. Sources: Adapted from [39].*

There are several departments, and the research and evaluation department coordinates all the research-oriented formalities in the CRP. CBR collects donation and undergoes several income-generating activities to enhance the endowment to run the healthcare services (i.e. CRP cafeteria, nursery, woodshop, etc.). **Figure 3** demonstrates the CRP management organogram with several services and activities throughout the country.

## **6. The rehabilitation personnel in the CRP hospital**

The CRP (2016) reported that all of 755 dedicated employees are working throughout this organization and its branches. However, there is no exact data for the total number of separate rehabilitation professionals.

## **7. Stroke and post-stroke care pathways in Bangladesh**

The rehabilitation service systems and stroke care depend on the severity of the patients and the episodes of the stroke attack [52]. They have mentioned two phases; the acute phase and the sub-acute phase of stroke care. However, Pitthayapong et al. [2] added the post-stroke phase and it is started at the end of the acute and subacute periods of stroke.

## **7.1 Acute stroke care**

Acute stroke care means care that takes place 24–48 hours after stroke, and during this period they need more intensive comprehensive services including rehabilitation if possible [52]. Particularly, inpatient rehabilitation care units of the hospitals serve the acute stroke care services, and the tertiary/specialized hospitals and divisional general hospitals provide comprehensive stroke care services under the healthcare services structure of Bangladesh (Directorate General of Health Services [53]; Bhowmik et al. [7]; & Nessa et al. [37]).

## **7.2 Subacute stroke care**

At the end of the acute period of stroke, the sub-acute period of stroke starts, and the duration of this phase is one week until one month [52]. At this period the neurological condition of the stroke patients is more stabilized than during the acute stroke period, and from this phase, they attend a regular rehabilitation program [54]. The acute and sub-acute stroke patient services are similarly available in the tertiary/specialized hospitals and divisional general hospitals in Bangladesh (Directorate General of Health Services [53]; Bhowmik et al. [7]; Nessa et al. [37]).

## **7.3 Post-stroke care**

Post-stroke care is care that started at the end of the acute and sub-acute phase of stroke patients [55]. However, Habib and Hirschfeld [56] found that the post-stroke care with the integration of rehabilitation services was effective. The limited specialized public and private hospitals at the tertiary level and the CRP hospital provide after-stroke/post-stroke rehabilitation services. The NGOs and Upazila health complex hospitals provide preventive and promotive services for reducing the risk factors of the second episode of stroke attack in the health systems of Bangladesh (Biswas et al. [40] & Ahmed et al. [10]).

The stroke care pathways in the Bangladesh health service system are complex and difficult to control. According to Biswas et al. [40], first, the patient visits the Upazila health complex, and if the responsible health professional notices any signs and symptoms of the stroke risk factors, then they suggest that the patient has to continue the preventive and promotive services from the NCDs corner. Directorate General of Health Services [53] reported that according to the stroke management guideline; if the patient needs emergency services, they are referred to the district hospital for secondary care. Thus, the district hospital takes care of this patient according to their available resources. If the patient's condition becomes more severe, then the district hospital refers the patient to the tertiary or specialized hospitals for more intensive care and neurological treatment.

According to this stroke management guideline, after completing the acute stage, some of the hospitals send them to the rehabilitation hospital or the rehabilitation unit of the hospitals for early rehabilitation services [53]. Moreover, the rehabilitation

## **Figure 4.**

*Stroke and post-stroke care pathways along with the rehabilitation services in Bangladesh. Adopted from: Directorate General of Health Services [53]; Ahmed et al. [10]; Nessa et al. [37]; and Bhowmik et al. [7].*

professionals are working with those post-stroke patients with a set of standard goals, and after achieving this goal, they send them back to the community or home to continue community-based rehabilitation services by several NGOs [10, 20, 39]. Similarly, they are continuing preventive and promotive services through NCDs corner of the primary care level to reduce the second chance of stroke attack [40]. This study concentrated only on the post-stroke out-patient rehabilitation services system in Bangladesh. According to Ahmed et al. [10], CRP is a rehabilitation center for serving post-stroke rehabilitation services in Bangladesh. It is serving hospital-based inpatient, out-patient, domiciliary, and community-based rehabilitation services. **Figure 4** shows the stroke and post-stroke care pathways along with the rehabilitation services in Bangladesh.

## **8. The CRP post-stroke out-patient rehabilitation services pathways**

According to Runa [29], CRP is the biggest rehabilitation hospital in Bangladesh. It provides comprehensive post-stroke rehabilitation services following a Multi-Disciplinary Team (MDT) approach. The MDT team is composed of a physician, physiotherapist, occupational therapist, speech and language therapist, rehabilitation nurse, and patient's caregiver.

According to the CRP service delivery process [39], at the first contact, the patient comes to the reception (1) to collect the serial token, and after collecting the token, they have to wait in the waiting areas (2) for MDT screening (3). The MDT professionals screen the patient's condition and consequently recommend the patient for further rehabilitation services. According to the MDT recommendations, the patient goes to the laboratory (4) for the clinical test if recommended and reception

#### **Figure 5.**

*Demonstrated the overall post-stroke outpatient rehabilitation services pathways in the CRP hospital. Sources and Adopted: From, CRP [39].*

(5) for the appointment of outpatient rehabilitation services. There are three departments; physical therapy, occupational therapy, and speech and language therapy for post-stroke rehabilitation services. After collecting the therapists' appointment from the reception, the patient has to go to the recommended departments (6) to receive the therapy services and wait for therapy timing (7). However, the patient may have to visit several departments based on the patient's needs. The repetition of the therapy session depends on the patients' physical stability and availability of the therapy session. The three departments professional demonstrate a health education program (8) at the end of their therapy session. The main purpose of this program is to provide knowledge about stroke risk factors prevention and health promotional activities.

At the end of the session, according to the therapist's recommendation, the patient may have to go to the pharmacy (9) and the reception (10) again for further appointments. Finally, the patient goes back home (11, 12) and comes again on another day for a laboratory report and the next appointments if needed. Otherwise, the patient and the patient's caregiver can get help from CRP telemedicine services (13) and CBR services. Using this telecommunications service, they can continue their therapy services at home (**Figure 5**) [39].

## **9. Post-Stroke healthcare scenario of other underdeveloped and neighbor countries**

#### **9.1 India**

The Republic of India is a border country of Bangladesh. India is surrounded almost entirely by sharing its' borders within west, north, and east areas. It has been following a three-tiered model of health care service delivery. These tiered models comprise of primary, secondary, and tertiary level of healthcare services. The primary healthcare centers are particularly focusing on prevention, recognition, and referral for rehabilitation. The secondary level at district hospitals has fortified with medical doctors and other general facilities. At the divisional level, all tertiary care hospitals have equipped with all specialized facilities that are provided by public and private healthcare organizations [57]. There are enormous differences in accessibility and affordability in private and public hospitals for post-stroke healthcare services. For this circumstance, it's becoming a major challenge for the patients who are seeking quality healthcare facilities for after-stroke patients.

### **9.2 Myanmar**

The Republic of the Union of Myanmar has been sharing its border with the country of Bangladesh. Myanmar has been following pluralistic healthcare system followed by public, private, and NGO sectors. Ministry of Health (MOH) and other professional organizations have been working collaboratively for reducing communicable diseases. While communicable diseases declined, non-communicable diseases have been rising as a major concerning issue in Myanmar. The Department of Health (DOH) is mainly responsible for ensuring healthcare services through rural health centres (RHCs) and sub-rural health centres (Sub-RHCs) in the corresponding the municipality, district, and regional health centers. Preventive, promotive, and rehabilitative services have been providing for all citizens as well as for post-stroke patients to reduce premature deaths. All RHCs, Sub-RHCs are providing primary care services and at the regional level has available emergency and specialized hospital services based on the patients' need [58].

*Stroke and Healthcare Facilities in Bangladesh and Other Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.101915*

## **9.3 Nepal**

Nepal is a state of government that has spanned a decade of political disturbance, revolution, and ferocity from the years 1996 to 2006. That particularly affects the development of healthcare sectors in Nepal. In this regard, private sectors have been following a leading role in ensuring healthcare services for the citizens of Nepal. Nepal's healthcare system is struggling to control infectious diseases and the Ministry of Health and Population (MoHP) has made a significant achievement in reducing infectious diseases. However, due to demographic changes and urbanization, the burden of national diseases has shifted from infectious to non-infectious disease patterns [59]. Wherein, 108 out of every 100,000 deaths in Nepal are occurring by cerebrovascular diseases and almost 543/100,000 persons have led a Disability-Adjusted Life Years (DALY) after their stroke [60]. Public and private sectors have been providing curative and rehabilitative services but, patients have to depend on the private sector for emergency and specialized hospital facilities. The affordability of medical treatment has considered a major role in accessing hospital facilities for all citizens. Besides, out-of-pocket payment is a very common problem in Nepal to receive in-patients hospital services.

## **9.4 Bhutan**

The Royal Government of Bhutan provides free health care services by following the principles of primary healthcare strategy. Bhutan has improved slowly on the way to building a strong health system. However, the Ministry of Health (MoH) has faced several burdens of diseases where the prevalence of non-communicable diseases (NCDs) is aggravated. To fight against the growing trend of NCDs, Bhutan has applied a multisectoral national action plan to prevent health risks of NCDs [61].

#### **9.5 Maldives**

The Maldives is a developing country where the government is the head of the country. The Maldives has achieved a distinguished improvement in the health status of all citizens in gaining five out of eight Millennium Development Goals (MDGs) that creates a strong basement in achieving sustainable development goals (SDGs). However, considering the socioeconomic and environmental changes, the country has faced new challenges in controlling non-communicable diseases (NCDs). About 81% of total deaths are caused by NCDs in the Maldives. To address the burden of NCDs, a multisectoral national plan of action has been developed and implemented in focusing on preventive and promotional health interventions to bring changes in lifestyles and reduce health risks of NCDs. The Ministry of Health (MoH) is primarily responsible for ensuring primary health care facilities for all citizens, where, some private hospitals and NGOs provide healthcare in collaboration with the public sector. The government has spent the maximum amount of the total budget in the health sector. For instance, out-of-pocket payments for healthcare services are declining [59, 62].

## **10. Conclusion**

The burden of NCDs as well as stroke is not an issue of a particular country. Globally, it is now a common public health concerning issue. World Health Organization has been working worldwide in dropping down the risk of NCDs. Several countries have adopted a multisectoral collaboration approach to improve health status and work collaboratively with the participation of all individuals in different sectors. In Bangladesh, the Ministry of Health and Family Welfare in cooperation with various NGOs and private organizations has launched NCD corner at the Upazila level for providing preventive, promotional, and rehabilitative services in the community for persons who are having health risks and after-stroke disability. The scarcity of healthcare personnel is also an important barrier for providing such services. At the same time, healthcare financing and lack of infrastructure are the most important hindering factors for maintaining these kinds of services in the community. Therefore, this is the time for the ministry of health and family welfare to work with other ministries and donor agencies for the betterment of all citizens of Bangladesh.

## **11. The way to meet the challenges**


## **Acknowledgements**

**Ethical approval**: Not applicable. **Informed consent**: Not applicable. **Animal Studies**: Not applicable. **Funding support**: We are thankful to the Society of Speech and Language Therapists (SSLTs) in Bangladesh for their overall support to complete this article. Also, thankful to all authors those were sharing their thought and ideas to write this article.

## **Conflict of interest**

The study authors declared that there is no conflict of interest.

*Stroke and Healthcare Facilities in Bangladesh and Other Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.101915*

## **Appendices and nomenclature**


*Post-Stroke Rehabilitation*

## **Author details**

Mohammad Shaikhul Hasan1,2,4\*, Kanida Narattharaksha1 , Md. Sazzad Hossain3,4 and Nahar Afrin2,4

1 College of Health Systems Management (CHSM), Graduate School, Naresuan University, Phitsanulok, Thailand

2 Centre for the Rehabilitation of the Paralysed (CRP), Chapain, Savar, Dhaka, Bangladesh

3 Speech and Language Therapy Department, Bangladesh Health Professions' Institute (BHPI) the Academic Institute of CRP, Chapain, Savar, Dhaka, Bangladesh

4 Members, Society of Speech and Language Therapists (SSLTs), Chapain, Savar, Dhaka, Bangladesh

\*Address all correspondence to: mdshaikhulh59@email.nu.ac.th

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Stroke and Healthcare Facilities in Bangladesh and Other Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.101915*

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## **Chapter 3**

## Post-Stroke Balance Impairments Assessment: Clinical Scales and Current Technologies

*Paulina Ortega-Bastidas, Britam Gómez, Karen Barriga, Francisco Saavedra and Pablo Aqueveque*

## **Abstract**

This chapter aims to address the different impairments in the balance after stroke, beginning with an introduction on the main dysfunctions that can be observed, specifically in different transfers as sit-to-stand and gait. Also, a review of the main test and assessment scales most used in the clinical settings in this population. Finally, the application of new technologies and the technological advances used in clinical settings for human analysis focusing on balance are addressed. For example, the types of technologies used, their applications, and the combination with the existing clinical assessment tools. As a closure, we explain the importance of early detection and treatment of balance impairments in the post-stroke population to prevent falls.

**Keywords:** balance, impairments, stroke, assessment, technology

## **1. Introduction**

All functional activities performed by human beings require adequate postural control to carry them out successfully and efficiently. Postural control is the ability to maintain balance against gravitational forces by maintaining or returning the body mass center on its base support [1, 2]. This emerges from the interaction between subjects, tasks, and environment [2, 3]. Any task requires adequate postural control, but each task also requires an orientation and a stability component [2].

In clinical practices, there is no consensus about only conceptual definitions related to equilibrium, balance, or postural control, and their elements like posture, orientation, and stability. Therefore, it is interesting to at least define basic biomechanical concepts to better understand postural control and further definitions addressed in this chapter.

From a biomechanical point of view, posture refers to the alignment and orientation of the body with respect to its environment [3]. Postural orientation is the ability to maintain an adequate relation between body segments and environment due to performing a task, and postural stability is the ability to control the center of mass within the base support [2, 3].

Nowadays, postural control is no longer considered as only one system or reflex set for upright position and balance, it is considered a complex motor skill due to the interaction of multiple sensorimotor processes [4]. The two main goals of postural control are keeping postural orientation and postural equilibrium [2–4].

The human body in order to achieve stability and orientation requires a complex interaction between musculoskeletal components, neuromuscular synergies, individual sensory systems, sensory strategies, anticipatory and adaptive mechanisms, and internal representations [2]. The central nervous system (CNS) must organize the information coming from the different sensory receptors to determine the position of the body in space [2]. The sensory information coming from the different sensory systems (visual, somatosensory, and vestibular) allows to detect the position of the body and the movement in space in relation to the force of gravity and the environment [2, 3, 5]. Each sense provides specific information about the position and movement of the body, that is, each sense provides different references for postural control [2]. In the higher levels, the CNS sensory information is transformed into significative information, known as perception, and then it is selected the best sensorimotor strategies to achieve the goal of a specific task, to control external perturbance, and to adapt movement to the environmental requirements [2].

Also, postural orientation involves active control of alignment and tone of the body related to gravity, base support, visual information, and internal references [2, 3]. Spatial orientation requires the interpretation and integrated information of the visual, vestibular, and somatosensory systems. On the other hand, postural equilibrium involves the coordination of sensorimotor strategies to control the center of mass during internal and external disturbances [3, 4]. For a better explanation of the different sensory systems and sensory strategies to maintain postural control, see the diagram in **Figure 1**.

There are multiple causes and factors that could lead to dysfunctions in postural control and balance systems. In neurological populations, is commonly observed that

#### **Figure 1.**

*Postural control by sensory systems and strategies. Summary information collected from Shumway-Cook and Woollacott [2], Cano de La Cuerda [3], Cano de la Cuerda and Callado Vasquez [5].*

*Post-Stroke Balance Impairments Assessment: Clinical Scales and Current Technologies DOI: http://dx.doi.org/10.5772/intechopen.101984*

this deficit affects the ability to stand and walk, increasing the risk of falling and injury [2].

Within neurological populations, we can find stroke patients. Stroke is a common disease [6] that generates great morbidity, mortality, and different degrees of disability, causing a great economic impact on families and society [1].

A stroke can lead to a wide range of impairments that predispose the subjects to falls. One of the principal impairments observed in this population is balance dysfunction [7, 8]. It has been reported that 83% of stroke patients present balance impairments, which lead to gait problems, such as low gait speed and alterations in different gait phases increasing the risk of falling [1]. The incidence of falls in this population within the first six months after a stroke is about 37 and 73%, and the rate of falls in chronic stroke patients is double than healthy subjects [8].

Falls and fear of falling contribute to a sedentary lifestyle with increased limitations in activities of daily living (ADL) and decreased quality of life. In addition, falls increase hospitalization time and generate a large emotional and economic impact for patients, families, and society [1, 9, 10].

The present chapter pretends to expose the principal deficiencies related to balance impairments, observed during the sit-to-stand transfer and gait after a stroke. Also, the main scales and tests for the assessments of balance used in clinical settings, as well as the technologies and new trends that allow for objective analysis of balance dysfunction in this population are reviewed.

## **2. Principals balance impairments after stroke**

As said before, postural control alterations contribute to a loss of stability with a high impact on the quality of life in neurological populations [1, 2]. Balance and postural control impairments cause a series of alterations and dysfunctions during daily life activities, mainly during sit-to-stand transfer and gait [11, 12].

In this section, the main alterations on the sit-to-stand transfer as well as in gait related to balance impairments in post-stroke populations are reviewed.

#### **2.1 Impairments in sit-to-stand transfer after stroke**

Sit-to-stand (STS) transfer is considered a fundamental prerequisite to achieve successfully daily life activities [11–13]. Also, it is considered a strong predictor factor of independence and is the main rehabilitation goal because it promotes independent locomotion, as well as upper limb and hand recovery [13]. In post-stroke populations, this transfer is commonly affected, and it is not easy to regain the ability to stand up from a chair safely [11].

The STS transfer has been widely analyzed [11, 14, 15], and has been described as the movement of the body mass center towards the vertical from a sitting position to an upright position without losing balance [11]. This transfer is a transition to the upright position, and it requires a movement of the mass center from a more stable position into a less one with both lower limbs extended [11, 15]. In order to simplify its analysis, the STS transfer has been divided into phases, depending on kinematics variables, ground action forces, and the movement of the mass center [11].

One of these classifications includes four phases for the analysis, considering trunk movement, seat-off, the achievement of an upright position, and the vertical stabilization at the end of the transfer [11]. Another classification considers two principal

phases [11, 15], which basically includes three events, onset of STS, seat-off, and end of STS [15].

Associated with this transfer, there have been described different movement determinants in healthy subjects, such as angular displacements of lower limbs and trunk, as well as muscle activation pattern and weight-bearing distribution [16].

Indeed, there are differences in the performance of sit-to-stand transfer between healthy and post-stroke subjects [11, 13–15].

Normally, people with hemiparesis show a loss of coordinated movement between the trunk and knees. Therefore, it can be observed a completed knee extension at the end of the STS despite the hip it is still extending. Also, they show an increased center of pressure and move the trunks in a mediolateral direction towards the non-paretic side, as well as a decreased anterior pelvic tilt [11, 15, 16]. When observed lower limbs, it can be identified less muscle activity in the paretic limb, specifically of tibialis anterior, quadriceps, and soleus, showing problems in the correct activation muscle timing to achieve STS [11, 15].

To avoid the risk of falling, people with stroke adopt compensatory strategies, such as exaggeration of the anterior projection of the center of mass before standing up. This population also shows a decrease in knee moment on the paretic side and an increase in weight distribution asymmetry [11, 15, 16]. It has been suggested a correlation between asymmetry in weight-bearing with functional abilities in stroke. It states that those who carry less weight on their paretic limb obtain poor mobility scores in the functional independence scales. These same results have been demonstrated by Cheng et al. who consider the asymmetric distribution of weight-bearing during STS as a mediator of falls [11, 16].

All of these compensatory strategies are carried out to achieve the sit-to-stand transfer successfully and safely, but this population takes more time in the execution of this task, increasing the risk of falling. Because of the big amount of compensatory strategies used by the stroke population, this transfer is considered an indicator of the risk of falling [11, 16].

#### **2.2 Principal gait impairments after stroke**

Similar to STS, independent walking or ambulation is also considered a prerequisite for the performance of activities of daily living [14]. Gait requires an adequate speed to be considered community ambulation, between 1.1 and 1.5 m/s [14]. Also, locomotion is a motor skill, in which control systems in every step must bear weight, give anterior and lateral stability, and keep the center of mass forward, as well as an antigravitatory postural control to provide support and balance to prevent falls [10, 11, 14].

Gait dysfunction represents a major problem in the stroke population and causes difficulties in daily life activities [12, 17]. Approximately 80% of stroke patients experience gait problems in the first 3 months after symptom onset. It has been reported that 18% of subjects are unable to walk, while 11% walk with assistance and the remaining 50% walk independently [12]. It is important to note that only 7% of users who walk independently achieve community walking, which means that they manage to walk 500 meters continuously at an adequate walking speed that allows them to cross the street safely [16].

On the other hand, 70% of stroke patients with community walking suffer falls in the first year, most of these falls are the result of loss in balance. Therefore, there is a high risk of falls in those subjects with stroke who walk independently [12].

*Post-Stroke Balance Impairments Assessment: Clinical Scales and Current Technologies DOI: http://dx.doi.org/10.5772/intechopen.101984*

#### **Figure 2.**

*Balance and gait impairments after stroke. Summary information collected from Boukadida et al. [11], Perry [17], Dickstein [18], Wang et al. [19] Hugues et al. [22], Van Duijnhoven [23], Silva et al. [24], Brière et al. [25], Balandan [26].*

Post-stroke gait disturbances and their treatment have been extensively researched [12, 18–20]. Mainly, we could find impairments associated with alterations in spatialtemporal characteristics and biomechanical alterations [12, 19].

Some of the characteristics of hemiparetic gait related to spatiotemporal variables include decreased cadence, prolonged swing duration on the paretic side, prolonged duration on the nonparetic side, and asymmetry in stride length [19]. As well as the increase of the double support phase and the decrease in gait speed [16, 19].

These characteristics contribute to an unsteady gait pattern, leading to restricted walking within the home and an increased risk of falls [21].

In general, due to a stroke, we can observe different impairments that may occur in the paretic lower extremity, such as abnormal recruitment of motor units, muscle weakness, abnormal activation of muscle synergies, spasticity, proprioceptive impairment, restriction in range of motion, which could enhance a poor gait pattern along with balance disturbances and increased risk of falls [13, 18, 22].

**Figure 2** shows the main features in balance impairments related to sit-to-stand, standing balance, and gait after stroke. It is important to highlight that there are more features related to each transfer, but we aim to clarify the most common one in this population.

## **3. Tests and scales for static and dynamic equilibrium assessment**

Nowadays, it has become relevant to observe the quality of the movement patterns to discriminate between actual recovery and compensatory movement patterns in stroke rehabilitation [10]. Balance impairments are common in this population and they are determinants factor that influences independence and quality of life; therefore, balance became an important goal to be included in rehabilitation programs [21]. For this purpose, the use of accurate, reliable, and valid assessment tools to measure outcomes in stroke populations related to research and clinical practice is recommended [7].

Normally, rehabilitation professionals perform the evaluation by means of observation and the application of scales and instruments, which provide a certain level of objectivity [27]. Generally, the different methodology used for assessing balance can be divided into observational (e.g., the Romberg test), scales and tests, and testing instrumental equipment (e.g., posturography) [28].

The Berg balance scale (BBS) is a widely used tool in clinical settings and is considered the gold standard for assessing functional balance and fall risk in adults [2, 3, 21, 29]. It has been used extensively to measure outcomes in research involving older adults with a variety of conditions, for example, balance impairments, stroke, Parkinson's disease, vestibular disorders, and in a variety of health care settings [30–32]. It contains 14 items related to the static and dynamic tasks of daily living [3]. The tasks on this scale progress in difficulty from sitting to bipedal, to bipedal with a narrow support base, to tandem gait and one leg support. The score is calculated on a 5-point ordinal scale for each item, where 0 refers to the inability to complete the test and 4 refers to being able to complete the test independently [3, 29]. The maximum score is 56 points that indicates adequate postural balance and no risk of falls, and a score equal to or less than 45 points indicates a risk of falls [3]. Specifically, values between 56 and 41 points indicate a low risk of falling, between 40 and 21 points a medium risk of falling, and between 20 and 0 points a high risk of falling. Its application lasts between 10 and 20 minutes [29–32]. Another widely used test is the Timed up and Go (TU & Go) test, which measures dynamic balance and functional mobility in adults, as well as in the neurological population [33–35]. The TU & Go is a simple test that can be applied anywhere and consists of the subject standing up from a chair, walking three meters, turning around, walking back to the chair, and sitting down on the chair again. The controlled variable is the total time in seconds the subject takes to perform the test, which is then correlated with the risk of falling [34–36]. Score assumed to be normal if the time is ≤10 seconds, mild risk of falling between 11 and 20 seconds, and high risk >20 seconds [37]. This test has demonstrated excellent inter- and intra-rater reliability with values greater than 0.95, with adequate predictive value for falls in older adults and stroke patients [38, 39]. Some advantages of the TU & Go test are its simplicity and short duration of application. Additionally, it requires little equipment and allows subjects with functional impairment to perform the test [3]. However, one limitation is that although it provides information on the risk of falls, it is not able to determine the risk objectively in subjects with greater difficulties. Barry et al. mention that a limitation in the predictive value of the test could be explained by the fact that it is a single test that evaluates balance and equilibrium in a general way. Therefore, it could be improved by being combined with technological tools for motion analysis [40].

Commonly, in clinical practice, this test is combined with the application of other clinical tests such as the 10-meter walk test, and its results are compared with those obtained in the Berg balance scale [30]. These tests as a whole make it possible to assess the risk of falls, walking speed, and balance of the different patients, making it possible to objectively assess their functional level and to determine the relevant intervention strategies.

Gait speed has been shown to be a predictor for different clinical outcomes, such as response to rehabilitation, level of dependency, frailty, disability, falls, institutionalization, cognitive loss, hospitalization, cardiovascular events, and mortality. Its decrease has been associated with a lower quality of life, social participation, and the presence of depressive symptoms [41]. Middleton et al. define it as the sixth vital sign due to its broad predictive capacity. The 10-meter walk test has proven to be a robust, validated, reliable,

## *Post-Stroke Balance Impairments Assessment: Clinical Scales and Current Technologies DOI: http://dx.doi.org/10.5772/intechopen.101984*

and sensitive tool that can be applied in both clinical and research contexts, and in a wide range of pathologies, such as the elderly, chronic stroke, incomplete spinal cord injury, multiple sclerosis, Parkinson's disease, among others [18, 38, 41, 42].

This test measures walking speed in meters per second (m/s) when walking a short distance of 10 meters. Then, the value obtained will be categorized into the four categories proposed by Perry et. Al, which are intra-domicile gait with speeds between 0 to 0.4 ms; dependent community gait with speeds from 0.4 to 0.8 m/s; community gait 0.8 to 1.2 m/s; and safe gait for crossing the street greater than 1.2 m/s [43].

On the other hand, there is the Functional Reach Scale. This scale was developed to assess the maximum limits of standing stability. Subjects are held in a standing position with feet shoulder-width apart and with one arm (hand grasped) elevated to 90 degrees of flexion. Without moving the feet, the patient is asked to reach as far as possible without losing balance. The distance reached is measured and compared with standardized references by age group as defined by Duncan et al. The functional reach test has satisfactory inter-rater reliability and has been reported as a predictor of falls in older adults [2, 3].

**Table 1** summarizes some specific characteristics of the tests and scales listed before.



#### **Table 1.**

*Test and scale for the assessment of balance in stroke populations.*

One of the most recent scales to measure balance is the Balance Evaluation Systems Test (BESTest), which is a balance assessment scale that allows identifying specific problems in postural control, such as biomechanical alterations, stability limits, postural response, anticipatory postural adjustments, sensory orientation, dynamic balance during gait, and cognitive effects. Although it is a new multitask scale, it includes 36 items to be evaluated with an estimated application time of 30 to 35 minutes [2, 3, 45, 46]. Its short version, the Mini-Balance Evaluation Systems Test (Mini-BESTest), was created in 2010, which contemplates 14 items and takes a total of 10 minutes to complete the assessment, with good inter- and intra-rater reliability in a sample of people with mixed conditions. The mini-BESTest has been shown to be a reliable and validated tool for assessing balance in chronic stroke patients [47].

As can be seen in this section, there is a wide range of scales and clinical tests that allow not only to assess balance but also to observe how the different components

behave during the performance of different tasks. Some of them are not only validated in populations with stroke. Therefore, the reader is suggested to review the specific psychometric properties of each of them and their validation in other neurological populations before using it.

## **4. Balance impairment treatments after stroke**

There are different therapeutic interventions to improve balance after stroke. According to Stein et al. [21] these interventions could be categorized into five main areas, exercise programs, biofeedback training, sensory training, cognitive training, and external devices.

Each of these areas will address different aspects of the multiple problems that can be found associated with balance impairments [21, 22]. Exercise programs are varied in form, maybe individual or group-based, and include a variety of impairment-oriented elements. Some may include functional activities such as sit-to-stand and balance tasks due to daily life activities, for example, reaching and standing on unstable surfaces [21].

Also, there are different intervention models such as constraint-induced therapy, task-oriented approach, as well as neurophysiological intervention approach such as the Bobath concept, proprioceptive neuromuscular facilitation, and other neurodevelopment models, which have been traditionally used in the treatment of post-stroke patients [5].

The incorporation of visual and sensory training has been shown to be effective in the treatment of balance, as well as the promotion of weight-bearing in seated and upright positions [21–23, 48]. On the other hand, the incorporation of therapeutic strategies that involve trunk work in the recovery of dynamic balance during sitting, sit-to-stand, and gait is relevant [49].

Since, trunk function has been associated with gait and balance ability in stroke patients and has been shown to be a useful predictor of recovery of gait, balance, and activities of daily living [49].

Recently, a meta-analysis by Hugues et al. concluded that physical therapy has various benefits on postural balance and stability after stroke. It suggests that functional task training, associated with musculoskeletal and/or cardiopulmonary interventions, as well as sensory interventions, appear to be effective in improving balance and postural stability. However, the authors ask for caution with this result, due to "the weak methodological quality of studies," among other methodological elements [21, 42].

Even though there are several therapeutic approaches and categories of physical therapy, we believe it is important to highlight that each exercise program should be individualized according to the individual's own capabilities and should be supervised by a therapist.

## **5. Technological tools and systems for the evaluation and treatment in post-stroke patients**

## **5.1 Technological tools for monitoring and for the diagnostic support of post-stroke patients**

At a commercial level, a large number of technological systems allow to evaluate different aspects of gait, balance, and strength beyond the typical clinical methodologies, as seen in the previous section.

From the perspective of systems that are capable of evaluating movement and even mobility variables for clinical use, there are camera-based motion analysis laboratories whose measurement is carried out using software for motion analysis (**Figure 3**).

On the other hand, in the last 30 years, there has been an increase in the use of inertial sensors for motion analysis, whose reduction in size and consumption, in addition to the improvement in algorithms for motion tracking, have allowed them to be positioned as an attractive alternative for the study of movement objectively and quantitatively (**Figure 4**).

Some other commercial alternatives are illustrated in **Table 2**.

Another type of element is highly used in the clinical field for the evaluation of gait and static and dynamic balance correspond to systems that measure plantar pressures for the estimation of mobility variables. Technological alternatives range from highly accurate mats for gait and balance evaluation, to systems that embed pressure sensors within insoles to evaluate uncontrolled environments (**Figure 5**).

Some other examples are illustrated in **Table 3**.

**Figure 3.**

*Optitrack system for human motion analysis using a camera-based system. Image obtained from Optitrack official website [50].*

#### **Figure 4.**

*Inertial-based systems for a clinical movement analysis perspective. From left to right: APDM mobility lab, G-walk, and QMUV. Images obtained from the official website of G-walk [51], APDM [52], and QMUV [63].*

*Post-Stroke Balance Impairments Assessment: Clinical Scales and Current Technologies DOI: http://dx.doi.org/10.5772/intechopen.101984*


#### **Table 2.**

*Commercial technological alternatives used to evaluate motor impairment conditions in post-stroke patients.*


#### **Table 3.**

*Technological systems to assess motor impairments using plantar pressures in post-stroke patients.*

#### **Figure 5.**

*Pressure-based systems to analyze gait and posture. From left to right: GAITRite and Xsensor. Images obtained from the official website of Xsensor [58] and GAITRite [59].*

### **5.2 Technological systems for post-stroke patients rehabilitation**

As mentioned at the beginning of this section, the technological tools for the treatment of post-stroke subjects seek to reduce the impact of the disabling condition to improve the quality of life of the patient through rehabilitation therapies to train or adapt the lost function.

From this perspective, the development of serious games for rehabilitation has taken on great importance in the treatment since, they make patients hooked on their treatment, avoiding problems associated with early abandonment from their therapies. Systems that use interactive platforms such as the famous Kinect (camera system) [63] and Nintendo Wii (multisensory system with inertial control and pressure platform) [64] started a massive adoption in the field of game development to support the rehabilitation. However, although they continue to be used in clinical settings for interactive treatment, these technologies are no longer commercially available and are obsolete.

Because of the great technological advance in animation and graphic processing systems, serious games for immersive or semi-immersive rehabilitation using virtual reality helmets (HTC-vive, Oculus, among others) have allowed to establish an environment that mimics in controlled conditions in the daily life of people in order to train typical activities such as brushing teeth, cooking and eating in a safe

## *Post-Stroke Balance Impairments Assessment: Clinical Scales and Current Technologies DOI: http://dx.doi.org/10.5772/intechopen.101984*

environment [65]. Also, semi-immersive elements have made it possible to instrumentalize the highly used mirror movement test to increase patients' perception of movement. All these systems that support the mobility of the upper and lower extremities allow the development of augmented reality environments or interactive systems that enrich the experience of the patient and provide more information about the patient's condition [66]. Some commercial rehabilitation options include Tyromotion's PABLO (interactive upper extremity therapy), TYMO (interactive system for balance and coordination training), and DIEGO (interactive arm and shoulder rehabilitation) systems (**Figure 6**) [67].

Leaving aside the treatment systems and focusing on systems that have the potential to be used in everyday life, functional electrical stimulation tools (FES) appear, which correspond to systems that, through the injection of controlled electrical pulses, allow to recover the mobility of limbs, improving grip in upper limb cases and improving gait in case of foot drop stimulators. Although upper limb stimulators have not yet become widespread, in the literature, there is great evidence of efforts by researchers to generate alternatives to train or regain mobility of the arms and hands. Alternatively, and more commonly, there are electronic orthoses for droop foot, where by means of a system that allows the generation of controlled pulses from the detection of gait cycle events, the control of dorsiflexion can be recovered in poststroke patients [68]. Commercial examples are SmartFES, XFT-2001, ODFS Pace, among others (**Figure 7**) [68–70].

On the other hand, health professionals and the scientific community have developed alternatives to treat post-stroke who, due to different factors such as economical, geographical, physical, and/or environmental, are unable to attend rehabilitation centers. The need for the above has increased as a result of the recent COVID-19

#### **Figure 6.**

*Interactive rehabilitation systems developed from Tyromotion. From left to right: PABLO,TYMO, and DIEGO. Images obtained from the official website of Tyromotion [67].*

#### **Figure 7.**

*Functional electrical stimulation systems commercially available. From left to right: ODFS pace, SmartFES, and XFT-2001. Images obtained from the official website of SmartFES [68], XFT-2001 [69], and Odstock [70].*

pandemic that incorporates post-stroke people as a population at risk [71]. Regarding this, different types of treatment that use technology to rehabilitate communication skills [72], upper limb rehabilitation, and/or remote activities of daily living have been evaluated, proving to be almost as effective as face-to-face treatments. Although there is a lack of information on the cost-effectiveness relationship with respect to traditional treatments, it is evident that the role of telerehabilitation is of vital importance in rural areas or in health emergencies where patients do not have access to opportune care or monitoring of their condition [73, 74].

In this section, some tools typically used for the evaluation and treatment of poststroke patients are mentioned. However, the intention is to provide a general overview of the systems most used internationally, existing alternatives that improve their proposal in terms of accessibility and costs.

## **6. Conclusion**

Stroke generates primary and secondary impairments that reduce the functional capacity of these patients, leading to less functional independence and quality of life. One of the main impairments associated with this population is impaired balance, both static and dynamic. This impairment in particular generates a great impact on the dysfunction of activities of daily living and main transfers such as bipedal sedentary transfer and gait. Moreover, in this pathology, 14–65% of individuals fall at least once in the hospital, and between 37 and 73% suffer falls in the next 6 months after discharge [75].

Specifically, people with stroke are at increased risk of fall-related fractures. Other adverse consequences may include fear of falling with subsequent reduction in activity, de-conditioning, and increased risk of falls. Bower et al. state that it has recently been shown that the identification of movement and balance variables, for example by measuring walking speed, application of the timed up and go test, and the Berg Balance Scale, have been shown to be strong predictors of fall risk following stroke [8].

However, as mentioned above, there are some deficiencies in the clinical tests and scales, since they fail to fully determine the variables and problems associated with balance impairment. The use of clinical scales and tests, associated with the use of technologies, could allow the adequate assessment of each of the limitations in static and dynamic balance during the different transfers performed by people with sequelae of stroke.

In this chapter, we have presented a list of alternatives to treat and evaluate the stroke patient in all phases of treatment, providing plenty of evidence of systems for movement analysis and treatment, especially useful for the treating professional, and of highly technological elements to improve adherence to rehabilitation therapies.

Finally, it is important to highlight that a specific assessment of the impairments that contribute to an unfavorable balance in subjects with stroke is necessary for each rehabilitation process, as well as the early incorporation of functional therapeutic activities aimed at their recovery and the prevention of the risk of falls.

## **Acknowledgements**

This work was supported by the Vice-rectory for research and development (VRID) of the Universidad de Concepción: "Clinical validation of a human motion *Post-Stroke Balance Impairments Assessment: Clinical Scales and Current Technologies DOI: http://dx.doi.org/10.5772/intechopen.101984*

analysis system based on inertial measurement sensors in a Chilean population at risk of falls" [Cod.- 220.092.003-M].

## **Conflict of interest**

Pablo Aqueveque, Britam Gómez and Francisco Saavedra were developers of SmartFES and QMUV devices. The remaining authors have no conflicts of interest to declare.

## **Author details**

Paulina Ortega-Bastidas1,2\*, Britam Gómez3 , Karen Barriga<sup>1</sup> , Francisco Saavedra<sup>3</sup> and Pablo Aqueveque<sup>3</sup>

1 Faculty of Medicine, Kinesiology Department, Universidad de Concepción, Concepción, Chile

2 Health Sciences PhD Programme, Universidad Rey Juan Carlos, Madrid, Spain

3 Faculty of Engineering, Electrical Engineering Department, Universidad de Concepción, Concepción, Chile

\*Address all correspondence to: portegab@udec.cl

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 2
