Community Ambulation of Stroke Individuals

Original Editor - Joshua Samuel

Top Contributors - Joshua Samuel, Laura Ritchie, Wendy Walker, Evan Thomas and Scott Buxton

Introduction

A stroke is a drastic life-changing event that affects not only the person who may be disabled, but also their family and caregivers. It has a devastating effect on a person’s physical function as well as his/her perceptual abilities such as encountering environmental factors.[1]
World-wide over the past four decades, the annual age-standardized stroke incidence rates has been decreased by 1.1 percent in high-income countries but has increased by 5.3 percent in low to middle income counties.[2]

Need for Community Ambulation in Patients Following Stroke

Going forward, the number of individuals with a stroke living with residual disabilities will be increasing and hence there is a need for these individuals to be active participants in society, despite physical impairments. The environment in which an individual lives can impose a number of barriers on his/her ability to function independently.

Disability was considered as a physical entity but currently the understanding of “disability” is complex, dynamic, multidimensional and contested. Responses to disability have changed drastically and it has now more often being seen as a human right issue.[3]

Recently, the ICF (WHO) promoted the “Bio-psycho-social model”, which understands the functioning and disability as a dynamic interaction between health conditions and contextual factors both personal and environmental factors.[4]


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Walking in the Real World

[5]

Environment describes the world in which people with different levels of functioning must live and act. Environmental factors includes the natural & built environment, products & technology, support & relationships, attitudes and services & policies. These environmental factors can either be facilitators or barriers[6]

A person’s environment has a huge impact on the extent and experience of disability. Inaccessible environment create disability by creating barriers to participation. An example of the possible negative impact of environment could be a wheelchair user in a building without an accessible bathroom or lift. Environmental factors includes a wider set of issues rather simply as physical and information access. Policies and service delivery systems, including the rules underlying service provision can also be barriers. The important social determinant of health has been, “inequality is a major cause of disability”[7]

Walking in the real world is highly complex, requiring cognitive flexibility to address motor requirements, while attending to a range of environmental stimuli or concurrent tasks. This opens up a new dimension for us to consider the interaction of environment with the people affected by stroke to help improve our knowledge on their needs and requirements.

Measuring Environmental Factors

A measure which could be used to assess these environmental factors is needed so that a clearer understanding of the affecting environmental barriers could be obtained from stroke individuals. Several instruments are available to measure the environmental factors, of which, the measures which assesses environment using theICF framework are obtained.

Environmental factors can be quantified as either “environmental facilitators” (factors that increase participation) or “environmental barriers” (factors that decrease participation). A review was done, which founded about totally 8 instruments, that measures the environmental factors. [8]

The 8 Instruments are as follows:

  1. Community health environment checklist (CHEC)
  2. Craig hospital inventory of environmental factors (CHIEF)
  3. Facilitators and barriers survey (FABS)
  4. Home and community environment instrument (HACE)
  5. Individually prioritized problem assessment (IPPA)
  6. Measure of the quality of the environment (MQE)
  7. Neighborhood environment walk-ability scale (NEWS)
    8. ICF checklist

Checklist for Environmental Factors

Environmental Factors (EF) as such are broadly categorized into the following 5 chapters of ICF as:#Products and technology

  1. Natural environment
  2. Support and relationships
  3. Attitudes
  4. Services, systems and policies
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Major Environmental Barriers for Stroke

[9]

From the studies done till date we could see three major themes of environmental barriers experienced by their stroke participants were social, physical, and attitudinal barriers. The sub-themes included were lack of social support and inaccessible medical services for social barriers; in-accessible pathways and toilets for physical barriers, and negative attitudes of others towards them for attitudinal barriers. [10]

People with disabilities encountered more barriers in community participation than in home & transport or mobility settings. Majority of people used environmental supports (accessibility, social & system) to meet their goals. People with functional limitations who live in communities that were more restrictive felt more limited in doing daily activities butdid not perform these daily activities any less frequently[11]

Physical requirements associated with community mobility are complex and should not be limited. A conceptual model was presented in which attributes of physical environment a grouped into8 dimensions as: distance, time, ambient conditions, terrain characteristics, physical load, attentional demands, postural transitions and traffic level. These demands have to be met for an individual to be mobile within a particular environment. [12]

Physical and structural barrier was higher, which might be due to poor roads or side-walks with cracks or pot-holes and crowded places which are a common sight in the locality of developing countries. 
The design of majority of the public places (bus stop or railway station) and buildings (non availability of ramps or lifts or escalators) which is still not yet designed accessible to the impaired stroke individuals is also a notable factor. Also, barrier to technology usage (computers or mobile phones or remote controls for television / air-conditioner) could be related to lack of devices that can be easily used by stroke individuals. [13]

The service & assistance barrier and policy barrier follows next as the most impact barrier perceived by post-stroke participants as about 24% of stroke group participants perceived transportation services, systems and policies as an environmental barrier.

Government & public services, providing equal opportunity were identified as moderate environmental barriers. [14]

Supporting the WHO’s current conceptual model of disability, physical ability has a major effect on the impact of environmental barriers perceived by post-stroke individuals. [15]

Stroke individuals who are low in their physical ability faced more environmental barriers and this in-turn had a major impact on their social participation, with individuals facing more environmental barriers are socially isolated and those who are more physically able faces less environmental barriers and are more socially participating. [16]

Evidence Based Review

The environmental barriers reported from studies varies, which could be attributed to the stroke individual's characteristics, local environmental and cultural variations. One major factor is duration post-stroke as less is the duration, new barriers emerge as they come across new social dimensions as each day passes. Age of stroke individuals is also a notable factor as lesser the age there is more need to participate in the environment and subsequently could have faced more environmental barriers. Also the environmental difference is another major factor starting with lack of proper maintenance of surroundings, inaccessible places, lack of quality medical care, transportation difficulties, crowded areas, availing government policies / benefits, help from community and also cultural differences may have contributed to higher impact of environmental barriers for post-stroke individuals from different parts of the world. [17] [18] [19] [20] [21]

Conclusion

Several factors in the environment, in which we live, determine our level of activity and social participation. In the process of encountering into the environment, starting from taking a step outside from the house to the street, the disabled post-stroke hemiplegic individuals faces many barriers, which has been clearly inferred from this article. Alarmingly, the impact of environmental barriers experienced by stroke individuals is on a higher range, which subsequently reduces their social participation and are more isolated. This definitely needs to be noted from a Physiotherapist point of view, as we have to address this need of our stroke patients, which is to be an “active member” of the society. Thus, a holistic rehabilitation involving creating awareness about disability, accessible services and training our stroke participants to overcome or modify these environmental barriers is needed, which will help them to participate actively in the society and to an extent that satisfies their social needs. Research is needed to establish the role of environmental barriers in various other aspects of the life of people disabled by stroke, so that most of their possible problems could be observed and rehabilitated holistically.

Recent Related Research (from Pubmed)

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References

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