Relationship Between Wheelchair Propulsion andIndependent Walking in Hemiplegic Stroke
Background and Purpose We studied the relationship between wheelchair propulsion and final walking ability in hemiplegic stroke patients who were unable to walk independently 3 or more weeks after stroke.
Methods Sixty hemiplegic stroke patients unable to walk independently 3 weeks or more after stroke were entered in a study comparing independent walking and wheelchair propulsion. Eight patients were lost to follow-up. Of the remaining 52 patients, 29 were entered 3 weeks and 23 were entered 4 to 10 weeks after stroke. Assessments were performed on admission and 4 and 14 weeks later.
Results Fifteen of the 17 patients able to propel a wheelchair through a simple course at 3 weeks after stroke learned to walk independently (χ2=9.94, P=.01), but none of the 12 who failed learned to walk (χ2=12, P=.001). At the final assessment, the positive association between wheelchair propulsion and walking had been lost: 21 of 21 walkers and 18 of 31 nonwalkers could propel a wheelchair (χ2=0.23, P=NS). The negative association remained: 13 of 31 nonwalkers failed the wheelchair test, but 0 of 21 walkers failed (χ2=13.0, P=.001). Visual field deficits were significantly more common in patients unable to walk or propel a wheelchair than in walkers (χ2=6.66, P=.01). Laterality had no effect on outcome.
Conclusions Ability to propel a wheelchair 3 weeks after stroke in hemiplegic patients unable to walk is the most accurate guide to walking potential that has been reported to date.
The ability to walk independently is the single most important factor in determining whether a patient with a hemiplegic stroke of recent onset who was previously independent can return home from the hospital to live alone if support from family, friends, and outside agencies is limited.
At Greenwich District Hospital in London during an abortive study of the factors that influence the ability of hemiplegic patients to propel a wheelchair, we noted that patients who did not master wheelchair propulsion did not learn to walk. We were unable to find any reports describing either positive or negative associations between wheelchair propulsion and walking in hemiplegia; we undertook the present study to check our original observation and to determine whether other significant relationships existed between these two activities in hemiplegic patients.
Subjects and Methods
The study was limited to hospital inpatients with recent-onset stroke hemiplegia who were unable to walk independently 3 weeks or more after onset. Patients with previous strokes affecting the same or the opposite side as the recent stroke were admitted only if they had been walking independently before the recent stroke. Patients with confusion or additional significant medical or locomotor problems were excluded.
Visual field deficits, comprising complete or partial hemianopsia or visual inattention, were recorded only in patients without significant dysphasia because we were unable to achieve consistent responses in patients with such dysphasia.
Independent walking was defined as the ability to rise from a chair unaided, without pulling on a fixed object, and to walk 5 m with or without an aid and without verbal or physical assistance.
Independent wheelchair propulsion was defined as the ability to propel a wheelchair without verbal or physical assistance along a corridor 2 m wide for 10 m, turn into a room through a doorway 1.5 m wide, turn around within the room, and reenter the corridor. Two attempts were allowed. All patients had been in their wheelchairs for at least 3 days before the first test and were instructed in wheelchair propulsion. All wheelchairs used had two large propelling wheels at the rear and two small front wheels. Propulsion was usually achieved using the nonparalyzed hand and foot, but some patients with partial recovery were able to contribute with the affected side. No monodrive chairs, which allow movement of both driving wheels from one side, were used. All patients continued to occupy wheelchairs throughout the study.
Thirty-four patients were entered at 3 weeks and 26 patients were entered at 4 to 10 weeks after stroke. All were incapable of walking. Assessments of wheelchair propulsion and walking were performed on admission and 4 and 14 weeks later; the planned final assessment was a minimum of 17 weeks after stroke. Previous experience in our unit agreed with that of Reding and Potes1 that hemiplegic stroke patients unable to walk independently 17 weeks after stroke, who had been undergoing an adequate rehabilitation program, were very unlikely ever to achieve independent walking. If a patient walked before the scheduled intermediate or final assessment, their “final assessment” was performed at that time. All patients who had a final assessment remained in the hospital until that assessment; during this period they were maintained on active rehabilitation as long as they showed any ability to respond to such a program.
All observations were performed by one observer (L.C.C.). Statistical analysis was performed using the χ2 test.
Eight of the 60 patients entered did not complete the study: 4 died, 1 was found to have a cerebral tumor, and 3 were transferred to a nursing home before the final assessment. Twenty-nine of the remaining 52 patients entered the study 3 weeks after stroke, and 23 entered 4 to 10 weeks after stroke. Eighteen had significant dysphasia, and 14 of the remainder had visual field deficits. Forty-three patients (83%) were aged 65 years or more (16 men and 27 women). For other details, see Table 1⇓. The final functional levels of the 52 entrants are given in Table 2⇓.
Table 3⇓ shows the very close relationship between wheelchair propulsion 3 weeks after stroke and future independent walking. The positive association between wheelchair propulsion and future independent walking at 3 weeks after stroke (Table 3⇓) was lost by the final assessment, whereas the negative association remained (Table 4⇓).
Failure to pass the wheelchair test on admission did not absolutely preclude independent walking. Six of the 23 late entrants learned to walk, and 1 of these failed the wheelchair test at entry (6 weeks after stroke) but passed 4 weeks later.
Laterality and significant dysphasia had no effect on outcome. Gender was influential only in the final group, which could neither walk nor propel a wheelchair. This included 12 women and 1 man (χ2=5.77, P=.05). There was no obvious reason for this. The only significant difference in visual field deficits was between walkers and the final group (χ2=6.66, P=.01).
We do not know why wheelchair propulsion and walking are so closely related in hemiplegia. Our experience and that of Webster et al2 indicate that a normal adult using only one upper limb and the ipsilateral lower limb can learn to propel a wheelchair in a few minutes. Webster et al2 3 have shown that patients with right hemispheric stroke with hemispatial neglect were liable to sideswipe obstacles and hit obstacles directly in their path in a wheelchair obstacle course. Patients with right hemispheric stroke without spatial neglect, as tested, were more liable to sideswipe obstacles than left-hemispheric stroke patients or control subjects. Webster et al discuss the possible reasons for this, but walking ability is not mentioned in either article. We have found no other articles relating neurological deficits in stroke to wheelchair propulsion ability and no articles whatsoever relating wheelchair propulsion ability to walking.
Recovery of walking in hemiplegia has been much less well reported than recovery of activities of daily living. In 1986 Jongbloed4 reviewed 33 reports published between 1950 and 1986 concerning the prediction of functional recovery in stroke patients as assessed within 3 months of onset. She concluded that a prior stroke, old age, urinary and bowel incontinence, and visuospatial neglect were generally regarded as adverse prognostic factors and that sex and laterality were not important. None of the 33 studies she reviewed analyzed walking in isolation; therefore, it is impossible to determine how closely, if at all, the adverse factors she reported are linked to future independent walking.
Reding and Potes1 in 1988 showed that, in patients entering a rehabilitation program 2 to 8 weeks after stroke unable to walk, future walking ability was closely related to the complexity of the neurological deficit present on admission. More than 90% of patients with pure motor deficit, 35% of patients with motor and somatic sensation loss, and only 3% of patients with motor, somatic sensation loss, and hemianopsia learned to walk independently for 150 ft. Functioning in activities of daily living was similarly linked. These findings agree with those of Allen and others,5 6 7 8 who have shown that complexity of neurological loss is related to functional outcome; on the other hand, Lincoln et al9 found that the most important factor influencing outcome was the degree of motor loss and that perceptual deficits were not of particular importance. Bohannon10 11 has shown that standing balance and lower limb strength are both significantly related to achieving independent walking, and Friedman12 found that age, line bisection error, and leg power were the best predictors of independent ambulation.
We feel that walking is a key issue in stroke recovery. Anyone can live alone at home, no matter how handicapped, if support from outside agencies is unlimited. If it is limited, then walking is the most important factor in determining whether a hemiplegia stroke patient can live alone. Significant dementia is not a problem in uncomplicated hemiplegia; dysarthria, dysphagia, and urinary incontinence usually recover with time. Dysphasia is not related to functional ability,13 and patients can live independently with one functionless upper limb. If a patient has even limited independent walking, they can almost certainly transfer independently in and out of a wheelchair and on and off a toilet. They will be able to stand unaided for limited periods, thereby greatly facilitating washing, dressing, and toileting. Without the ability to walk, any patient who lives alone and who has only limited outside support will find it very difficult to manage.
Although the number of patients in this study is small, if our findings can be replicated elsewhere, testing hemi-plegic stroke patients who are unable to walk for wheelchair propulsion ability at 3 weeks after onset will be the best available guide to independent walking potential.
- Received September 12, 1994.
- Revision received December 29, 1994.
- Accepted January 13, 1995.
- Copyright © 1995 by American Heart Association
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