Bobath therapy is inferior to task-specific training and not superior to other interventions in improving lower limb activities after stroke: a systematic review

Relationship between apathy/post-stroke depression and gait training in patients with stroke

BACKGROUND

We examined the effect of gait training on apathy/post-stroke depression (PSD) in patients with walking disorders after stroke, and the effect of apathy/PSD on gait reacquisition in subacute stroke.

METHODS

Fifty-five participants with gait disorders after stroke underwent gait training for 6 weeks. Outcome measurements included Apathy Scale (AS), Center for Epidemiologic Studies Depression Scale (CES-D), Mini-Mental State Examination, Lower Extremity Function of Stroke Impairment Assessment Set, and Functional Independence Measure-TRANSFER and -WALK scores. These scores of the participants were divided into groups with or without apathy based on AS scores for statistical analysis.

RESULTS

Both groups showed significant differences in all outcomes after gait training. In addition, even if the participants had apathy at baseline, there were no significant differences in outcomes other than AS/CES-D between the two groups after gait training. Logistic regression analysis showed that only Mini-Mental State Examination and Lower Extremity Function of Stroke Impairment Assessment Set scores affected the reacquisition of independent walking (odds ratio: 1.332, P = 0.015; odds ratio: 1.364, P = 0.005, respectively). AS and CES-D scores had no effects on gait reacquisition.

CONCLUSION

Gait training may be beneficial for both physical impairment and psychiatric symptoms in patients with stroke and may prevent poor functional recovery caused by apathy and PSD. As opposed to previous studies that have shown a negative impact of apathy and PSD on functional recovery, our results suggest that apathy/PSD may not negatively affect functional recovery when gait training is conducted in subacute stroke.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation to improve function and mobility are used after stroke. There is considerable controversy around the relative effectiveness of approaches, and little known about optimal delivery and dose. Some physiotherapists base their treatments on a single approach; others use components from several different approaches.

OBJECTIVES

Primary objective: To determine whether physical rehabilitation is effective for recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.

SECONDARY OBJECTIVE

To explore factors that may impact the effectiveness of physical rehabilitation approaches, including time after stroke, geographical location of study, intervention dose/duration, intervention provider, and treatment components. Stakeholder involvement: Key aims were to clarify the focus of the review, inform decisions about subgroup analyses, and co-produce statements relating to key implications.

SEARCH METHODS

For this update, we searched the Cochrane Stroke Trials Register (last searched November 2022), CENTRAL (2022, Issue 10), MEDLINE (1966 to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and the Chinese Biomedical Literature Database (to November 2022).

SELECTION CRITERIA

Inclusion criteria: Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke.

EXCLUSION CRITERIA

RCTs of upper limb function or single treatment components.

PRIMARY OUTCOMES

measures of independence in activities of daily living (IADL) and motor function.

SECONDARY OUTCOMES

balance, gait velocity, and length of stay.

DATA COLLECTION AND ANALYSIS

Two independent authors selected studies according to pre-defined eligibility criteria, extracted data, and assessed the risk of bias in the included studies. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

In this review update, we included 267 studies (21,838 participants). Studies were conducted in 36 countries, with half (133/267) in China. Generally, studies were heterogeneous, and often poorly reported. We judged only 14 studies in meta-analyses as at low risk of bias for all domains and, on average, we considered 33% of studies in analyses of primary outcomes at high risk of bias. Is physical rehabilitation more effective than no (or minimal) physical rehabilitation? Compared to no physical rehabilitation, physical rehabilitation may improve IADL (standardised mean difference (SMD) 1.32, 95% confidence interval (CI) 1.08 to 1.56; 52 studies, 5403 participants; low-certainty evidence) and motor function (SMD 1.01, 95% CI 0.80 to 1.22; 50 studies, 5669 participants; low-certainty evidence). There was evidence of long-term benefits for these outcomes. Physical rehabilitation may improve balance (MD 4.54, 95% CI 1.36 to 7.72; 9 studies, 452 participants; low-certainty evidence) and likely improves gait velocity (SMD 0.23, 95% CI 0.05 to 0.42; 18 studies, 1131 participants; moderate-certainty evidence), but with no evidence of long-term benefits. Is physical rehabilitation more effective than attention control? The evidence is very uncertain about the effects of physical rehabilitation, as compared to attention control, on IADL (SMD 0.91, 95% CI 0.06 to 1.75; 2 studies, 106 participants), motor function (SMD 0.13, 95% CI -0.13 to 0.38; 5 studies, 237 participants), and balance (MD 6.61, 95% CI -0.45 to 13.66; 4 studies, 240 participants). Physical rehabilitation likely improves gait speed when compared to attention control (SMD 0.34, 95% CI 0.14 to 0.54; 7 studies, 405 participants; moderate-certainty evidence). Does additional physical rehabilitation improve outcomes? Additional physical rehabilitation may improve IADL (SMD 1.26, 95% CI 0.82 to 1.71; 21 studies, 1972 participants; low-certainty evidence) and motor function (SMD 0.69, 95% CI 0.46 to 0.92; 22 studies, 1965 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Additional physical rehabilitation may improve balance (MD 5.74, 95% CI 3.78 to 7.71; 15 studies, 795 participants; low-certainty evidence) and gait velocity (SMD 0.59, 95% CI 0.26 to 0.91; 19 studies, 1004 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Is any one approach to physical rehabilitation more effective than any other approach? Compared to other approaches, those that focus on functional task training may improve IADL (SMD 0.58, 95% CI 0.29 to 0.87; 22 studies, 1535 participants; low-certainty evidence) and motor function (SMD 0.72, 95% CI 0.21 to 1.22; 20 studies, 1671 participants; very low-certainty evidence) but the evidence in the latter is very uncertain. The benefit was sustained long-term. The evidence is very uncertain about the effect of functional task training on balance (MD 2.16, 95% CI -0.24 to 4.55) and gait velocity (SMD 0.28, 95% CI -0.01 to 0.56). Compared to other approaches, neurophysiological approaches may be less effective than other approaches in improving IADL (SMD -0.34, 95% CI -0.63 to -0.06; 14 studies, 737 participants; low-certainty evidence), and there may be no difference in improving motor function (SMD -0.60, 95% CI -1.32 to 0.12; 13 studies, 663 participants; low-certainty evidence), balance (MD -0.60, 95% CI -5.90 to 6.03; 9 studies, 292 participants; low-certainty evidence), and gait velocity (SMD -0.17, 95% CI -0.62 to 0.27; 16 studies, 630 participants; very low-certainty evidence), but the evidence is very uncertain about the effect on gait velocity. For all comparisons, the evidence is very uncertain about the effects of physical rehabilitation on adverse events and length of hospital stay.

AUTHORS' CONCLUSIONS

Physical rehabilitation, using a mix of different treatment components, likely improves recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to 'usual' rehabilitation, may provide added benefits. Physical rehabilitation approaches that focus on functional task training may be useful. Neurophysiological approaches to physical rehabilitation may be no different from, or less effective than, other physical rehabilitation approaches. Certainty in this evidence is limited due to substantial heterogeneity, with mainly small studies and important differences between study populations and interventions. We feel it is unlikely that any studies published since November 2022 would alter our conclusions. Given the size of this review, future updates warrant consensus discussion amongst stakeholders to ensure the most relevant questions are explored for optimal decision-making.

Analyzing the Impact of Rehabilitation Utilizing Neurofunctional Exercises on the Functional Status of Stroke Patients

Background/Objectives: Physical rehabilitation based on neurofunctional exercises can have a positive impact on restoring functionality and enhancing the quality of life of these individuals. Therefore, the purpose of this study is to analyze the effects of rehabilitation, including neurofunctional exercises, on the functional status of stroke patients. Methods: The cohort study design included 102 male and female participants: 51 patients underwent physiotherapy rehabilitation including neurofunctional exercises (SG), while the other 51 did not follow a rehabilitation program based on neurofunctional exercises (CG). The participants were assessed twice: once during their stay in the early neurology department after the first stroke, and again six months later. The assessments were conducted using the Barthel Scale (BS), the Rankin Scale (RS), and the National Institutes of Health Stroke Scale (NIHSS). Results: Baseline comparisons revealed significantly greater BS (p = 0.001) in the CG compared to the SG. Conversely, the SG had a significantly higher NIHSS than the CG at baseline (p = 0.001), as well as higher RS (p < 0.001). Within the SG, there were significant increases in BS (p < 0.001), while no significant differences were found between baseline and post 6 months in RS (p = 0.537) and NIHSS (p = 0.475). Regarding the CG, significant increases were observed in BS (p = 0.005) and NIHSS (p < 0.001), while no significant differences were found in RS (p = 0.335). Conclusions: In conclusion, this study reveals that incorporating neurofunctional exercises does not appear to play a significant role in the patients' progress. The controlled group, engaged in home-based activities, showed greater improvements in their condition.

The Bobath concept (NDT) in adult neurorehabilitation: a scoping review of conceptual literature

PURPOSE

This scoping review aims to describe how Bobath concept is conceptualized, operationalized, and studied in adult neurorehabilitation.

METHODS

The Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guidelines were adopted. Non-scientific and research articles were searched in electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science, ScienceDirect, and Physiotherapy Evidence Database (PEDro), with the keywords "Bobath" or "Neurodevelopmental Treatment", published in English, Spanish, and Portuguese, between 2013 and 2023.

RESULTS

Of the 78 publications identified, 31 articles addressed the conceptual underpinnings of Bobath concept (seven theoretical papers, seven Delphi/surveys/mixed methods studies, four qualitative studies, one scoping review, 10 letters to the editor, and two editorials), comprising five themes: (a) theoretical principles; (b) clinical principles; (c) clinical reasoning; (d) conceptualizing movement; and, current (e) evidence debate. The revised definition and the Model of Bobath Clinical Practice provide a clarification of the unique aspects of Bobath concept. A new clinical skill was identified beyond facilitation - visuospatial kinesthetic perception - as well as how Bobath experts conceptualize movement, which are all integral to clinical reasoning.

CONCLUSIONS

This review provides an updated Bobath clinical framework that gathers the theoretical foundations and clinical practice principles that require careful consideration in the design of future intervention studies.Implications for rehabilitationThis scoping review consolidates the clinical and theoretical principles of contemporary Bobath practice, providing a clear framework for clinicians.The Model of Bobath Clinical Practice (MBCP) framework enables detailed documentation of movement analysis and movement diagnosis, guiding clinical reasoning and interventions.This review identifies fundamental principles and practices to inform future Bobath intervention studies, ensuring their clinical relevance.A framework with specific recommendations has been developed to guide Bobath intervention studies, enhancing the integration of clinical practice, education, and research.

Bobath, NeuroDevelopmental Therapy, and clinical science: Rebranding versus rigor

This letter to the editor is on the invited review by Mayston et al. on pages 564–572 of this issue.

Functional Training for Lower Extremities in Stroke Survivors: A Scoping Review

Engaging in meaningful and repetitive goal-oriented functional tasks can effectively enhance neuroplasticity and facilitate recovery following a stroke. This particular approach has primarily been studied in relation to functional outcomes and has predominantly focused on late subacute and chronic stroke patients. However, there is a lack of information regarding the standardized protocol of lower extremity functional training, its constituent elements, and its impact on motor recovery during the early subacute phase of stroke. The aim of this study was to examine the available evidence related to the intervention protocol of lower extremity functional training in order to identify common training elements and assess their impact on motor and functional outcomes in stroke survivors. A systematic search was conducted on PubMed and Scopus, covering the period from 2000 to 2022. A total of 1786 articles were retrieved and screened based on predefined inclusion criteria. A total of 36 articles were included in this review. The primary findings were classified into categories such as intervention protocols for functional training and their constituent elements, outcome measures utilized, minimal clinically important differences (MCID) reported, and the conclusions drawn by the respective studies. Only a limited quantity of studies reported on the intervention protocol of lower extremity functional training. The majority of these studies focused on the efficacy of functional training for enhancing gait and balance, as evaluated through functional outcome assessments, particularly in the context of chronic stroke patients. In most studies, the evaluation of outcomes was typically based on statistical significance rather than clinical significance. In light of these findings, it is recommended that future studies be conducted during the early subacute phase of stroke to further investigate the impact of functional training on motor outcomes. This will contribute to a broader understanding of the benefits of functional training in facilitating motor recovery in the lower extremities and its clinical significance in stroke survivors.

Biomechanical Gait Effects of a Single Intervention with Wearable Closed Loop Control FES System in Chronic Stroke Patients. A Proof-of-Concept Pilot Study

Foot drop is a gait disturbance characterized by difficulty in performing ankle dorsiflexion during the swing phase of the gait cycle. Current available evidence shows that functional electrical stimulation (FES) on the musculature responsible for dorsal ankle flexion during gait can have positive effects on walking ability. This study aims to present a proof of concept for a novel easy-to-use FES system and evaluates the biomechanical effects during gait in stroke patients, compared to unassisted walking. Gait was quantitatively evaluated in a movement analysis laboratory for five subjects with chronic stroke, in basal condition without assistance and in gait assisted with FES. Improvements were found in all temporospatial parameters during FES-assisted gait, evidenced by statistically significant differences only in gait speed (p=0.02). Joint kinematics showed positive changes in hip abduction and ankle dorsiflexion variables during the swing phase of the gait cycle. No significant differences were found in the Gait Deviation Index. In conclusion, the present pilot study demonstrates that the use of this FES system in the tibialis anterior muscle can cause gait functional improvements in subjects with foot drop due to chronic stroke.

Effects of whole body vibration on functional capacity and respiratory functions in individuals with stroke: A randomized controlled study

BACKGROUND

Management of respiratory-related functional problems using sensory rehabilitation strategies has been poorly researched in patients with stroke.

OBJECTIVE

This study aimed to investigate whether whole body vibration (WBV) training has an effect on functional capacity and respiratory functions in patients with stroke.

METHODS

In the randomized-controlled study, 28 participants were randomized into two groups: one receiving neurodevelopmental treatment (NDT; n = 13) and one receiving both NDT and WBV (NDT + WBV; n = 15). The primary outcome measures were 6-minute walking test (6MWT) and pulmonary function test which evaluate functional and respiratory capacity. Secondary outcome included the chest circumference measurement to evaluate the thoracic expansion ability.

RESULTS

Both groups showed positive significant changes in walking distance and maximum oxygen consumption volume (VO2max), inspiratory capacity, vital capacity and chest circumference measurement scores (p <  0.05). While the NDT +WBV group showed a significantly greater increase in walking distance and VO2max levels than the NDT group (p <  0.05), there were no significant group differences in respiratory function flow and volume parameters, and chest circumference measurement.

CONCLUSION

The addition of WBV training to the treatment program has some incremental benefits on increasing functional capacity and thoracic expansion, and rehabilitating respiratory dysfunction.

Principles into Practice: An Observational Study of Physiotherapists use of Motor Learning Principles in Stroke Rehabilitation

OBJECTIVE(S)

To describe a) how motor learning principles are applied during post stroke physiotherapy, with a focus on lower limb rehabilitation; and b) the context in which these principles are used, in relation to patient and/or task characteristics.

DESIGN

Direct non-participation observation of routine physiotherapy sessions, with data collected via video recording. A structured analysis matrix and pre-agreed definitions were used to identify, count and record: type of activity; repetitions; instructional and feedback statements (frequency and type); strategies such as observational learning and augmented feedback. Data was visualised using scatter plots, and analysed descriptively.

SETTING

6 UK Stroke Units PARTICIPANTS: 89 therapy sessions were observed, involving 55 clinicians and 57 patients.

RESULTS

Proportion of time spent active within each session ranged from 26% to 98% (mean 85, SD 19). The frequency of task repetition varied widely, with a median of 3.7 repetitions per minute (IQR 2.1-8.6). Coaching statements were common (mean 6.46 per minute), with 52% categorised as instructions, 14% as feedback, and 34% as verbal cues/motivational statements. 13% of instructions and 6% of feedback statements were externally focussed. Examining the use of different coaching behaviours in relation to patient characteristics found no associations. Overall, practice varied widely across the dataset.

CONCLUSIONS

To optimise the potential for motor skill learning, therapists must manipulate features of their coaching language (what they say, how much and when) and practice design (type, number, difficulty and variability of task). There is an opportunity to implement motor learning principles more consistently, to benefit motor skill recovery following stroke.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03792126). CONTRIBUTION OF THE PAPER.

Balance Rehabilitation through Robot-Assisted Gait Training in Post-Stroke Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Balance impairment is a common disability in post-stroke survivors, leading to reduced mobility and increased fall risk. Robotic gait training (RAGT) is largely used, along with traditional training. There is, however, no strong evidence about RAGT superiority, especially on balance. This study aims to determine RAGT efficacy on balance of post-stroke survivors.

METHODS

PubMed, Cochrane Library, and PeDRO databases were investigated. Randomized clinical trials evaluating RAGT efficacy on post-stroke survivor balance with Berg Balance Scale (BBS) or Timed Up and Go test (TUG) were searched. Meta-regression analyses were performed, considering weekly sessions, single-session duration, and robotic device used.

RESULTS

A total of 18 trials have been included. BBS pre-post treatment mean difference is higher in RAGT-treated patients, with a pMD of 2.17 (95% CI 0.79; 3.55). TUG pre-post mean difference is in favor of RAGT, but not statistically, with a pMD of -0.62 (95%CI - 3.66; 2.43). Meta-regression analyses showed no relevant association, except for TUG and treatment duration (β = -1.019, 95% CI - 1.827; -0.210, p-value = 0.0135).

CONCLUSIONS

RAGT efficacy is equal to traditional therapy, while the combination of the two seems to lead to better outcomes than each individually performed. Robot-assisted balance training should be the focus of experimentation in the following years, given the great results in the first available trials. Given the massive heterogeneity of included patients, trials with more strict inclusion criteria (especially time from stroke) must be performed to finally define if and when RAGT is superior to traditional therapy.

EFFECTS OF STRENGTH TRAINING ON PHYSICAL STABILITY IN DANCERS

ABSTRACT Introduction: Ballroom dance has evolved from a simple self-taught part of folklore to a technical, performative, and artistic competitive dance called the International Standard Dance. Objective: Study the effects of special lower limb strength training on the physical stability of dancers. Methods: 20 volunteers, students of a university specialized in dance, were divided into experimental and control groups, undergoing training of 30 minutes daily, 3 times a week, for 3 months. The control group followed the daily training, while the experimental group received special lower limb strength training. The relevant physical data measured before and after the intervention were statistically analyzed. Results: Compared to the control group, there was a significant difference in the athletes of the experimental group (P<0.05). The experimental group's lower limb strength and special skills were significantly improved. Conclusion: The lower extremity strength training protocol significantly improved the dancers’ muscle strength, proportionally increasing the stability of the sports skills. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

INFLUENCE OF WEIGHT TRAINING ON LOWER LIMB STRENGTH IN SOCCER PLAYERS

ABSTRACT Introduction Soccer games are of long duration and more confrontational; in the second half of the game, many players have a decline in their physical level, leading to loss of matches. Objective To explore the effect of weight training on lower limb fitness in soccer players. Methods 60 athletes were included as subjects and randomly divided into control group, weight training group, and traditional physical fitness training group. All athletes trained for 45 minutes 3 times a week for 6 weeks. Before and after training, lower limb strength and proprioception were evaluated, and the strength of the knee flexor and extensor group was assessed by isokinetic muscle tester. Results Both weight training and traditional physical training were able to improve the vertical jump performance of young soccer players, the training effects of both groups were equivalent. Conclusion Weight training has the same enhancing effect as traditional physical training in terms of strength and explosive power, promoting athletic performance in youth soccer players. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Early Rehabilitation Exercise after Stroke Improves Neurological Recovery through Enhancing Angiogenesis in Patients and Cerebral Ischemia Rat Model

Among cerebrovascular diseases, ischemic stroke is a leading cause of mortality and disability. Thrombolytic therapy with tissue plasminogen activator is the first choice for clinical treatment, but its use is limited due to the high requirements of patient characteristics. Therefore, the choice of neurological rehabilitation strategies after stroke is an important prevention and treatment strategy to promote the recovery of neurological function in patients. This study shows that rehabilitation exercise 24 h after stroke can significantly improve the neurological function (6.47 ± 1.589 vs. 3.21 ± 1.069 and 0.76 ± 0.852), exercise ability (15.68 ± 5.95 vs. 162.32 ± 9.286 and 91.18 ± 7.377), daily living ability (23.37 ± 5.196 vs. 66.95 ± 4.707 and 6.55 ± 2.873), and quality of life (114.39 ± 7.772 vs. 168.61 ± 6.323 and 215.95 ± 10.977) of patients after 1 month and 3 months, and its ability to promote rehabilitation is better than that of rehabilitation exercise administered to patients 72 h after stroke (p < 0.001). Animal experiments show that treadmill exercise 24 h after middle cerebral artery occlusion and reperfusion can inhibit neuronal apoptosis, reduce the volume of cerebral infarction on the third (15.04 ± 1.07% vs. 30.67 ± 3.06%) and fifth (8.33 ± 1.53% vs. 30.67 ± 3.06%) days, and promote the recovery of neurological function on the third (7.22 ± 1.478 vs. 8.28 ± 1.018) and fifth (4.44 ± 0.784 vs. 6.00 ± 0.767) days. Mechanistic studies have shown that treadmill exercise increases the density of microvessels, regulates angiogenesis, and promotes the recovery of nerve function by upregulating the expression of vascular endothelial growth factor and laminin. This study shows that rehabilitation exercise 24 h after stroke is conducive to promoting the recovery of patients’ neurological function, and provides a scientific reference for the clinical rehabilitation of stroke patients.

Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis

BACKGROUND AND OBJECTIVE

Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP.

METHODS

Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [-0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [-0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures.

CONCLUSIONS

We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.

What Competencies Does a Community Occupational Therapist Need in Neurorehabilitation? Qualitative Perspectives

More than three million people in Chile suffer from neurological conditions, and many of these become permanent users of health services with a community approach. In this way, disciplinary competencies in this area are relevant. We seek to characterize the competencies for community occupational therapy intervention in neurorehabilitation. Using a qualitative approach, interviews were conducted with eighteen professionals and were analyzed using content analysis. The main results are associated with the competencies of knowledge associated with theoretical biomedical and community elements. Skills range from health evaluation and intervention on micro- and macrosocial levels. Attitude is also an important skill, stemming from personal and relational spheres. These findings suggest that interventions are essentially on a personal and microsocial level, focusing first on pathology and treatment, and later comprehending the interactions with a patient's close social environment, such as family, schoolmates, and workmates and their physical environment at home, school, and the workplace. Although the final objective of community intervention is present in the discourse as being able to generate structural changes that favor well-being and social inclusion, concrete competencies are not appreciated on a macrosocial level.

The Bobath Concept (NDT) as rehabilitation in stroke patients: A systematic review

Background and Objectives:

The Bobath approach, also known as neurodevelopmental treatment (NDT), is a widely used concept in the rehabilitation of stroke patients with hemiparesis in many countries. This technique is being used since years all over the world; however, strong evidence of its usefulness is still not present. This review is aimed to find out its effectiveness based on the randomized controlled trials in the rehabilitation of stroke patients with motor disability and to compare it with other therapeutic techniques.

Materials and Methods:

A systematic literature search on PubMed Central, Science-Direct, Cochrane, Scopus, Clinical Trial Database, and Indian Clinical Trial Registry in English till 31^st July 2021 was undertaken. The review is published in Prospective Register of Systematic Reviews (PROSPERO) with registration number “CRD42019125400.” Physiotherapy Evidence-based Database (PEDro) score has been used for the quality assessment of the studies. Randomized clinical trials that studied the comparative effect of the NDT/Bobath concept on motor activity outcomes and cognition/behavior in stroke patients in comparison with other rehabilitative techniques were included.

Results:

No strong documentation describing the effectiveness of this neuro-developmental treatment or its supporting neuro-developmental treatment in comparison with other advanced neuro-physiotherapeutic techniques has been found so as to consider it as the recommended treatment for post-stroke hemiplegia/hemiparesis. Methodological aspects of selected studies for further research are suggested.

Interpretation and Conclusions:

This study is inconclusive in determining the effectiveness of the Bobath approach for the movement rehabilitation of stroke patients. These results are similar to the results of previous reviews done on the same topic.

Abdominal Acupuncture as an Adjunctive Therapy for the Recovery of Motor Function After Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Bo's abdominal acupuncture (BAA) is a novel therapy in alternative and complementary medicine and has been frequently used for stroke recovery in recent decades. However, no systematic evidence has been performed to confirm the effect and safety of BAA as an adjunctive therapy for post-stroke motor dysfunction (PSMD). Objectives: This review aimed to assess the efficacy and safety of BAA as an adjunctive therapy for improving allover motor function, upper limb motor function, lower limb motor function, and activities of daily living (ADL) in patients with PSMD. Methods: Seven databases were searched from inception to December 2020: Embase, PubMed, Cochrane Library, Chinese Biological Medicine Database, Chinese Scientific Journal Database, WAN FANG, and the China National Knowledge Infrastructure. All randomized controlled trials (RCTs) involving BAA plus another therapy vs. the same other therapy alone were identified. The methodological quality of the included trials was assessed according to the Cochrane risk of bias criteria. If more than half of the domains in a study are at low risk of bias, the overall quality of the study is low risk. We conducted a meta-analysis for primary outcomes using a random effects model and performed a narrative summary for the secondary outcome. We also conducted subgroup analysis for primary outcomes based on different add-on treatments to BAA. Random effects and fixed effects models were used to test the robustness of the pooled data. We also tested the robustness of the meta-analysis using specific methodological variables that could affect primary outcome measures. Results: Twenty-one trials with 1,473 patients were included in this systematic review. The overall quality of the 14 included trials (66.7%) was low risk. Meta-analyses indicated that the effect of the BAA group was better than that of the non-EA group on the Fugl-Meyer Assessment Scale (FMA) (weight mean difference (WMD) 9.53, 95% confidence interval (CI) 7.23 to 11.83, P < 0.00001), FMA for upper extremities (WMD 11.08, 95% CI 5.83 to 16.32, P < 0.0001), FMA for lower extremities (WMD 5.57, 95% CI 2.61 to 8.54, P = 0.0002), and modified Barthel Index (standardized mean difference (SMD) 1.02, 95% CI 0.65 to 1.39, P < 0.00001). Two trials (9.5%) reported BAA-related adverse events, and the most common adverse event was local subcutaneous ecchymosis. Conclusions: BAA as an adjunctive therapy may have clinical benefits for improving allover motor function, upper limb motor function, lower limb motor function, and ADL in patients with PSMD. BAA-related adverse events were rare, tolerable, and recoverable. However, our review findings should be interpreted with caution because of the methodological weaknesses in the included trials. High-quality trials are needed to assess the adjunctive role of BAA in patients with PSMD.

Effects of Task-Specific Training after Cognitive Sensorimotor Exercise on Proprioception, Spasticity, and Gait Speed in Stroke Patients: A Randomized Controlled Study

Background and objectives: Common problems in stroke patients include loss of proprioception, spasticity, and impaired gait. The purpose of this study was to examine the effects of task-specific training (TST) combined with cognitive sensorimotor exercise (CSE) on proprioception, spasticity and gait speed in stroke patients. Materials andMethods: Thirty-seven subjects were randomly divided into three groups; (1) the TST after CSE group (Experimental I, n = 13); (2) the TST group (Experimental II, n = 12), and (3) a conventional physical therapy training group (control group, n = 12). Evaluations were performed before the commencement of training and again eight weeks after training was initiated. An electrogoniometer was used to evaluate proprioception variation. The composite spasticity score (CSS) and MyotonePRO were used to evaluate spasticity. In addition, 10 m walk test was used to assess gait speed. Results: After training, the Experimental I group showed significant improvement in proprioception compared to the Experimental II and control group (p < 0.05). In CSS, gastrocnemius muscle tone (GMT) and gait speed among three groups, Experimental I group differed significantly after eight weeks of training compared to the control group (p < 0.05). Conclusions: These findings suggest that the TST combined with CSE provided significant improvements in proprioception, spasticity, and gait speed.

Development and Results of an Implementation Plan for High-Intensity Gait Training

BACKGROUND AND PURPOSE

High-intensity gait training is recommended in stroke rehabilitation to improve gait speed, walking distance, and balance. However, identifying effective and efficient implementation methods is a challenge for rehabilitation providers. This article describes the development of an implementation plan, presents findings of each implementation phase, and identifies the project's impact on clinicians and the health system.

METHODS

Two inpatient rehabilitation facilities, including 9 physical therapists, collaborated with a knowledge translation center to implement this program. We developed an implementation plan using the Knowledge-to-Action Framework and utilized the Consolidated Framework for Implementation Research to identify barriers and select implementation strategies. Using mix-methods research, including surveys and informal discussions, we evaluated current practice, barriers, outcomes, and the sustainability of high-intensity gait training in practice.

RESULTS

A multicomponent implementation plan that targeted barriers was developed. Before implementation, clinicians reported providing several balance, strength training, and gait interventions to improve walking. Barriers to using high-intensity gait training included knowledge, beliefs, adaptability of high-intensity gait training, resources, culture, and others. Twenty-six implementation strategies were selected to target the barriers. Surveys and informal discussions identified significant changes in perceived practice, adoption of high-intensity gait training, and positive impacts on the health system. The 2-year follow-up survey indicated that the new practice was sustained.

DISCUSSION AND CONCLUSIONS

Using a multicomponent implementation plan that targeted barriers, we successfully implemented high-intensity gait training in clinical practice. Contributors to successful implementation may include the implementation methods, usual care interventions, and clinicians' readiness for this change.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A352.).