Clinicians’ and patients’ impressions of change in motor performance as potential outcome measures for clinical trials

Two weeks of intensive sit-to-stand training in addition to usual care improves sit-to-stand ability in people who are unable to stand up independently after stroke: a randomised trial

QUESTION

Does intensive sit-to-stand training in addition to usual care improve sit-to-stand ability in people who are unable to stand up independently after stroke?

DESIGN

A multi-centre randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Thirty patients from two Sydney hospitals, < 3 months after stroke, with a mean Modified Rankin Scale score of 4 points (SD 0.5).

INTERVENTION

All participants received usual care. Participants in the experimental group attended two additional sessions of physiotherapy per day for 2 weeks. These sessions were individualised to the needs of each participant in order to increase the amount and intensity of sit-to-stand training.

OUTCOME MEASURES

Outcome measures were taken at baseline and at 2 weeks. The primary outcome was clinicians' impressions of sit-to-stand change, measured using videos and a 15-point Global Impressions of Change Scale. Secondary outcomes were sit-to-stand ability, composite strength of key muscles of the affected lower limb, gross lower limb extension strength, the Goal Attainment Scale, and ranking of change in ability to move from sitting to standing.

RESULTS

All participants completed the trial. The mean between-group difference for clinicians' impressions of sit-to-stand change was 1.57/15 points (95% CI 0.02 to 3.11). The secondary outcomes that indicated a treatment effect were gross lower limb extension strength and ranking of change in ability to move from sitting to standing, with mean between-group differences of 6.2 deg (95% CI 0.5 to 11.8) and -7 (95% CI -1 to -13), respectively.

CONCLUSION

Two weeks of intensive sit-to-stand training in addition to usual care improves sit-to-stand ability in people who are unable to stand up independently after stroke.

TRIAL REGISTRATION

ANZCTR 12616001288415.

Comparison of Responsiveness and Minimal Clinically Important Difference of the Capabilities of Upper Extremity Test (CUE-T) and the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP)

Background: The Capabilities of Upper Extremity Test (CUE-T) and the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) were both developed to detect change in upper extremity (UE) function in persons with tetraplegia. Objective: To compare the responsiveness and minimal clinically important difference (MCID) of the CUE-T and the quantitative prehension (QtP) scale of the GRASSP. Methods: Subjects included 69 persons with tetraplegia: 60 with acute and 9 with chronic injuries. Subjects were assessed twice 3 months apart using the CUE-T, QtP-GRASSP, and upper extremity motor scores (UEMS). Subjects rated their impression of change in overall and right/left UE function from -7 to +7. The standardized response mean (SRM) was determined for acute subjects. MCID was estimated using a small subjective change (2-3 points) and change in UEMS. Results: Subjects were 41.9 ± 18.1 years old, neurological levels C1-C7; 25 were motor complete. For acute subjects, the SRMs for total/side CUE-T scores were 1.07/0.96, and for the QtP-GRASSP they were 0.88/0.78. MCIDs based on subjective change for total/side CUE-T scores were 11.7/6.1 points and for QtP-GRASSP were 6.4/3.0 points. Based on change in UEMS, MCIDs for total/side were 11.9/6.3 points for CUE-T and 6.0/3.3 points for QtP-GRASSP. Some subjects had changes in the CUE-T due to its arm items that were not seen with the QtP-GRASSP. Conclusion: Both the CUE-T and QtP-GRASSP are responsive to change in persons with acute cervical spinal cord injury with large SRMs. The CUE-T detects some changes in UE function not seen with the QtP-GRASSP.

Using the unbiased perspectives of people living with a spinal cord injury in assessments of mobility

STUDY DESIGN

Clinometrics study.

OBJECTIVE

To devise a way of capturing the unbiased perspectives of people living with a spinal cord injury (SCI) in assessments of mobility.

SETTING

SCI unit and community.

METHODS

Three groups of raters used the Global Impression of Change Scale (GICS) to rate change in mobility of a cohort of patients with a recent SCI. The three groups of raters were as follows: 10 people with a recent SCI, 10 people with an established SCI and 10 physiotherapists. The ratings were done after viewing 51 pairs of videos depicting one of three motor tasks: sitting unsupported, transferring and walking. Each pair of videos showed the same person performing the same motor task on two occasions. The videos were taken between 1 h and 5 months apart and presented side by side, randomly left or right, on the screen. Raters were asked to score the amount of change in performance between the two videos on a 7-point Global Impression of Change Scale (GICS). Intra-rater reliability for the three motor tasks and three groups of raters was determined using intra-class correlation coefficients.

RESULTS

People with an SCI were reliable at rating change in patients' abilities to transfer and walk with ICC's ranging from 0.66 to 0.81 (95% Confidence interval bounds ranging from 0.51 to 0.94). Physiotherapists were consistently but only marginally more reliable at rating than people with an SCI.

CONCLUSIONS

Videos and the GICS may provide a way of using the unbiased perspectives of people living with spinal cord injury in assessments of mobility.

Consumer preference in ranking walking function utilizing the walking index for spinal cord injury II

STUDY DESIGN

Blinded rank ordering.

OBJECTIVE

To determine consumer preference in walking function utilizing the walking Index for spinal cord injury II (WISCI II) in individuals with spinal cord injury (SCI)from the Canada, the Italy and the United States of America.

METHOD

In all, 42 consumers with incomplete SCI (25 cervical, 12 thoracic, 5 lumbar) from Canada (12/42), Italy (14/42) and the United States of America (16/42) ranked the 20 levels of the WISCI II scale by their individual preference for walking. Subjects were blinded to the original ranking of the WISCI II scale by clinical scientists. Photographs of each WISCI II level used in a previous pilot study were randomly shuffled and rank ordered. Percentile, conjoint/cluster and graphic analyses were performed.

RESULTS

All three analyses illustrated consumer ranking followed a bimodal distribution. Ranking for two levels with physical assistance and two levels with a walker were bimodal with a difference of five to six ranks between consumer subgroups (quartile analysis). The larger cluster (N=20) showed preference for walking with assistance over the smaller cluster (N=12), whose preference was walking without assistance and more devices. In all, 64% (27/42) of consumers ranked WISCI II level with no devices or braces and 1 person assistance higher than multiple levels of the WISCI II requiring no assistance. These results were unexpected, as the hypothesis was that consumers would rank independent walking higher than walking with assistance.

CONCLUSION

Consumer preference for walking function should be considered in addition to objective measures in designing SCI trials that use significant improvement in walking function as an outcome measure.

Training unsupported sitting does not improve ability to sit in people with recently acquired paraplegia: a randomised trial

QUESTION

Do people with recently acquired paraplegia benefit from a six-week motor retraining program aimed at improving their ability to sit unsupported?

DESIGN

A randomised controlled trial with concealed allocation, assessor blinding, and intention-totreat analysis.

PARTICIPANTS

32 people with recently acquired paraplegia and limited ability to sit unsupported.

INTERVENTION

All participants undertook standard inpatient rehabilitation over a six-week period. Experimental participants received three additional 30-minute sessions per week of motor retraining directed at improving their ability to sit unsupported.

OUTCOME MEASURES

The three primary outcomes were the Maximal Lean Test, Maximal Sideward Reach Test, and the Performance Item of the Canadian Occupational Performance Measure (COPM). The secondary outcomes were the Satisfaction Item of the COPM, Participants' Impressions of Change, Clinicians' Impressions of Change, the T-shirt Test, and the Spinal Cord Injury Falls Concern Scale.

RESULTS

The mean between-group differences for the Maximal Lean Test, Maximal Sideward Reach Test and the Performance Item of the COPM were -20 mm (95% CI -64 to 24), 5% arm length (95% CI -3 to 13) and 0.5 points (95% CI -0.5 to 1.5), respectively. The secondary outcomes did not differ significantly between groups.

CONCLUSION

People with recently acquired paraplegia do not benefit from a six-week motor retraining program directed specifically at improving their ability to sit unsupported. Their ability to sit unsupported does, however, improve over time, suggesting that the practice of activities of daily living has important carry-over effects on unsupported sitting, rendering additional training redundant.

TRIAL REGISTRATION

ACTRN12608000464369.