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Role of physiotherapy on quality of life in stroke survivors – a systematic

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226 Indian Journal of Forensic Medicine & Toxicology, April-June 2020, Vol. 14, No. 2

Role of Physiotherapy on Quality of Life in Stroke Survivors –

A Systematic Review

Kanase Suraj B1, G.Varadharajulu2, Pragati V. Salunkhe3, Mayuri D.Burungale3

1
Associate Professor, 2Dean, 4Assistant professor, Faculty of Physiotherapy. Krishna College of physiotherapy,
near Dhebewadi road, Malkapur, Karad

Abstract
Background: Stroke is one of the most common disease with lots of impairments and disabilities. Prevalence
of stroke is increasing day by day globally. Young stroke is becoming very common. The overall functional
capacity of the individual is hampered where the prognosis is question mark. It largely depends upon
site, stage, duration of lesion. The overall quality of function is deteriorated. Patients live their lives with
dependency. According to previous studies, role of various health care professionals have been analyzed and
studied. Physiotherapy is a branch where use of exercise and electrotherapy plays their role in rehabilitating
patients with stroke

Aim: To study the role of physiotherapy on quality of life in stroke survivors.

Methodology: A systematic narrative review was conducted to find out the efficacy of physiotherapy
treatment on quality of life in stroke survivors.

Conclusion: Stroke has complex process of recovery. Stroke survivors are left with disabilities. It causes
depression in patients as well as their family members. Physiotherapy has a significant role in improving
impairments and disabilities. This in turn helps in improving quality of life

Keywords: Physiotherapy, Stroke, Quality of life, Systematic narrative review.

Introduction everything from physical health, family, education,

employment, wealth, safety, security to freedom,
The Constitution of the World Health Organization religious beliefs, and the environment1.
(WHO) defines health as “A state of complete physical,
mental, and social well-being not merely the absence of Quality of life and general health has various
disease.” domains. Broadly they include physical health,
psychological, level of independence, social relations,
It involves accessing health not only in terms of spirituality/ religion/ personal beliefs and environmental
effects of health care, indication and severity of diseases factors.
but also focuses on well being by measuring the quality
of life related to health care. WHO defines Quality of Quality of life is largely affected by type of food
Life as an individual’s perception of their position in life consumed, education, family life, emotional security,
in the context of the culture and value systems in which opportunities for activities etc. Health is one of the major
they live and in relation to their goals, expectations, issues that affects a persons quality of life.
standards and concerns. It is largely affected by
individual’s psychological beliefs, physical health and Stroke and quality of life:
social involvement. It serves as a reference against In 1970, the World Health Organization defined
which an individual or society can measure the different stroke as ‘rapidly developed clinical signs of focal (or
domains of one’s own life. It is the general well-being of global) disturbance of cerebral function, lasting more
individuals and societies, outlining negative and positive than 24 hours or leading to death, with no apparent cause
features of life. It observes life satisfaction, including
 Indian Journal of Forensic Medicine & Toxicology, April-June 2020, Vol. 14, No. 2 227

other than of vascular origin’2. Physiotherapy is an established field in stroke

rehabilitation but uncertainties remain about the most
Globally, cerebrovascular accident (stroke) is the appropriate intensity of therapy input. Stroke tends to
second leading cause of death and the third leading cause result in a wide range of disabilities which have been
of disability3. The ratio of stroke is largely based in low shown to benefit from rehabilitation, in particular
and middle income countries. Death and disability is physiotherapy. Varieties of approaches are used in order
very common after stroke. In past few decades the ratio to regain functional independence in trunk along with
of stroke is increased in these counties as compared to upper and lower extremities. Most of the members of
high income countries. Young strokes are very common the therapeutic team in stroke rehabilitation take the
nowadays with hemorrhagic type overtaking the effectiveness of physical treatments after stroke for
ischemic. According to the World Health Organization, granted. The evidence available today suggests that it
15 million people suffer stroke worldwide each year. Of does not matter which form of treatment is chosen and that
these, 5 million die and another 5 million are permanently any of the available approaches will improve the patient’s
disabled. High blood pressure contributes to more than functional status. In other words, if an optimal treatment
12.7 million strokes worldwide. In developed countries, exists, we have, so far, failed to identify it. Until further
the incidence of stroke is declining, largely due to efforts evidence emerges, we should therefore select therapies
to lower blood pressure and reduce smoking. However, that are most cost-effective and that can be given to
the overall rate of stroke remains high due to the aging of the largest number of patients7. Physiotherapists play
the population. Almost half of stroke-related mortality an inherent role in the multidisciplinary palliative care
may be attributable to modifiable risk factors (i.e. team emphasizing on improving function and quality of
hypertension, diabetes, dietary risks, impaired glucose life in patients who are deemed to require physical and
intolerance, obesity, smoking, air pollution, alcohol use, functional dimensions of care9. It is important to analyze
hypercholesterolemia, and physical inactivity), which the role of physiotherapy in rehabilitating stroke and
are mostly the outcome of poor clinical management, understanding its importance on quality of life.
limited access to health care, and late detection of
underlying risk factors4. Physical therapy techniques:

Studies have shown that the Quality of life in Conventional exercises are traditionally practiced
stroke patients were decreased5 . Even with progress in throughout the world. Its role in establishing upper limb
treatment approaches for stroke and its prevalence ratio, control has been found to be effective. Biofeedback
the quality of life and social-related events caused by has been shown to have better results in both acute and
stroke has received limited attention. Stroke is an medical chronic stroke patients along with routine exercises8.
emergency which puts burden on medical care services
as well as personal where loss of productivity in terms Exercise therapy:
of activities and quality of living is compromised. Stroke Consists of passive movement, assisted movements,
presents with both structural and functional impairments active movement, assisted-resisted active movements,
which largely affects the physical performance. Motor and resisted movement. The techniques are to be
and cognitive impairments are common. Gait, balance, applied in anatomical planes or as functional movement
limb function, psychological issues contribute to decline direction. These techniques can be performed on land
in quality of work. or in water. The latter is termed as “hydrotherapy”.
Variety of treatment approaches is available for Best examples of therapeutic exercise techniques are
management. Medicine, physiotherapy, ayurveda, relaxation, massage, suspension therapy, muscle-
homeopathy etc has its own contribution in reversing the re-education, progressive resisted exercise, floor
loss and improving functional gain. aerobics, active mobility exercises, mobilization and
stabilization exercise, proprioceptive neuromuscular
Anxiety is more important in determining health facilitation (facilitation and inhibition techniques);
related quality of life (HQOL) than depression6. Even breathing exercise; postural training; work simulation,
alteration in upper extremity functions adds to impaired work conditioning and work hardening; graded activity
quality of function. program and cognitive-behavioral training10. In recent
times many neurophysiologic approaches have come up
Physiotherapy in Stroke:
228 Indian Journal of Forensic Medicine & Toxicology, April-June 2020, Vol. 14, No. 2

which work exactly at the site of lesion. They work on Motor relearning programme:
principle of neuronal plasticity thereby having a huge
impact on quality of life in stroke survivors. MRP works on the concept of analysis, finding the
missing component, practicing it and transference of
Neurophysiological approaches: training. Task related training has shown to improve
walking performance post stroke16. It works on concept
Bobath concept: of relearning phenomenon thereby enhancing neuronal
Bobath concept, also known as neuro developmental plasticity.
treatment, is a widely used approach in the rehabilitation Roods approach:
of hemiparetic subjects in many countries. Bobath
therapy has shown to have better functional outcome11. For every motor output proper and sequential
It works on principles of Normal postural alignment, sensory input is required. Roods approach works on
Inhibition versus facilitation, Assessment versus this concept through sequence of primitive reflexes and
treatment. milestones in order to achieve motor output. Various
inhibitory and facilitatory techniques are used in order
Constrained induced movement therapy: to regain motor control.
Original form of CIMT contains three components Brunstrom technique:
(1) Intensive graded practice of the paretic upper limb
aimed at enhancing task-specific use of the affected limb The predominant basis of the Brunnstrom approach
for up to 6 hours a day for 2 weeks (i.e., shaping) (2) is the use of reflexes to develop movement behaviour
constraining or FU of the non-paretic upper limb with through (1) sensory stimulation to inhibit spasticity
a mitt to promote the use of the more impaired limb and (2) functional retraining to enhance movement
during 90% of the waking hours; and (3) adherence- control. A strong functional emphasis remains a feature
enhancing behavioral methods designed to transfer of the Brunnstrom approach as a therapeutic tool for
the gains obtained in the clinical setting or laboratory neurological dysfunction17.
to the patients’ real-world environment (i.e., transfer
package)13 Electrotherapy:

A total of 24 patients were randomized to constraint- It is a branch of physiotherapy where low, medium
induced movement therapy or Bobath Concept group. and high frequency currents are used to gain therapeutic
Main measures were the Motor Activity Log-28, the Wolf effects in various disorders.
Motor Function Test, the Motor Evaluation Scale for Electrical modalities:
Arm in Stroke Patients and the Functional Independence
Measure. Constraint-induced movement therapy and the Various electrotherapy modalities are been routinely
Bobath Concept have similar efficiencies in improving used in treatment of impairments secondary to stroke.
functional ability, speed and quality of movement in the Reducing Pain, improving sensory input, maintaining
paretic arm among stroke patients with a high level of muscular properties are the primary uses. Electrical
function. Constraint-induced movement therapy seems stimulation, hot moist packs and exercises have shown
to be slightly more efficient than the Bobath Concept in to improve shoulder subluxation in stroke which is a
improving the amount and quality of affected arm use12. main barrier for improving upper extremity functions20.

Proprioceptive neuromuscular facilitation: Functional electrical stimulation:

Pelvic proprioceptive neuromuscular facilitation Functional electrical stimulation (FES) is a treatment

(PNF) helps to improve control of pelvis which is a key that applies small electrical charges to a muscle that has
point for maintaining trunk control, gait and balance14. become paralysed or weakened, due to damage in your
PNF has shown to establish significant changes in motor brain or spinal cord. Research on its use in stroke for
function and functionality after training, suggesting that both foot drop and to assist finger movements, was first
this program can be useful for rehabilitation of chronic published in the late 1970s. In the mid-1980s, a group
stroke survivors15. based in Salisbury in the UK started to look at using
FES. Originally their work was in people with spinal
 Indian Journal of Forensic Medicine & Toxicology, April-June 2020, Vol. 14, No. 2 229

cord injuries; from this initial work they went on to voiding program.
develop devices for people with MS in the early 1990s
and it continues to be used today. Electrical stimulation Preventive complications:
of the nerves result in contraction of muscles supplied by Stroke, can come up with number of complications
them. This technique can be used to improve the muscle like shoulder pain, pressure sores, DVT etc. shoulder
strength, control the movements, bowel, bladder and pain interferes sleep and therapy22. Physiotherapy
sexual functions, maintenance of posture, standing and should be thought of as a first-line management for
walking. FES is becoming popular in the treatment of patients with subacromial impingement syndrome23.
shoulder subluxation, spasticity and weakness of upper Both exercises and electrical agents play role is reducing
and lower limbs in hemiplegic patients. pain. Positioning and bed mobility exercises helps to
EMG and biofeedback: reduce pressure sores. Aim of positioning is to prevent
development of abnormal posture, spasticity and
This is a technique by which subject is made aware of contractures. Normal anatomical alignment of head,
activity of muscles for better self regulation of the motor trunk and limbs should be maintained. I125 labelled
functions. Electromyographic biofeedback (EMG‐BFB) fibrinogen leg scans of patients with hemiplegia have
is a technique that is believed to have additional benefit shown evidence of DVT in 30-75% during the first
when used with standard physiotherapy for the recovery week after stroke24 . Mobilization of patient as early as
of motor function in stroke patients18. EMG biofeedback possible reduces the chances of blood clot formation and
helps to recall anagrams using the cues. Mentally subject risks of DVT.
improves the performance by knowing the results of
previous activity. Conclusion
Activity of daily living training: Stroke has complex process of recovery. Stroke
survivors are left with disabilities. It causes depression in
Individuals with stroke have difficulty in gaining patients as well as their family members. Physiotherapy
functional independence in order to perform their has a significant role in improving impairments and
activities of daily living. Physiotherapy works with a disabilities. This in turn helps in improving quality of
primary goal of achieving it. Spastic muscles make it life.
very difficult to achieve voluntary control. Variety of
interventions have been tried out and have shown to Conflict of Interest: No conflicts of interest
have significant impact on achieving positive results. Source of Funding: KIMSDU Karad
Task-oriented training resulted in improved hand
function and activities of daily living in stroke patients19. Ethical Clearance: From institutional ethical
Therapeutic gymnasium consists of instrumental committee of KIMSDU karad
training for achieving functional mobility in upper and
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