Neuromusculoskeletal Physiotherapy: Encouraging Self-management

Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE): a randomized controlled trial protocol

BACKGROUND

Residual disability after stroke is substantial; 65% of patients at 6 months are unable to incorporate the impaired upper extremity into daily activities. Task-oriented training programs are rapidly being adopted into clinical practice. In the absence of any consensus on the essential elements or dose of task-specific training, an urgent need exists for a well-designed trial to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke Initiative is a parallel group, three-arm, single blind, superiority randomized controlled trial of a theoretically-defensible, upper extremity rehabilitation program provided in the outpatient setting.The primary objective of ICARE is to determine if there is a greater improvement in arm and hand recovery one year after randomization in participants receiving a structured training program termed Accelerated Skill Acquisition Program (ASAP), compared to participants receiving usual and customary therapy of an equivalent dose (DEUCC). Two secondary objectives are to compare ASAP to a true (active monitoring only) usual and customary (UCC) therapy group and to compare DEUCC and UCC.

METHODS/DESIGN

Following baseline assessment, participants are randomized by site, stratified for stroke duration and motor severity. 360 adults will be randomized, 14 to 106 days following ischemic or hemorrhagic stroke onset, with mild to moderate upper extremity impairment, recruited at sites in Atlanta, Los Angeles and Washington, D.C. The Wolf Motor Function Test (WMFT) time score is the primary outcome at 1 year post-randomization. The Stroke Impact Scale (SIS) hand domain is a secondary outcome measure.The design includes concealed allocation during recruitment, screening and baseline, blinded outcome assessment and intention to treat analyses. Our primary hypothesis is that the improvement in log-transformed WMFT time will be greater for the ASAP than the DEUCC group. This pre-planned hypothesis will be tested at a significance level of 0.05.

DISCUSSION

ICARE will test whether ASAP is superior to the same number of hours of usual therapy. Pre-specified secondary analyses will test whether 30 hours of usual therapy is superior to current usual and customary therapy not controlled for dose.

TRIAL REGISTRATION

www.ClinicalTrials.gov Identifier: NCT00871715

A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: a pilot study of immediate and long-term outcomes

OBJECTIVE

To evaluate the immediate and long-term effects of 2 upper-extremity rehabilitation approaches for stroke compared with standard care in participants stratified by stroke severity.

DESIGN

Nonblinded, randomized controlled trial (baseline, postintervention, 9mo) design.

SETTING

Inpatient rehabilitation hospital and outpatient clinic.

PARTICIPANTS

Sixty-four patients with recent stroke admitted for inpatient rehabilitation were randomized within severity strata (Orpington Prognostic Scale) into 1 of 3 intervention groups. Forty-four patients completed the 9-month follow-up.

INTERVENTIONS

Standard care (SC), functional task practice (FT), and strength training (ST). The FT and ST groups received 20 additional hours of upper-extremity therapy beyond standard care distributed over a 4- to 6-week period.

MAIN OUTCOME MEASURES

Performance measures of impairment (Fugl-Meyer Assessment), strength (isometric torque), and function (Functional Test of the Hemiparetic Upper Extremity [FTHUE]).

RESULTS

Compared with SC participants, those in the FT and ST groups had significantly greater increases in Fugl-Meyer motor scores (P=.04) and isometric torque (P=.02) posttreatment. Treatment benefit was primarily in the less severe participants, where improvement in FT and ST group Fugl-Meyer motor scores more than doubled that of the SC group. Similar results were found for the FTHEU and isometric torque. During the long term, at 9 months, the less severe FT group continued to make gains in isometric muscle torque, significantly exceeding those of the ST group (P<.05).

CONCLUSIONS

Task specificity and stroke severity are important factors for rehabilitation of arm use in acute stroke. Twenty hours of upper extremity-specific therapy over 4 to 6 weeks significantly affected functional outcomes. The immediate benefits of a functional task approach were similar to those of a resistance-strength approach, however, the former was more beneficial in the long-term.

Nurses' perceptions of physiotherapists as rehabilitation team members

OBJECTIVE

To investigate nurses' perceptions of physiotherapists as members of the rehabilitation team. This study arose from the current emphasis that is placed on good multidisciplinary teamwork for effective rehabilitation and the awareness that different team members often have different perceptions of their respective roles within the team.

DESIGN

Semi-structured interviews, the results of which were then subject to content analysis.

SETTING AND SUBJECTS

Experienced rehabilitation nurses in two rehabilitation wards within a National Health Service Trust.

RESULTS

Nurses perceived the role of physiotherapists as being concerned with mobility and movement, and valued the therapists' knowledge and skills in these areas. They felt, however, that physiotherapists had insufficient understanding of the demands and pressures of nursing practice and lacked recognition of the nurses' professional autonomy in decision-making in rehabilitation. Nurses viewed nursing and physiotherapy as two quite distinct and different roles within rehabilitation, despite some role overlap. Physiotherapy was perceived as specific and measurable, while nursing was perceived as generalized and undefined. These perceptions extended to their views on patient-staff interactions and organizational structures. Some of the differences, such as organizational structures, created barriers to rehabilitation. Others, such as physiotherapy expertise in mobility, were valued for their contribution to rehabilitation. Areas were identified where the two professions can assist each other in professional skills.

CONCLUSION

Nurses valued the role and contribution of physiotherapists, but identified areas in which barriers existed to effective interprofessional working, particularly in relation to organizational factors and interprofessional relationships.