Restoring Movement and Functional Ability after Stroke

Can body awareness training improve recovery following stroke: A study to assess feasibility and preliminary efficacy

BACKGROUND

Impairments in body awareness are common after stroke and are associated with decreased participation and performance in everyday activities.

OBJECTIVES

To explore the feasibility and safety of a body awareness program after stroke, and identify the preliminary efficacy of class-based lessons compared to home-based lessons on sensation, body awareness, motor impairment and quality of life.

METHODS

A two-armed pilot randomized controlled trial with a nested qualitative descriptive study was conducted. Individuals with a diagnosis of stroke (at least three months post injury) were randomized to either class-based face-to-face body awareness lessons or home-based individually performed body awareness lessons. Outcome measures were safety, feasibility, sensation, body awareness, motor impairment, self-efficacy and quality of life. Semi-structured interviews were used to allow greater exploration and understanding of participants' experience of the program.

RESULTS

Twenty participants were randomized, 16 participants completed the program. Feasibility was greater in the class-based group. No adverse events were detected. The class-based group led to improvement in body awareness (p = 0.002), quality of life (p = 0.002), and the arm (p = 0.025) and leg (p = 0.005) motor impairment scores. Qualitative data similarly indicated that the class-based group experienced a stronger sense of awareness, achievement and connection than the home-based group.

CONCLUSIONS

Body awareness training was safe, feasible and acceptable in people with stroke. Individuals in the class-based group showed greater benefit compared to those receiving home-based therapy.

Effects of Feldenkrais Awareness Through Movement on Balance in Adults With Chronic Neurological Deficits Following Stroke: A Preliminary Study

The Feldenkrais Method is a complementary approach to motor learning that purports to induce change in chronic motor behaviors. This preliminary study describes the effects of a Feldenkrais program on balance and quality of life in individuals with chronic neurological deficits following stroke. Two male (48 and 53 years old) and 2 female participants (61 and 62 years old), 1 to 2.5 years poststroke, participated as a group in a 6-week Feldenkrais program. Pretest and posttest evaluations of the Berg Balance Scale (BBS), the Dynamic Gait Index (DGI), and the Stroke Impact Scale (SIS) were administered. Data were analyzed using aWilcoxon signed-rank test. DGI and BBS scores improved an average of 55.2% (p=.033) and 11% (p=.034), respectively. SIS percentage recovery improved 35%. Findings suggest that gains in functional mobility are possible for individuals with chronic stroke using Feldenkrais movement therapy in a group setting.

Defining the content of individual physiotherapy and occupational therapy sessions for stroke patients in an inpatient rehabilitation setting. Development, validation and inter-rater reliability of a scoring list

Objective : To develop a valid and reliable scoring list to define the content of individual physiotherapy and occupational therapy sessions for stroke patients in inpatient rehabilitation.

Design : A list was developed based on previous lists, neurological textbooks and recorded therapy sessions. Content validity was verified and inter-rater reliability evaluated on videos of treatment sessions. In each of four rehabilitation centres, a researcher recorded and scored five physiotherapy and five occupational therapy sessions. These 40 treatment sessions were also scored by the first author. The scores of the researchers and first author were statistically compared.

Settings and subjects : Forty stroke patients in four European rehabilitation centres.

Results : The scoring list consists of 49 subcategories, divided into 12 categories: mobilization; selective movements; lying (balance); sitting (balance); standing (balance); sensory and visual perceptual training and cognition; transfers; ambulatory activities; personal activities of daily living; domestic activities of daily living; leisure- and work-related activities; and miscellaneous. Comparing the frequency of occurrence of the categories resulted in intraclass correlation coefficients, indicating high reliability for eight categories, good for one, and fair for two. One category was not observed. Spearman rank correlation coefficients were high to very high for 24 subcategories and moderate for four. Twenty-one subcategories contained too few observations to enable calculation of Spearman rank correlation coefficients. Average point-to-point percentage of agreement in time of the treatment sessions equalled 76.6 ± 16.2%.

Conclusions : The list is a valid and reliable tool for describing the content of physiotherapy and occupational therapy for stroke patients.

Study design and methods of the BoTULS trial: a randomised controlled trial to evaluate the clinical effect and cost effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A

BACKGROUND

Following a stroke, 55-75% of patients experience upper limb problems in the longer term. Upper limb spasticity may cause pain, deformity and reduced function, affecting mood and independence. Botulinum toxin is used increasingly to treat focal spasticity, but its impact on upper limb function after stroke is unclear.The aim of this study is to evaluate the clinical and cost effectiveness of botulinum toxin type A plus an upper limb therapy programme in the treatment of post stroke upper limb spasticity.

METHODS

TRIAL DESIGN

A multi-centre open label parallel group randomised controlled trial and economic evaluation.

PARTICIPANTS

Adults with upper limb spasticity at the shoulder, elbow, wrist or hand and reduced upper limb function due to stroke more than 1 month previously.

INTERVENTIONS

Botulinum toxin type A plus upper limb therapy (intervention group) or upper limb therapy alone (control group).

OUTCOMES

Outcome assessments are undertaken at 1, 3 and 12 months. The primary outcome is upper limb function one month after study entry measured by the Action Research Arm Test (ARAT). Secondary outcomes include: spasticity (Modified Ashworth Scale); grip strength; dexterity (Nine Hole Peg Test); disability (Barthel Activities of Daily Living Index); quality of life (Stroke Impact Scale, Euroqol EQ-5D) and attainment of patient-selected goals (Canadian Occupational Performance Measure). Health and social services resource use, adverse events, use of other antispasticity treatments and patient views on the treatment will be compared. PARTICIPANTS are clinically reassessed at 3, 6 and 9 months to determine the need for repeat botulinum toxin type A and/or therapy.Randomisation : A web based central independent randomisation service. Blinding: Outcome assessments are undertaken by an assessor who is blinded to the randomisation group.

SAMPLE SIZE

332 participants provide 80% power to detect a 15% difference in treatment successes between intervention and control groups. Treatment success is defined as improvement of 3 points for those with a baseline ARAT of 0-3 and 6 points for those with ARAT of 4-56.

TRIAL REGISTRATION

ISRCTN78533119 Eudra CT 2004-002427-40 CTA 17136/0230/001 FUNDING: National Institute for Health Research, Health Technology Assessment Programme. Ipsen Ltd provide botulinum toxin type A (Dysport(R)).

The effect of the GENTLE/s robot-mediated therapy system on arm function after stroke

OBJECTIVE

To evaluate the effect of robot-mediated therapy on arm dysfunction post stroke.

DESIGN

A series of single-case studies using a randomized multiple baseline design with ABC or ACB order. Subjects (n = 20) had a baseline length of 8, 9 or 10 data points. They continued measurement during the B - robot-mediated therapy and C - sling suspension phases.

SETTING

Physiotherapy department, teaching hospital.

SUBJECTS

Twenty subjects with varying degrees of motor and sensory deficit completed the study. Subjects attended three times a week, with each phase lasting three weeks.

INTERVENTIONS

In the robot-mediated therapy phase they practised three functional exercises with haptic and visual feedback from the system. In the sling suspension phase they practised three single-plane exercises. Each treatment phase was three weeks long.

MAIN MEASURES

The range of active shoulder flexion, the Fugl-Meyer motor assessment and the Motor Assessment Scale were measured at each visit.

RESULTS

Each subject had a varied response to the measurement and intervention phases. The rate of recovery was greater during the robot-mediated therapy phase than in the baseline phase for the majority of subjects. The rate of recovery during the robot-mediated therapy phase was also greater than that during the sling suspension phase for most subjects.

CONCLUSION

The positive treatment effect for both groups suggests that robot-mediated therapy can have a treatment effect greater than the same duration of non-functional exercises. Further studies investigating the optimal duration of treatment in the form of a randomized controlled trial are warranted.

Stroke Rehabilitation in Europe

Background and Purpose— Physiotherapy (PT) and occupational therapy (OT) are key components of stroke rehabilitation. Little is known about their content. This study aimed to define and compare the content of PT and OT for stroke patients between 4 European rehabilitation centers.

Methods— In each center, 15 individual PT and 15 OT sessions of patients fitting predetermined criteria were videotaped. The content was recorded using a list comprising 12 therapeutic categories. A generalized estimating equation model was fitted to the relative frequency of each category resulting in odds ratios.

Results— Comparison of PT and OT between centers revealed significant differences for only 2 of the 12 categories: ambulatory exercises and selective movements. Comparison of the 2 therapeutic disciplines on the pooled data of the 4 centers revealed that ambulatory exercises, transfers, exercises, and balance in standing and lying occurred significantly more often in PT sessions. Activities of daily living, domestic activities, leisure activities, and sensory, perceptual training, and cognition occurred significantly more often in OT sessions.

Conclusion— This study revealed that the content of each therapeutic discipline was consistent between the 4 centers. PT and OT proved to be distinct professions with clear demarcation of roles.

Development of a schedule of current physiotherapy treatment used to improve movement control and functional use of the lower limb after stroke: a precursor to a clinical trial

OBJECTIVE

To develop a treatment schedule of physical therapy techniques used to improve movement control and functional use of the paretic lower limb after stroke in U.K. clinical centers to be involved in a subsequent clinical trial of experimental interventions given in addition to routine clinical practice.

METHODS

Ten physiotherapists experienced in stroke rehabilitation who worked in or near the clinical centers to be involved in a subsequent clinical trial completed an individual semi-structured interview. The verbatim transcripts were condensed independently by 2 researchers into a draft list of interventions. The researchers then resolved disagreement through discussion and produced a preliminary list of interventions. At a focus group meeting, the participating physiotherapists discussed the preliminary list, refined it to produce a final list, and then transformed it into a draft treatment schedule. The draft treatment schedule was piloted in clinical practice. Refinements were made, and the final treatment schedule was produced.

RESULTS

The treatment schedule consists of an A4 recording form with instructions and glossary of terms printed on the back. Each treatment record provides information including duration of treatment, treatment aims, and the 45 specific physical therapy interventions provided in the 11 sections (e.g., "splinting techniques" and "function - in sitting towards standing").

CONCLUSION

A treatment schedule was produced, which can now be used in a subsequent phase II evaluative trial.

Defining the Bobath concept using the Delphi technique

BACKGROUND AND PURPOSE

The Bobath concept, based on the work of Berta and Karel Bobath, offers therapists working in the field of neurological rehabilitation a framework for their clinical interventions. It is the most commonly used approach in the UK. Although they recognize that over the last half-century the concept has undergone considerable developments, proponents of the Bobath concept have been criticized for not publishing these changes. The aim of the present study was to use the Delphi technique to enable experts in the field to define the current Bobath concept.

METHOD

A four-round Delphi study design was used. The sample included all members of the British Bobath Tutor's Association, who are considered experts in the field. Initial statements were identified from the literature, with respondents generating additional statements during the study. The level of agreement was determined using a five-point Likert scale. The respondents were then provided with feedback on group opinions and given an opportunity to re-rate each statement. The level of group consensus was set at 80%.

RESULTS

Fifteen experts took part. The response rate was 85% in the first round, and 93% in each subsequent round. Ten statements from the literature were rated with a further 12 generated by the experts. Thirteen statements achieved consensus for agreement and seven for disagreement.

CONCLUSIONS

The Delphi study was an effective research tool, maintaining anonymity of responses and exploring expert opinions on the Bobath concept. The experts stated that Bobath's work has been misunderstood if it is considered as the inhibition of spasticity and the facilitation of normal movement, as described in some literature. They agreed that the Bobath concept was developed by the Bobaths as a living concept, understanding that as therapists' knowledge base grows their view of treatment broadens.

Rehabilitation interventions for vegetative and minimally conscious patients

Brain injury rehabilitation is a complex and challenging task for all members of the multidisciplinary team. Medical advances have allowed more severely impaired patients to survive and consequently the number of patients in the vegetative and minimally conscious states have proportionately increased. Thus, the need for evidence-based practice and further research demonstrating the effects of specific rehabilitation interventions is required. This article reviews the current research and consensus on rehabilitation for patients in the vegetative and minimally conscious states.