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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 26-31

Comparison of immediate effect of lateral wedge and uniform lift on the symmetry of weight-bearing during quiet stance and sit-to-stand activities among individuals with chronic stroke


Department of Physiotherapy, All India Institute of Physical Medicine and Rehabilitation, Mumbai, Maharashtra, India

Date of Submission03-Dec-2019
Date of Decision14-Feb-2020
Date of Acceptance19-Mar-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Drashti Nilesh Rughani
Flat No. 304, C-Tower, Raj Residency-2, Near Parkland Residency, Vapi - 396 191, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_4_19

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  Abstract 


CONTEXT: Following stroke, weight-bearing asymmetry during stance and functional activities may arise from the compensatory pattern of learned nonuse.
AIMS: The aim of the study was to compare the immediate effect of lateral wedge and uniform lift under the foot of the nonparetic lower limb on the symmetry of weight-bearing in individuals with chronic stroke during quiet stance (QS) and sit-to-stand (STS) activities.
SETTINGS AND DESIGN: This study was conducted in a physiotherapy department of a tertiary health-care setting and this was a cross-sectional experimental study.
SUBJECTS AND METHODS: Convenience sampling method was used for this study. Eighty participants who fulfilled the study criteria were included in this study. The percentage of body weight borne by each leg was assessed using a force platform system during the activities of QS and STS during three conditions: Barefoot, ¼th inch lateral wedge and ¼th inch uniform lift under nonparetic lower limb.
STATISTICAL ANALYSIS USED: Repeated-measures ANOVA and post hoc analysis were used for the statistical analysis.
RESULTS: During QS activity, the percentage of weight-bearing improved significantly using lateral wedge and uniform lift (P < 0.0001) as compared to barefoot. During STS activity, no significant difference in the percentage of weight-bearing was noted during the conditions of barefoot, lateral wedge, and uniform lift (P = 0.0567).
CONCLUSIONS: Both lateral wedge and uniform lift were found to be equally effective in improving the symmetry of weight-bearing during QS activity. However, the introduction of lateral wedge or uniform lift had no significant improvement in weight-bearing symmetry during STS activity when compared with the barefoot.

Keywords: Chronic stroke, lateral wedge, symmetry of weight-bearing, uniform lift


How to cite this article:
Rughani DN, Ravindran R. Comparison of immediate effect of lateral wedge and uniform lift on the symmetry of weight-bearing during quiet stance and sit-to-stand activities among individuals with chronic stroke. Physiother - J Indian Assoc Physiother 2020;14:26-31

How to cite this URL:
Rughani DN, Ravindran R. Comparison of immediate effect of lateral wedge and uniform lift on the symmetry of weight-bearing during quiet stance and sit-to-stand activities among individuals with chronic stroke. Physiother - J Indian Assoc Physiother [serial online] 2020 [cited 2020 Jul 6];14:26-31. Available from: http://www.pjiap.org/text.asp?2020/14/1/26/288366




  Introduction Top


Lower extremity functions of standing and sit to stand (STS) are often affected after a stroke, restricting their functional activities.[1],[2]

Lateral wedge[3],[4] and uniform lift[1],[5],[6] are the most common methods used to compel and shift the body weight from the nonparetic lower limb to the paretic lower limb, respectively. However, there is a lack of evidence to prove that any one method is superior over the other, and as per the literature, their use was limited during static standing and ambulation.[3],[7],[8]

The aim and objectives of the study were to examine and compare the immediate effect of ¼th inch lateral wedge and ¼th uniform lift under the foot of the nonparetic lower limb on the symmetry of weight-bearing in individuals with chronic stroke during quiet stance (QS) and STS activities.


  Subjects and Methods Top


The study was carried out in physiotherapy department, All India Institute of Physical Medicine and Rehabilitation, Mumbai, and the study duration was 12 months (from September 2016 to October 2017). This was a cross-sectional experimental study design and a convenience sampling method was used for this study. The prevalence of patients with stroke as per the 2015 statistics reported to the physiotherapy department at All India Institute of Physical Medicine and Rehabilitation was 300 per year. The prevalence of asymmetry in independent ambulating stroke survivors is 55.5%. Going by this prevalence, the number of stroke patients having asymmetry in weight-bearing for 1 year would be 167 individuals. Considering factors such as inclusion criteria, exclusion criteria, consent to participate, and dropout, it was decided to recruit a sample of 80 individuals for this study.

Patients with unilateral chronic stroke (a period of more than 6-month duration) with asymmetrical stance and who were able to stand independently for up to 5 min and able to rise from a chair without the use of hands, walking aids, and orthotic devices were included in this study. Patients with a history of other neurological diseases, with cognitive (Mini-Mental State Examination [MMSE] <24), auditory, or visual deficit were excluded from this study. Patients with fixed contracture/deformity in the lower limb and with any associated musculoskeletal condition which may interfere with the study were also excluded from this study.

The study was approved by the Institutional Ethics Committee of All India Institute of Physical Medicine and Rehabilitation, Mumbai and the Synopsis Approval Committee of Maharashtra University of Health Sciences, Nashik, prior to the recruitment of participants. All the participants were explained the nature of the study, their role in the study, and their rights as per the informed consent document in the language best known to them. Individuals who fulfilled the above-mentioned inclusion and exclusion criteria and who gave a written informed consent were included in this study. Eighty individuals (65 men and 15 women) with unilateral hemiparesis 6 months poststroke, ranging in age from 26 to 75 years, participated in the study. Of 80 participants, 32 had right hemiparesis and 48 had left hemiparesis.

Procedure

After recruiting the participants [Figure 1], the first step was to collect the demographic data from all of them to gather information regarding the age, time since stroke onset, and type of stroke, followed by cognitive assessment using MMSE. The second step was to select lateral wedge and uniform lift as per the participants shoe sizes. ¼th inch of lateral wedge [Figure 2] and ¼th inch of uniform lift [Figure 3] was used in this study. Research studies have proven that ¼th inch of lateral wedge, when placed under the nonparetic limb, would provide an inclination equal to 5° which is helpful in shifting the weight toward the paretic limb.[3],[8] Furthermore, this ¼th inch would not provide any deviation in a patient's ambulation. The third step was to undergo experimental test on the Neurocom Balance Master Computerized Force Platform System [Figure 4]. Participants underwent two activities on the Neurocom Balance Master Computerized Force Platform System, namely QS [Figure 5], [Figure 6], [Figure 7] and STS activity [Figure 8]. The Balance Master consists of two force platforms connected to a computer which measures the vertical forces exerted through the patient's feet and the surface of the platform. The Balance Master machine is a reliable tool for complex test of balance and found to be more valid with a dynamic test which is a valid indicator of functional balance performances. The equipment was used by Rodriguez and Aruin, Liston and Brouwer in their study to assess the symmetry and balance parameters.[3],[9] Both the QS and STS activities measure the percentage (%) of body weight borne by each leg. The above activities were done in three different conditions.
Figure 1: Flowchart of methodolog

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Figure 2: ¼th inch lateral wedge

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Figure 3: ¼th inch uniform lift

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Figure 4: Neurocom Balance Master Computerized Force Platform System with different step heights

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Figure 5: Examination of quiet stance activity during barefoot condition

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Figure 6: Examination of quiet stance activity using the lateral wedge under the nonparetic lower limb

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Figure 7: Examination of quiet stance activity using the uniform lift under the nonparetic lower limb

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Figure 8: Examination of sit.to.stand activity

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  1. Barefoot, i.e., without lateral wedge or uniform lift
  2. ¼th inch lateral wedge introduced under the foot of the nonparetic lower limb
  3. ¼th inch uniform lift introduced under the foot of the nonparetic lower limb.


Each participant was given demonstration and practice trial of the study method. Three measurements were taken during each activity with three different conditions, namely barefoot, lateral wedge, and uniform lift. After each condition of barefoot, lateral wedge, and uniform lift, 1-min rest interval was given to the participants. After the completion of QS activity, 5-min interval was given to the participants before the start of STS activity. Following both the activities, their mean values were calculated and recorded.

Outcome measure

Percentage (%) of weight bearing on the paretic limb (WP) during QS and STS activities was calculated and recorded from Balance Master Computerized Force Platform.

Statistical analysis

Analysis of data for this study was done using software SPSS (SPSS Statistics for Windows, version 18.0, SPSS Inc., Chicago, Ill., USA). The level of significance was kept at P < 0.05 at 95% confidence interval level for all statistical analyses. All the data were assessed for normality using Shapiro–Wilk normality test. The data followed a Gaussian curve of normal distribution during both QS and STS activities, and therefore, parametric tests were used to analyze the data.

Repeated-measures ANOVA was used to see whether there was a significant difference in the percentage of weight-bearing in the paretic limb between the three conditions: bare foot, lateral wedge, and uniform lift. This was followed by Tukey's multiple comparison tests (post hoc analysis) to see which conditions performed better.


  Results Top


The results of QS activity [Table 1] and [Table 2] showed that the percentage (%) of weight-bearing on the paretic limb (WP) varied from 38.01% to 44.69%. Participants showed a significant improvement on weight-bearing symmetry using lateral wedge and uniform lift as compared to the barefoot (P < 0.0001) [Figure 9]. However, no real difference in the percentage of weight-bearing on the paretic limb when comparing lateral wedge and uniform lift (P = 0.6344) was noted.
Table 1: Percentage of weight-bearing on the paretic limb (WP) during three conditions of quiet stance activity using repeated-measures ANOVA test

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Table 2: Percentage of weight-bearing on the paretic limb during three conditions of quiet stance activity using Tukey multiple comparison (Post hoc analysis) test

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Figure 9: Percentage of weight bearing improved significantly using lateral wedge and uniform lift compared with barefoot (Tukey's test, P < 0.05). Data expressed as mean ± standard deviation. Participants with chronic stroke n < 80

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The results of STS activity [Table 3] showed that the percentage (%) of weight-bearing on the paretic limb (WP) varied from 30.02% to 42.04%. During the dynamic activity of STS, the percentage of weight-bearing did not improve during any of the three conditions (barefoot, wedge, and lift) (P = 0.0567) [Figure 10]. Thus, no statistically significant difference between the three conditions was noted.
Table 3: Percentage of weight-bearing on the paretic limb during three conditions of sit-to-stand activity using repeated-measures ANOVA test

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Figure 10: No significant improvements were noted between the conditions of barefoot, lateral wedge, and uniform lift (Tukey's test, P > 0.05). Data expressed as mean ± standard deviation. Participants with chronic stroken = 80

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  Discussion Top


Asymmetry is commonly seen during standing and functional activities such as STS and walking. About 55.5% independent ambulating stroke survivors show gait asymmetry.[7] According to the American Heart Association, stroke individuals are more prone to falls during transitional activities due to asymmetrical weight-bearing.[10] Studies have shown that this asymmetry results from poor postural control, muscle weakness, impaired force generation, and sensory-motor deficit.[2]

As per the literature,[11] there is an underloading of the paretic limb not only during static task of standing but also during dynamic task of STS. Majority of individuals with stroke bear less weight on the paretic limb. They range between 25% and 43% of body weight during standing task and 25% and 38% of body weight during dynamic task of STS.

In this study, 80 participants were compared for the immediate effect of lateral wedge and uniform lift during QS and STS activities. During QS activity, when comparing lateral wedge to uniform lift, it was found that both lateral wedge and uniform lift are equally effective in improving the symmetry of weight-bearing among individuals with chronic stroke. The possible effect after the application of lateral wedge or uniform lift could be as a result of shift in the center of gravity from the nonparetic lower limb to the midline and hence forcing the paretic lower limb to load more and therefore improves symmetry of weight-bearing.[1],[3]

During STS activity, the introduction of lateral wedge and uniform lift had not brought any significant improvement in weight-bearing symmetry. Since the static activity of QS requires minimal activity of postural leg muscles, STS is a complex task and involves various determinants[12] such as (1) trunk symmetry during STS activity, (2) STS is a dynamic activity which requires the activation of postural leg muscles in a dynamic manner, particularly the knee musculature, (3) proper timing of recruitment of muscles of the lower limb, and (4) symmetry of weight-bearing. However, in stroke population, these determinants are affected due to various factors which thereby will affect the quality of STS activity such as (1) trunk deviations toward the normal side before seat-off,[13],[14] (2) reduced force generation within the paretic muscles,[11],[15],[16] (3) delayed recruitment of muscles at proper timing,[17],[18],[19] and (4) asymmetrical weight-bearing.[15] Thus, ¼th inch lateral wedge and ¼th inch uniform lift when compared to barefoot are not sufficient enough to overcome the above determinants of the complex task of STS.

The major limitations of this study were examining the immediate effect of a ¼th inch lateral wedge and ¼th inch uniform lift on the symmetry of weight-bearing during QS and STS activities. The authors acknowledge the huge variation of the study participants' age group, however, would like to clarify that the outcome measure of the study (symmetrical weight bearing) is less likely to be affected by age and more so by the condition. Hence, the emphasis is given to the duration of the condition and not the age of the participant.

Future research is essential to study the efficacy of lateral wedge or uniform lift during targeted therapeutic intervention or functional activities, as it may bring about better loading of the paretic lower limb in both static and dynamic activities. Improved loading can increase the extensor load receptor transmission to the central nervous system,[20],[21] thereby further recruitment of antigravity postural lower limb muscles which can reduce the learned disuse of the paretic limb.


  Conclusion Top


Both lateral wedge and uniform lift were found to be equally effective in improving the symmetry of weight-bearing during QS activity. However, the introduction of lateral wedge or uniform lift had no significant improvement in the symmetry of weight-bearing during STS activity when compared with the barefoot.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aruin AS, Hanke T, Chaudhuri G, Harvey R, Rao N. Compelled weightbearing in persons with hemiparesis following stroke: The effect of a lift insert and goal-directed balance exercise. J Rehabil Res Dev 2000;37:65-72.  Back to cited text no. 1
    
2.
Wall JC, Turnbull GI. Gait asymmetries in residual hemiplegia. Arch Phys Med Rehabil 1986;67:550-3.  Back to cited text no. 2
    
3.
Rodriguez GM, Aruin AS. The effect of shoe wedges and lifts on symmetry of stance and weight bearing in hemiparetic individuals. Arch Phys Med Rehabil 2002;83:478-82.  Back to cited text no. 3
    
4.
Yu WH, Liu WY, Wong AM, Wang TC, Li YC, Lien HY. Effect of forced use of the lower extremity on gait performance and mobility of post-acute stroke patients. J Phys Ther Sci 2015;27:421-5.  Back to cited text no. 4
    
5.
Aruin AS, Rao N, Sharma A, Chaudhuri G. Compelled body weight shift approach in rehabilitation of individuals with chronic stroke. Top Stroke Rehabil 2012;19:556-63.  Back to cited text no. 5
    
6.
Chitra J, Mishra S. A comparative study on the effect of compelled body weight shift therapy (CBWST) and modified constraint induced movement therapy (M CIMT) on weight bearing symmetry and balance in stroke patients. Int J Therapies Rehabilit Res 2015;4:209-18.  Back to cited text no. 6
    
7.
Patterson KK, Parafianowicz I, Danells CJ, Closson V, Verrier MC, Staines WR, et al. Gait asymmetry in community-ambulating stroke survivors. Arch Phys Med Rehabil 2008;89:304-10.  Back to cited text no. 7
    
8.
Chen CH, Lin KH, Lu TW, Chai HM, Chen HL, Tang PF, et al. Immediate effect of lateral-wedged insole on stance and ambulation after stroke. Am J Phys Med Rehabil 2010;89:48-55.  Back to cited text no. 8
    
9.
Liston RA, Brouwer BJ. Reliability and validity of measures obtained from stroke patients using the Balance Master. Arch Phys Med Rehabil 1996;77:425-30.  Back to cited text no. 9
    
10.
Nyberg L, Gustafson Y. Patient falls in stroke rehabilitation. A challenge to rehabilitation strategies. Stroke 1995;26:838-42.  Back to cited text no. 10
    
11.
Eng JJ, Chu KS. Reliability and comparison of weight-bearing ability during standing tasks for individuals with chronic stroke. Arch Phys Med Rehabil 2002;83:1138-44.  Back to cited text no. 11
    
12.
Boukadida A, Piotte F, Dehail P, Nadeau S. Determinants of sit-to-stand tasks in individuals with hemiparesis post stroke: A review. Ann Phys Rehabil Med 2015;58:167-72.  Back to cited text no. 12
    
13.
Mazza C, Stanhope SJ, Taviani A, Cappozzo A. Biomechanical modeling of sit-to-stand to upright posture for mobility assessment of persons witch chronic stroke. Arch Phys Med Rehabil 2006;91:288-97.  Back to cited text no. 13
    
14.
Lecours J, Nadeau S, Gravel D, Teixera-Salmela L. Interactions between foot placement, trunk frontal position, weight-bearing and knee moment asymmetry at seat-off during rising from a chair in healthy controls and persons with hemiparesis. J Rehabil Med 2008;40:200-7.  Back to cited text no. 14
    
15.
Lomaglio MJ, Eng JJ. Muscle strength and weight-bearing symmetry relate to sit-to-stand performance in individuals with stroke. Gait Posture 2005;22:126-31.  Back to cited text no. 15
    
16.
Roebroeck ME, Doorenbosch CA, Harlaar J, Jacobs R, Lankhorst GJ. Biomechanics and muscular activity during sit-to-stand transfer. Clin Biomech (Bristol, Avon) 1994;9:235-44.  Back to cited text no. 16
    
17.
Prudente C, Rodrigues-de-Paula F, Faria CD. Lower limb muscle activation during the sit-to-stand task in subjects who have had a stroke. Am J Phys Med Rehabil 2013;92:666-75.  Back to cited text no. 17
    
18.
Cheng PT, Chen CL, Wang CM, Hong WH. Leg muscle activation patterns of sit-to-stand movement in stroke patients. Am J Phys Med Rehabil 2004;83:10-6.  Back to cited text no. 18
    
19.
Silva A, Sousa AS, Pinheiro R, Ferraz J, Tavares JM, Santos R, et al. Activation timing of soleus and tibialis anterior muscles during sit-to-stand and stand-to-sit in post-stroke vs. healthy subjects. Somatosens Mot Res 2013;30:48-55.  Back to cited text no. 19
    
20.
Dietz V. Evidence for a load receptor contribution to the control of posture and locomotion. Neurosci Biobehav Rev 1998;22:495-9.  Back to cited text no. 20
    
21.
Dietz V, Duysens J. Significance of load receptor input during locomotion: A review. Gait Posture 2000;11:102-10.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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