The Bobath concept in stroke rehabilitation: a focus group study of the experienced physiotherapists' perspective

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.

MHealth devices demonstrate validity and reliability in detecting steps in chronic stroke survivors who rely on assistive devices

PURPOSE

To assess the concurrent validity and reliability of five mHealth devices (STEPZ, Health, Pacer, Google Fit, and Fitbit Inc.®) in counting steps among individuals with chronic stroke using assistive devices (AD). Our primary objective was to identify significant variations in step counts between AD users and non-users.

METHODS

In a cross-sectional study, individuals performed a 2-min walking test while carrying two smartphones (Android OS and iOS) equipped with four different applications (STEPZ, Health, Pacer, and Google Fit), alongside a Fitbit Inc.® device. A visual video recording served as criterion-standard measure for step counting. Each participant completed four walking trials. Two proficient researchers conducted data collection in a controlled environment at a single day.

RESULTS

Twenty-four individuals were included. The devices were valid for individuals in individuals with chronic stroke who used AD (0.52 ≤ r ≥ 0.89), except for Health (iOS). There is no agreement between the criterion-standard and Health (iOS), and all other devices showed adequate reliability (0.107 ≤ CCI [2, 1] ≥ 0.701). There was no difference in stepping counting when the individuals used or not the AD.

CONCLUSIONS

Health for iOS is neither valid nor reliable for individuals with chronic stroke who are AD users. There is no difference in step counting were when the individuals with chronic stroke are users or non-users of AD.

Sensory training combined with motor training improves trunk proprioception in stroke patients: a single-blinded randomized controlled trial

OBJECTIVES

Inadequate trunk function is the underlying cause of many problems such as impaired balance and mobility. Although there have been trunk-based physiotherapy approaches in recent years, almost all of these approaches focus on motor problems. This study aims to investigate the effects of sensory training combined with trunk-centered Bobath exercises on trunk control and proprioception, balance, gait, and the activity of daily living (ADL).

MATERIALS AND METHODS

This study is a randomized controlled trial included with twenty-seven stroke patients. Participants were separated into two groups, Group 1; 'sensory training combined with trunk-centered Bobath exercises' and Group 2; 'trunk-centered Bobath exercises'. Trunk-centered Bobath exercises were used for motor training. Sensory training included transcutaneous electric nerve stimulation and a set of exercises that provide tactile and proprioceptive stimulation. Trunk Impairment Scale, Trunk Reposition Error, Berg Balance Scale, 2-minute walk test, and Barthel Index were used to assess trunk control, trunk proprioception, balance, gait, and ADL respectively.

RESULTS

Intra-group analysis results showed that trunk control, trunk proprioception, balance, gait, and ADL improved in both groups after treatment (p < 0.05). The changes in the Trunk Reposition Error values of the participants in Group 1 before and after treatment was found to be significantly higher than Group 2 (p < 0.05).

CONCLUSIONS

The findings indicated that the application of trunk-centered motor training is effective in improving trunk proprioception and trunk control, balance, gait, and ADL in stroke patients. Also, sensory training combined with trunk-centered motor training was found more effective in improving trunk proprioception than solely motor training.

Effect of rTMS intervention on upper limb motor function after stroke: A study based on fNIRS

Background

Stroke is a disease with a high fatality rate worldwide and a major cause of long-term disability. In the rehabilitation of limb motor function after stroke, the rehabilitation of upper limb function takes a long time and the recovery progress is slow, which seriously affects the patients' self-care ability in daily life. Repeated transcranial magnetic stimulation (rTMS) has been increasingly used to improve limb dysfunction in patients with stroke. However, a standardized reference for selecting a magnetic stimulation regimen is not available. Whether to increase the inhibition of the contralateral hemispheric motor cortex remains controversial. This study has evaluated the effects of different rTMS stimulation programs on upper limb function and corresponding brain functional network characteristics of patients with stroke and sought a new objective standard based on changes in brain network parameters to guide accurate rTMS stimulation programs.

Method

Thirty-six patients with stroke were selected and divided into control group and treatment group by number table method, with 18 patients in each group, and 3 patients in the control group were turned out and lost due to changes in disease condition. The treatment group was divided into two groups. TMS1 group was given 1 Hz magnetic stimulation in the M1 region of the contralesional hemisphere +10 Hz magnetic stimulation in the M1 region of the affected hemisphere, and the TMS2 group was given 10 Hz magnetic stimulation in the M1 region of the affected hemisphere. The control group was given false stimulation. The treatment course was once a day for 5 days a week for 4 weeks. The Fugl-Meyer Assessment for upper extremity (FMA-UE) sand near-infrared brain function were collected before treatment, 2 weeks after treatment, and 4 weeks after treatment, and the brain function network was constructed. Changes in brain oxygenated hemoglobin concentration and brain network parameters were analyzed with the recovery of motor function (i.e., increased FMA score). Meanwhile, according to the average increment of brain network parameters, the rTMS stimulation group was divided into two groups with good efficacy and poor efficacy. Network parameters of the two groups before and after rTMS treatment were analyzed statistically.

Results

(1) Before treatment, there was no statistical difference in Fugl-Meyer score between the control group and the magnetic stimulation group (p = 0.178).Compared with before treatment, Fugl-Meyer scores of 2 and 4 weeks after treatment were significantly increased in both groups (p <0.001), and FMA scores of 4 weeks after treatment were significantly improved compared with 2 weeks after treatment (p < 0.001). FMA scores increased faster in the magnetic stimulation group at 2 and 4 weeks compared with the control group at the same time point (p <0.001).TMS1 and TMS2 were compared at the same time point, FMA score in TMS2 group increased more significantly after 4 weeks of treatment (p = 0.010). (2) Before treatment, HbO2 content in healthy sensory motor cortex (SMC) area of magnetic stimulation group and control group was higher than that in other region of interest (ROI) area, but there was no significant difference in ROI between the two groups. After 4 weeks of treatment, the HbO2 content in the healthy SMC area was significantly decreased (p < 0.001), while the HbO2 content in the affected SMC area was significantly increased, and the change was more significant in the magnetic stimulation group (p < 0.001). (3) In-depth study found that with the recovery of motor function (FMA upper limb score increase ≥4 points) after magnetic stimulation intervention, brain network parameters were significantly improved. The mean increment of network parameters in TMS1 group and TMS2 group was significantly different (χ ² = 5.844, p = 0.016). TMS2 group was more advantageous than TMS1 group in improving the mean increment of brain network parameters.

Conclusion

(1) The rTMS treatment is beneficial to the recovery of upper limb motor function in stroke patients, and can significantly improve the intensity of brain network connection and reduce the island area. The island area refers to an isolated activated brain area that cannot transmit excitation to other related brain areas. (2) When the node degree of M1_Healthy region less than 0.52, it is suggested to perform promotion therapy only in the affected hemisphere. While the node degree greater than 0.52, and much larger than that in the M1_affected region. it is suggested that both inhibition in the contralesional hemisphere and high-frequency excitatory magnetic stimulation in the affected hemisphere can be performed. (3) In different brain functional network connection states, corresponding adjustment should be made to the treatment plan of rTMS to achieve optimal therapeutic effect and precise rehabilitation treatment.

Influence of the Passive Stabilization of the Trunk and Upper Limb on Selected Parameters of the Hand Motor Coordination, Grip Strength and Muscle Tension, in Post-Stroke Patients

Objective: Assessment of the influence of a stable trunk and the affected upper limb (dominant or non-dominant) on the parameters of the wrist and hand motor coordination, grip strength and muscle tension in patients in the subacute post-stroke stage compared to healthy subjects. Design: An observational study. Setting: Stroke Rehabilitation Department. Subjects: Thirty-four subjects after ischemic cerebral stroke and control group-32 subjects without neurological deficits, age and body mass/ height matched were included. Main measures: The tone of the multifidus, transverse abdominal and supraspinatus muscles were assessed by Luna EMG device. A HandTutor device were used to measure motor coordination parameters (e.g., range of movement, frequency of movement), and a manual dynamometer for measuring the strength of a hand grip. Subjects were examined in two positions: sitting without back support (non-stabilized) and lying with stabilization of the trunk and the upper limb. Results: Passive stabilization of the trunk and the upper extremity caused a significant improvement in motor coordination of the fingers (p ˂ 0.001) and the wrist (p < 0.001) in patients after stroke. Improved motor coordination of the upper extremity was associated with an increased tone of the supraspinatus muscle. Conclusions: Passive stabilization of the trunk and the upper limb improved the hand and wrist coordination in patients following a stroke. Placing patients in a supine position with the stability of the affected upper limb during rehabilitation exercises may help them to access latent movement patterns lost due to neurological impairment after a stroke.

Effects of Inspiratory Muscle Training on Respiratory Muscle Strength, Trunk Control, Balance and Functional Capacity in Stroke Patients: A single-blinded randomized controlled study

Objective: Aim of the study was to examine the effects of inspiratory muscle training (IMT) on respiratory function, respiratory muscle strength, trunk control, balance, and functional capacity in stroke patients.Methods: 21 stroke individuals were randomly divided into two groups as control group and treatment group. Respiratory function test, Maximal Inspiratory Pressure (MIP) and Maximal Expiratory Pressure (MEP) were evaluated. Also, Trunk Impairment Scale (TIS), Timed Up and Go Test (TUG) Berg Balance Scale (BBS), and Six-Minute Walk Test (6MWT) were performed. Neurodevelopmental treatment program was performed in both groups for 5 days a week for 6 weeks, and IMT was given to the treatment group. IMT was started from 40% of MIP.Results: After treatment, respiratory functions, respiratory muscle strength, and trunk control and balance improved in the treatment group. In the control group; however, only the balance level was improved. When the changes in the evaluation parameters between the groups were compared, there were only statistically significant differences in the TIS, Peak Expiratory Flow (PEF) and MIP in the treatment group (p˂0.05), the change amounts in other evaluation parameters were similar (p˃0.05). When the effect size of the groups was compared, the effect size of the variables in the treatment group was found to be higher.Conclusions: As a conclusion, IMT, which was given in addition to the neurological physiotherapy and rehabilitation program to our patients, improved inspiratory muscle strength and trunk control. We believe that this result will raise awareness for physiotherapists working in the field of neurological rehabilitation about including respiratory muscle training in the rehabilitation program of stroke patients.

Impact of virtual reality game therapy and task-specific neurodevelopmental treatment on motor recovery in survivors of stroke

Background/Aims

This study aimed to compare the impact of virtual reality game therapy and task-specific neurodevelopmental training on the motor recovery of upper limb and trunk control, as well as physical function, in people who have had a stroke.

Methods

This randomised, assessor-blinded clinical trial was conducted with 34 patients with post-stroke duration of 135 ± 23 days. Patients with first-onset cortical stroke aged 40–60 years, Mini-Mental State Examination score >20, ability to complete a nine-hole peg test within 120 seconds, ability to lift the affected arm at shoulder level and independent standing were included. Patients were excluded if they had unilateral neglect and musculoskeletal injuries of the affected limb in the past 2 months. Outcome measures used were the Fugl-Meyer Upper Extremity Scale, Action Research Arm Test, Trunk Impairment Scale and Stroke Impact Scale-16. The virtual reality game therapy group performed interactive table tennis, boxing and discus throwing games. The neurodevelopmental treatment group underwent task-specific movements of the upper limb in sitting and standing. All patients performed 45 minutes of treatment, 5 days a week for 4 weeks.

Results

Both groups showed improvements in all measures after training (P<0.05). There was a between-group difference of 3.47 points in Fugl-Meyer Upper Extremity Scale in favour of the virtual reality game therapy.

Conclusions

Both treatment regimens resulted in equal improvements in hand dexterity and trunk control after stroke. Virtual reality game therapy improved the upper limb motor recovery of stroke survivors to a greater extent than neurodevelopmental treatment.

Dose-Response Effect of Daily Rehabilitation Time on Functional Gain in Stroke Patients

OBJECTIVE

To demonstrate the effect of daily treatment time on recovery of functional outcomes and how each type of rehabilitation treatment influences the improvement of subgroups of functional outcomes in stroke patients.

METHODS

We conducted a retrospective study in 168 patients who were admitted to the Department of Rehabilitation Medicine between 2015 and 2016. Patients who experienced their first-ever stroke and unilateral lesions were included. All patients underwent conventional rehabilitation treatment, and each treatment was administered one to two times a day depending on individual and treatment room schedules. Based on the mean daily treatment time, patients were divided into two groups: a high-amount group (n=54) and low-amount group (n=114). Outcomes were measured through the Korean version of Modified Barthel Index (MBI), FuglMeyer Assessment of the upper extremity, Trunk Impairment Scale (TIS), and Berg Balance Scale (BBS) scores on admission and at discharge.

RESULTS

The functional change and scores at discharge of MBI, TIS, and BBS were greater in the high-amount group than in the low-amount group. Among various types of rehabilitation treatments, occupational therapy training showed significant correlation with MBI, TIS, and BBS gain from admission to discharge.

CONCLUSION

The amount of daily mean treatment in post-stroke patients plays an important role in recovery. Mean daily rehabilitation treatment time seems to correlate with improved balance and basic activities of daily living after stroke.

Physical therapist's clinical reasoning in patients with gait impairments from hemiplegia

Background: During stroke rehabilitation, physical therapists (PTs) perform gait analysis and design treatments based on this analysis. Objectives: To investigate the current trends in PTs clinical reasoning in assessing and managing gait in persons with hemiplegia. Design: A qualitative study using a phenomenological approach using a semi-structured interview protocol with FG. Methods: Participants consisted of expert and novice PTs working in a neurologic rehabilitation setting. FG were conducted in person and via web. Constant comparative qualitative analysis was used to analyze the qualitative data. Results: A total of 22 PTs participated in five FG (2 novice and 3 expert groups). From the analysis of qualitative data, five themes emerged. Novice and experienced clinicians: 1) take a systematic approach to examination and evaluation of persons with hemiplegia; 2) are in agreement in common gait deficits found in persons with hemiplegia; 3) may differ in their approach to treatment based on the amount of experience of the clinician; 4) generally agree on the manner in which orthotics are used in the management of persons with hemiplegia; and 5) demonstrate professional accountability to patients concerning the use of orthotic devices. Conclusions: This qualitative study provided insight into the variability in PTs' strategies for gait analysis, and their identification and interpretation of common deviations and impairments in persons with hemiplegia following stroke. Reluctance to utilize orthotics for patients with hemiplegia was a consistent theme across FG.

Modified Approach to Stroke Rehabilitation (MAStR): feasibility study of a method to apply procedural memory concepts to transfer training

OBJECTIVE

Training and implementation for a multidisciplinary stroke rehabilitation method emphasizing procedural memory.

BACKGROUND

Current practice in stroke rehabilitation relies on explicit memory, often compromised by stroke, failing to capitalize on better-preserved procedural memory skills. Recruitment of procedural memory requires consistency and practice, characteristics difficulty to promote on inpatient rehabilitation units. We designed a method Modified Approach to Stroke Rehabilitation (MAStR) to maximize consistency and practice for transfer training with stroke patients.

DESIGN

Phase I, single-group study. MAStR has two innovations: (1) simplification of instructions to only three words, other direction provided non-verbally; (2) having all rehabilitation staff apply the same approach for transfers. Staff training in MAStR included review of written material describing the rationale for MAStR and demonstration of a transfer using MAStR. Enrolled patients completed each transfer with MAStR in addition to standard rehabilitation therapy.

RESULTS

The MAStR method was taught to a large, multidisciplinary rehabilitation staff (n = 31). Training and certification required 15 min per staff member. Five stroke patients were enrolled. No transfers with MAStR resulted in injury, no negative feedback was received from staff or patients. Staff reported satisfaction with the brief MAStR training and reported transfers were easier to complete with the MAStR method.

CONCLUSIONS

Feasibility was demonstrated for an innovative application of procedural memory concepts to stroke rehabilitation. All rehabilitation disciplines were successfully trained. MAStR was well-tolerated and liked by rehabilitation staff and patients. These results support pursuit of a Phase II pilot study.

Implementation of motor learning principles in physical therapy practice: Survey of physical therapists' perceptions and reported implementation

INTRODUCTION

The field of motor learning (ML) plays a pivotal role in physical therapy (PT), and its implementation has been shown to improve intervention outcomes. The objective of this study was to assess physical therapists' ML-related self-efficacy, self-reported implementation, and environmental workplace factors. An additional aim was to report the psychometric properties of a questionnaire that was developed to assess the above-mentioned constructs.

METHODS

An observational, cross-sectional survey was completed by 289 physical therapists (average age: 38.7 (9.7), with 11.3 (9.7) years of experience and 74% female). Construct validity, internal consistency, and test-retest reliability were tested. The main outcome measures were the scores of the three scales of the questionnaire, referring to self-efficacy in ML, implementation of ML principles, and workplace environment features.

RESULTS

The questionnaire had sound psychometric qualities. Respondents perceived ML as an integral part of PT. ML-related self-efficacy and implementation of ML principles were moderate (2.95/5 (0.7) and 3.04/5(0.8), respectively). PT practice had a significant effect on ML-related self-efficacy (p = 0.035) and implementation (p = 0.0031). Respondents who had undergone ML training in their graduate program reported higher ML-related self-efficacy (p = 0.007). Respondents who had postgraduate training in ML reported significantly more extensive implementation (p = 0.024). Lack of knowledge and lack of time were perceived as the major barriers to implementation.

CONCLUSIONS

Level of self-efficacy might be insufficient to support the systematic implementation of ML principles in practice. Addressing impeding individual- and organizational-level factors might facilitate ML self-efficacy and implementation. Postgraduate education facilitates ML implementation.

Home-based hand rehabilitation with a robotic glove in hemiplegic patients after stroke: a pilot feasibility study

OBJECTIVE

To evaluate the feasibility and safety of home rehabilitation of the hand using a robotic glove, and, in addition, its effectiveness, in hemiplegic patients after stroke.

METHODS

In this non-randomized pilot study, 21 hemiplegic stroke patients (Ashworth spasticity index ≤ 3) were prescribed, after in-hospital rehabilitation, a 2-month home-program of intensive hand training using the Gloreha Lite glove that provides computer-controlled passive mobilization of the fingers. Feasibility was measured by: number of patients who completed the home-program, minutes of exercise and number of sessions/patient performed. Safety was assessed by: hand pain with a visual analog scale (VAS), Ashworth spasticity index for finger flexors, opponents of the thumb and wrist flexors, and hand edema (circumference of forearm, wrist and fingers), measured at start (T0) and end (T1) of rehabilitation. Hand motor function (Motricity Index, MI), fine manual dexterity (Nine Hole Peg Test, NHPT) and strength (Grip test) were also measured at T0 and T1.

RESULTS

Patients performed, over a mean period 56 (49-63) days, a total of 1699 (1353-2045) min/patient of exercise with Gloreha Lite, 5.1 (4.3-5.8) days/week. Seventeen patients (81%) completed the full program. The mean VAS score of hand pain, Ashworth spasticity index and hand edema did not change significantly at T1 compared to T0. The MI, NHPT and Grip test improved significantly (p = 0.0020, 0.0156 and 0.0024, respectively) compared to baseline.

CONCLUSION

Gloreha Lite is feasible and safe for use in home rehabilitation. The efficacy data show a therapeutic effect which need to be confirmed by a randomized controlled study.

Examining impairment of adaptive compensation for stabilizing motor repetitions in stroke survivors

The hand, one of the most versatile but mechanically redundant parts of the human body, suffers more and longer than other body parts after stroke. One of the rehabilitation paradigms, task-oriented rehabilitation, encourages motor repeatability, the ability to produce similar motor performance over repetitions through compensatory strategies while taking advantage of the motor system's redundancy. The previous studies showed that stroke survivors inconsistently performed a given motor task with limited motor solutions. We hypothesized that stroke survivors would exhibit deficits in motor repeatability and adaptive compensation compared to healthy controls in during repetitive force-pulse (RFP) production tasks using multiple fingers. Seventeen hemiparetic stroke survivors and seven healthy controls were asked to repeatedly press force sensors as fast as possible using the four fingers of each hand. The hierarchical variability decomposition model was employed to compute motor repeatability and adaptive compensation across finger-force impulses, respectively. Stroke survivors showed decreased repeatability and adaptive compensation of force impulses between individual fingers as compared to the control (p < 0.05). The stroke survivors also showed decreased pulse frequency and greater peak-to-peak time variance than the control (p < 0.05). Force-related variables, such as mean peak force and peak force interval variability, demonstrated no significant difference between groups. Our findings indicate that stroke-induced brain injury negatively affects their ability to exploit their redundant or abundant motor system in an RFP task.

Effects of Home-based Telesupervising Rehabilitation on Physical Function for Stroke Survivors with Hemiplegia: A Randomized Controlled Trial

OBJECTIVE

The aims of this work were to evaluate the effects of home-based telesupervising rehabilitation on physical function for stroke survivors with hemiplegia and to determine if the rehabilitation therapy can relieve the burden on caregivers.

DESIGN

This study is a randomized, controlled, assessor-blinded trial. Stroke survivors were randomly assigned to either home-based telesupervising rehabilitation group or conventional rehabilitation group to receive physical exercise and electromyography-triggered neuromuscular stimulation. Modified Barthel Index, Berg Balance Scale, modified Rankin Scale, Caregiver Strain Index, root mean square of extensor carpi radialis longus and tibialis anterior muscle were measured at 3 time points: baseline, postintervention (12 weeks), and 12-week follow-up (24 weeks).

RESULTS

Both the home-based telerehabilitation and conventional rehabilitation groups demonstrated significant effects within groups over the 3 time points in increasing Modified Barthel Index, Berg Balance Scale, and root mean square value of extensor carpi radialis longus and tibialis anterior, as well as decreasing Caregiver Strain Index (P < 0.001), but none of the between-group differences was significant. For modified Rankin Scale, the percentage of participants of grades 0 and 1 in 2 groups increased over time without significant difference between the groups.

CONCLUSIONS

Home-based telesupervising rehabilitation is most likely as effective as the conventional outpatient rehabilitation for improving functional recovery in stroke survivors and could ease the burden of caregivers as conventional rehabilitation.

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Feasibility and efficacy of a robotic device for hand rehabilitation in hemiplegic stroke patients: a randomized pilot controlled study

OBJECTIVE

The purpose of the study was to evaluate the feasibility and efficacy of robot-assisted hand rehabilitation in improving arm function abilities in sub-acute hemiplegic patients.

DESIGN

Randomized controlled pilot study.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Thirty hemiplegic stroke patients (Ashworth spasticity index <3) were recruited and randomly divided into a Treatment group (TG) and Control group (CG).

INTERVENTIONS

Patients in the TG received intensive hand training with Gloreha, a hand rehabilitation glove that provides computer-controlled, repetitive, passive mobilization of the fingers, with multisensory feedback. Patients in the CG received the same amount of time in terms of conventional hand rehabilitation.

MAIN OUTCOME MEASURES

Hand motor function (Motricity Index, MI), fine manual dexterity (Nine Hole Peg Test, NHPT) and strength (Grip and Pinch test) were measured at baseline and after rehabilitation, and the differences, (Δ) mean(standard deviation), compared between groups. Results Twenty-seven patients concluded the program: 14 in the TG and 13 in the CG. None of the patients refused the device and only one adverse event of rheumatoid arthritis reactivation was reported. Baseline data did not differ significantly between the two groups. In TG, ΔMI 23(16.4), ΔNHPT 0.16(0.16), ΔGRIP 0.27(0.23) and ΔPINCH 0.07(0.07) were significantly greater than in CG, ΔMI 5.2(9.2), ΔNHPT 0.02(0.07), ΔGRIP 0.03(0.06) and ΔPINCH 0.02(0.03)] ( p=0.002, p=0.009, p=0.003 and p=0.038, respectively).

CONCLUSIONS

Gloreha Professional is feasible and effective in recovering fine manual dexterity and strength and reducing arm disability in sub-acute hemiplegic patients.

Jump training is feasible for nearly ambulatory patients after stroke

Objective: To evaluate the feasibility of jump training for nearly ambulatory patients after stroke.

Design: Case series.

Setting: A rehabilitation centre for adult people with neurological disorders.

Subjects: Six subacute, nearly ambulatory patients with hemiparesis due to stroke.

Interventions: A modified form of jump training performed over a period of six weeks.

Measures: Impairments: We used the Motricity Index to measure strength, the Fugl-Meyer subtest passive joint motion/pain for range of motion and pain and the modified Tardieu Scale to measure spasticity at baseline and after six weeks. Activity level: To assess walking ability we used the Functional Ambulation Category, to measure walking quality we used 10-m gait velocity, stride length and Rivermead Visual Gait Index and to assess walking capacity we used the six-minute walk test.

Results: No severe adverse events were observed during the study period. Motricity Index sum score of the affected leg increased from 38±11 points (mean±SD) to 56±15 points; P = 0.028. Modified Tardieu Scale and Fugl-Meyer subtest passive joint motion/pain remained unchanged over time (P=1.0; P=0.157, respectively). All patients were able to walk at the end of training (median Functional Ambulation Category grade five, P=0.023). Gait quality improved as shown in increased gait velocity (from 0.3±0.1 to 1.1±0.5 m/s; P = 0.028), improved stride length (from 0.3±0.1 to 0.6±0.2 m; P = 0.028) and improved Rivermead Visual Gait Index score (from 38.7±5.6 points to 24.8±7.0 points; P = 0.027). All patient increased gait capacity (from 97±33 m to 289±134 m; P = 0.028).

Conclusion: Jump exercises are feasible for selected subacute stroke patients with hemiparesis.

Efficacy of Bobath versus orthopaedic approach on impairment and function at different motor recovery stages after stroke: a randomized controlled study

Objective: To investigate the effectiveness of Bobath on stroke patients at different motor stages by comparing their treatment with orthopaedic treatment.

Design: A single-blind study, with random assignment to Bobath or orthopaedic group.

Setting: Physical therapy department of a medical centre.

Subjects: Twenty-one patients with stroke with spasticity and 23 patients with stroke at relative recovery stages participated.

Interventions: Twenty sessions of Bobath programme or orthopaedic treatment programme given in four weeks.

Main outcome measures: Stroke Impairment Assessment Set (SIAS), Motor Assessment Scale (MAS), Berg Balance Scale (BBS) and Stroke Impact Scale (SIS) for impairment and functional limitation level.

Results: Participants with spasticity showed greater improvement in tone control (change score: 1.209±1.03 versus 0.089±0.67, p =0.006), MAS (change score: 7.64±4.03 versus 4.009±1.95, p =0.011), and SIS (change score: 7.309±6.24 versus 1.259±5.33, p=0.023) after 20 sessions of Bobath treatment than with orthopaedic treatment. Participants with relative recovery receiving Bobath treatment showed greater improvement in MAS (change score: 6.149±5.55 versus 2.779±9.89, p=0.007), BBS (change score: 19.189±15.94 versus 6.859±5.23, p=0.015), and SIS scores (change score: 8.509±3.41 versus 3.629±4.07, p =0.006) than those with orthopaedic treatment.

Conclusion: Bobath or orthopaedic treatment paired with spontaneous recovery resulted in improvements in impairment and functional levels for patient with stroke. Patients benefit more from the Bobath treatment in MAS and SIS scores than from the orthopaedic treatment programme regardless of their motor recovery stages.

Effect of recommended positioning on stroke outcome at six months: a randomized controlled trial

Objective: To evaluate the effect on patient outcome of a teaching package for nurses designed to improve the positioning of stroke patients.

Design: Cluster randomized controlled trial with six-month follow-up.

Setting: Ten stroke rehabilitation hospital units located within one UK inner city region. These were randomized to control or intervention group.

Subjects: A sample of 120 patients admitted within four weeks of a first stroke and with a hemiplegia. No eligible patient refused to participate. Eighty-three (69%) completed the study.

Intervention: All nursing staff on the intervention units received a group teaching package to improve their clinical practice in patient positioning.

Main outcome measure: Rivermead Mobility Index (RMI) at six months post stroke. Patient's position was recorded using an established observational tool.

Results: After the teaching there was some evidence of better positioning in the intervention than the control group (difference in percentage of correct positions per patient 4.9%, 95% confidence interval (CI-0.1% to 9.9%, p-0.055). There was no evidence of differences between the two groups in any of the outcome measures at six months although there was a trend towards increased elbow flexor tone in the control group.

Conclusions: A teaching intervention to improve patient positioning made no significant impact on outcome at six months post stroke. However, following the teaching there was only a slightly higher incidence of recommended patient positioning within the intervention group. Thus, a teaching package may not be powerful enough to enable any effect on patient outcome to be measured.

Predicting those who will walk after rehabilitation in a specialist stroke unit

Objective: To establish whether the ability to use a wheelchair shortly after a stroke or continence are related to the likelihood of walking by time of discharge.

Design and subjects: An observational study in patients admitted to a stroke rehabilitation unit for under-65s over a three-year period.

Methods: Functional Independence Measure (FIM) subscores for walking were examined on all patients at time of admission and discharge. Walking was defined by an FIM ≤ 5 in that section. Comparisons were then made between those who could self-propel a wheelchair within a week of admission with those who could not. Continence (defined by an FIM subscore of ≥ 6 in that category) was also correlated to walking at discharge.

Main outcome measure: Walking at time of discharge defined by an FIM ≥ 5 in that section.

Results: From 393 admissions, 135 were excluded because they could already walk (FIM subscore ≥ 5 in that particular section) and three died during their admission. Out of the remaining 255 patients, 108 could self-propel on admission and 147 could not. While 105 (97%) of the self-propellors could walk by time of discharge, only 91 (62%) of the non-propellors could do so (χ2=42.237, df=1, P < 0.001, odds ratio (OR) 21.54 (6.52-71.51)). Although continence also predicted improved likelihood of walking, this was at a lower level of significance and correspondingly lower odds ratio (χ2=5.894, df=1, P=0.015, OR 1.94 (1.13-3.32)).

Conclusions: The ability to self-propel a wheelchair shortly after a stroke is a significant predictor of eventually being able to walk. Our data suggest that it is even more significant than continence, which is the most consistent predictor previously found.

Development of the Brunel Balance Assessment: a new measure of balance disability post stroke

Objective: To report the psychometric properties of the Brunel Balance Assessment (BBA), a new test of balance disability post stroke.

Design: Data from 92 subjects were collected and cohorts used to test hierarchical scaling, reliability and validity. Data from 80 people were used to test the hierarchical scaling using an inter-item correlation for redundancy, coefficient of reproducibility (CR) and scalability (CS) for the hierarchy and Cronbach's alpha coefficient for the internal consistency. Thirty-seven people participated in the reliability testing. Test / retest and inter-tester reliability were tested using the kappa coefficient. The testing was repeated on consecutive days to assess test / retest reliability and was scored simultaneously by two physiotherapists for inter-tester reliability. Fifty-five people participated in validity testing. The BBA was compared with the sitting Motor Assessment Scale (MAS), Berg Balance Test (Berg), Rivermead Mobility Index (RMI) using Spearman's rho.

Setting: Physiotherapy stroke services of six UK NHS trusts.

Participants: Hemiplegic stroke patients were recruited from physiotherapy services and the BBA used to assess their balance.

Results: The order of the items was revised and the original 14-point scale reduced to 12 points in the scale development. The revised scale formed a hierarchical scale. Inter-item correlations were < 0.9, coefficients of reproducibility and scalability were 0.99 and 0.69 respectively and Cronbach's alpha was 0.92. Reliability was high (100% agreement) for both aspects of reliability. Correlations with other balance measures were significant (0.83 / 0.97, p<0.01) indicating validity as measure of balance disability.

Conclusion: The BBA is a reliable, valid, hierarchical measure of balance disability post stroke that is suitable for use in the clinical setting.

The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part I: conceptual perspectives

OBJECTIVE

The study's purpose was to describe the range of knowledge pertaining to the Bobath concept/NDT in adult neurological rehabilitation, synthesize the findings, identify knowledge gaps and develop empirically based recommendations for future research. This article explores the conceptual literature.

METHODS

A scoping review of research and non-research articles published from 2007 to 2012. Two independent reviewers selected studies based on a systematic procedure. Inclusion criteria for studies were: electronically accessible English language literature with Bobath and/or neurodevelopmental therapy (NDT) as the subject heading in the title/keyword/abstract/intervention comparison with respect to adult neurological conditions. Data were abstracted and summarized with respect to study purpose, defining and operationalizing the Bobath concept, therapist demographics, recruitment, discussion and conclusions.

RESULTS

Of the 33 publications identified, 14 publications sought to define the theoretical foundations and identify key aspects of clinical practice of the contemporary Bobath concept. The publications comprised three theoretical papers, four surveys, a Delphi reported through two papers, one qualitative study, three letters to the editor and one editorial.

CONCLUSIONS

Knowledge derived from review of the conceptual literature provides clinicians with an updated Bobath clinical framework as well as identifying aspects of Bobath clinical practice that require careful consideration in future effectiveness studies. Implications for Rehabilitation The integration of posture and movement with respect to the quality of task performance remains a cornerstone of the redefined Bobath concept. A key fundamental principle of the clinical application of the Bobath concept since its inception is the selective manipulation of sensory information, namely, facilitation, to positively affect motor control and perception in persons post-central nervous system lesion. This is an aspect of Bobath clinical practice that requires further investigation. Study and treatment fidelity issues such as therapist expertise, the use of treatment logs to document individualized clinical practice, as well as therapist supervision and evaluation require careful consideration in the implementation of Bobath effectiveness studies such that causality can be determined.

Three different points of view in stroke rehabilitation: patient, caregiver, and physiotherapist

BACKGROUND

The similarities or differences of the three some (physiotherapists, patients, and caregivers) thought about the process of stroke rehabilitation can play a key role in the success of rehabilitation.

OBJECTIVE

The aim of this qualitative study was to investigate the perspectives of the three some, with regard to the two themes of the study: (1) What are the problems faced by the patients after stroke?; and (2) What does recovery after stroke mean to you?

METHODS

The qualitative questions and possible answers were prepared by four physiotherapists. The answers were matched to International Classification of Functioning (ICF) components. Seventy patients who were having treatment as in-patient rehabilitation centers, their caregivers, and physiotherapists were invited to the study. After the questions were asked and the possible response choices were presented, subjects were asked to prioritize these response choices.

RESULTS

One hundred and fifty-nine subjects, including 53 patients, 53 caregivers, and 53 physiotherapists, were included to the study. When the theme 1 were examined, we found that the patients' first priority was functional abilities (ICF: body function and structure) such as using the hands and feet while the caregivers and physiotherapists prioritized self-care problems (ICF: activity and participation). The most common response to the theme 2 was "being in same health condition before the disease" (ICF: activity and participation) among the patients and caregivers and "being able to move arm and leg on the affected side" (body function and structure) among the physiotherapists.

CONCLUSION

As a conclusion, problems faced by the patients, caregivers, and physiotherapists were perceived under the same ICF domain and that caregivers' and physiotherapists' priorities were the same.

[Intensity in the neurorehabilitation of spastic paresis]

Neurorestoration of motor command in spastic paresis requires a double action of stimulation and guidance of central nervous system plasticity. Beyond drug therapies, electrical stimulation and cell therapies, which may stimulate plasticity without precisely guiding it, two interventions seem capable of driving plasticity with a double stimulation and guidance component: the lesion itself (lesion-induced plasticity) and durable behavior modifications (behavior-induced plasticity). Modern literature makes it clear that the intensity of the neuronal and physical training is a primary condition to foster behavior-induced plasticity. When it comes to working on movement, intensity can be achieved by the combination of two key components, one is the difficulty of the trained movement, the other is the number of repetitions or the daily duration of the practice. A number of recent studies shed light on promising recovery prospects, particularly using the emergence of new technologies such as robot-assisted therapy and concepts such as guided self-rehabilitation contracts.

Interventions for improving upper limb function after stroke

BACKGROUND

Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

OBJECTIVES

To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

METHODS

SEARCH METHODS

We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

SELECTION CRITERIA

We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

DATA COLLECTION AND ANALYSIS

Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

MAIN RESULTS

Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

AUTHORS' CONCLUSIONS

Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

Effect of Gross Motor Group Exercise on Functional Status in Chronic Stroke: A Randomized Controlled Trial

[Purpose] The aim of this study was to understand the effects of task-oriented gross motor group exercise based on motor development on chronic stroke patients’ joint, bone, muscle, and motor functions and activities of daily living. [Subjects] Twenty-eight stroke patients hospitalized at P municipal nursing facility for the severely handicapped were randomly assigned to the gross motor group exercise group (experimental group, n=14) or the control group (n=14). [Methods] The two groups performed morning exercise led by a trainer for 30 minutes a day, 5 times a week for 6 weeks in total. The experimental group performed a gross motor group exercise in addition to this exercise for 50 minutes a day, 3 times a week for 6 weeks in total. Before the experiment, all subjects were measured with the Modified Barthel Index (MBI) and for their neuromuscular skeletal and motor-related functions according to the International Classification of Functioning, Disability and Health. [Results] Significant improvements were found in the experimental group’s neuromusculoskeletal and motor-related functions and MBI test, except for the stability of joint functions. The control group showed no significant difference from the initial evaluation. [Conclusion] The gross motor group exercise based on motor development is recommended for chronic stroke patients with severe handicaps.

Normalized gait parameters in NDT-Bobath post-stroke gait rehabilitation

The aim of the research was to evaluate the results of NDT-Bobath method in gait re-education of adult patients after ischemic stroke using normalized parameters of gait. The investigation group consisted of 60 patients, all sufferers of an ischemic stroke, and participated in a rehabilitation program: 10 sessions of NDT-Bobath therapy through 2 weeks (ten days of the therapy). Normalized parameters of gait were calculated based on anthropometric measures of patients and their gait parameters (gait velocity, cadence and stride length) measured in every patient on admission (before the therapy) and after the last session of the therapy to assess rehabilitation effects. Results among patients involved in the research were as follows: in normalized gait velocity: recovery in 42 cases (70 %), relapse in 10 cases (16,67 %), no measurable changes in 8 cases (13.33 %)in normalized cadence: recovery in 39 cases (65 %), relapse in 16 cases (26.67 %), no measurable changes in 5 cases (8.33 %)in normalized stride length: recovery in 50 cases (83.33 %), relapse in 4 cases (6.67 %), no measurable changes in 6 cases (10 %).

Observed statistically significant and favourable changes in health status of patients, described by normalized gait parameters, confirm effectiveness of the NDT-Bobath method.

What do acute stroke physiotherapists do to treat postural control and mobility? An exploration of the content of therapy in the UK

OBJECTIVE

To investigate the content of acute stroke physiotherapy to treat postural control and mobility problems.

DESIGN

Stroke physiotherapists recorded the interventions used to treat postural control and mobility during treatment sessions. They recorded five sessions for at least five patients each. Descriptive statistics assessed the frequency with which the interventions were used.

SETTING

Hospital-based acute stroke care.

SUBJECTS

Thirty-six acute stroke physiotherapists recorded 2374 interventions in 364 treatment sessions for 76 patients.

MAIN MEASURES

The Stroke Physiotherapy Intervention Recording Tool.

RESULTS

Facilitation techniques were the most frequently used interventions (n = 1258, 53%) with exercise (n = 115, 5%), teaching others how to help the patient (n = 99, 4%) and provision of equipment (n = 63, 3%) the least frequently used.

CONCLUSIONS

Acute stroke physiotherapists primarily use therapist-led 'hands-on' interventions to treat postural control and mobility problems. Interventions to promote activity or practice outside the treatment session are infrequently used.

The current theoretical assumptions of the Bobath concept as determined by the members of BBTA

The Bobath concept is a problem-solving approach to the assessment and treatment of individuals following a lesion of the central nervous system that offers therapists a framework for their clinical practice. The aim of this study was to facilitate a group of experts in determining the current theoretical assumptions underpinning the Bobath concept.A four-round Delphi study was used. The expert sample included all 15 members of the British Bobath Tutors Association. Initial statements were identified from the literature with respondents generating additional statements. Level of agreement was determined by using a five-point Likert scale. Level of consensus was set at 80%. Eighty-five statements were rated from the literature along with 115 generated by the group. Ninety-three statements were identified as representing the theoretical underpinning of the Bobath concept. The Bobath experts agreed that therapists need to be aware of the principles of motor learning such as active participation, opportunities for practice and meaningful goals. They emphasized that therapy is an interactive process between individual, therapist, and the environment and aims to promote efficiency of movement to the individual's maximum potential rather than normal movement. Treatment was identified by the experts as having "change of functional outcome" at its center.

WITHDRAWN: Orthotic devices after stroke and other non-progressive brain lesions

BACKGROUND

Post-stroke motor impairments cause difficulty controlling the joints of the affected limbs to produce useful movements. One way to manage this to use an orthosis to control the movement of the affected joints but evidence for their benefit is lacking.

OBJECTIVES

To determine the effectiveness of upper or lower limb orthoses on activity and impairment in people with stroke and other non-progressive brain lesions.

SEARCH STRATEGY

In February 2007 we searched the trials registers of the Cochrane Stroke, Movement Disorders and Injuries Groups, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2007), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1983), AMED (from 1985), PsycINFO (from 1967) and RECAL (from 1990), and other databases and trials registers. We screened reference lists, contacted lead authors and other researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials of orthoses applied to the upper or lower limb in people with stroke and other non-progressive brain lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials, extracted data, and assessed trial quality. Results for continuous outcomes were combined and analysed using mean difference or standardised mean difference, both with 95% confidence intervals and fixed-effect model.

MAIN RESULTS

We analysed 14 trials with 429 participants. The overall effect of lower limb orthoses on walking disability (speed), walking impairment (step/stride length) and balance impairment (weight distribution in standing) was significant and beneficial. There was no significant effect on postural sway (balance impairment) or mobility disability but the numbers of studies and participants were low. However, these were all cross-over trials that looked at the immediate effect while wearing the orthosis; they did not assess the effects of wearing an orthosis over the long term. Upper limb orthoses showed no effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain. However, this was based on only three trials.

AUTHORS' CONCLUSIONS

A lower limb orthosis can improve walking and balance but the included studies have only examined the immediate effects while wearing the orthosis; the effects of long-term use have not been investigated. An upper limb orthosis does not effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain, but this conclusion is based on only three trials.

A content analysis of physiotherapy for postural control in people with stroke: An observational study

PURPOSE

The lack of information about the content of therapy packages is a frequent criticism in stroke rehabilitation research. This study aimed to describe, in detail, the content of one aspect of physiotherapy; the rehabilitation of postural control.

METHODS

The design was a cross-sectional survey and the setting was in 11 NHS Trusts. The participants were 35 stroke physiotherapists working in acute and rehabilitation settings who recorded the treatment of 132 patients in 644 treatment sessions using the Stroke Physiotherapy Intervention Recording Tool. Analysis was carried out by descriptive statistics, one-way ANOVAS and chi-squares which were used to describe content of interventions and effects of the aim of treatment.

RESULTS AND CONCLUSIONS

Physiotherapists' clinical practice focused on therapist-led interventions, which aimed to normalize muscle tone and promote normal movement patterns. The most frequent interventions were 'preparation for treatment' (n = 1969, 43%), 'practising balance and walking activities' (n = 1583, 34%) and 'practising functional tasks' (n = 703, 15%). Interventions to encourage independence or activity outside the treatment session were rarely used. This pattern was seen regardless of the aim of treatment (the restoration of sitting balance, standing balance or stepping/walking).

Development of a framework for the evidence-based choice of outcome measures in neurological physiotherapy

BACKGROUND

Neurological physiotherapists recognize the need to include standardized outcome measures (OMs) in clinical practice but lack of information about the OMs available hampers utilization. This paper reports on the first stage of a project to identify the most robust OMs for use in neurological physiotherapy.

OBJECTIVE

To identify what physiotherapists perceive that they need to measure during a neurological assessment.

METHODS

Three separate workshops were held using patient vignettes to represent the acute, rehabilitation and community settings. Thirty senior neurological physiotherapists participated and were asked: 'What would you observe, test or measure if assessing this patient?' Data were analysed using thematic content analysis performed independently by each of the authors. Internal and external member checking ensured validity. In addition, the authors produced definitions of the items and domains identified in the data collection and subsequent content analysis.

RESULTS

Items from the data collection were classified into 16 domains that physiotherapists need to measure: Weakness; range of movement/contracture; pain; muscle tone/spasticity; sensation; ataxia/co-ordination; personal fatigue; oedema; subluxation; postural and balance impairment; walking impairment; upper limb; balance disability; walking disability; mobility disability and falls.

CONCLUSIONS

The domains that physiotherapists need to measure during clinical assessment were identified. In the second stage of the project these domains will inform systematic reviews to identify the most robust outcome measures for use in clinical practice.

Predicting recovery of dextrous hand function in acute stroke

PURPOSE

To determine the clinical characteristics during acute stroke that predicted dextrous function in the paretic hand at 6 months post-stroke.

METHOD

Fifty-seven patients within 5 days post-stroke were recruited in stroke wards. Recovery of dextrous hand function, indicated by a score of > or =35 of Action Research Arm Test, was assessed weekly in the first 4 weeks then monthly till 6 months post-stroke. The seven predictor candidates evaluated included side and site of brain infarct, stroke severity, cognition, spatial neglect, two-point discrimination (2-PD), muscle tone and muscle strength of the paretic upper extremity (UE).

RESULTS

Site of infarct, stroke severity, 2-PD and UE muscle strength had independent association with dextrous hand function at 6 months post-stroke. Stepwise multiple logistic regressions showed that the best early predictor was 2-PD in week 1 to 3 (Odds ratio [OR] ranged from 0.51-0.83) and UE muscle strength during the first 2 months post-stroke (OR > or = 1.04). The strongest predictor was muscle strength at week 4 post-stroke, followed by combined 2-PD and muscle strength at week 2 post-stroke.

CONCLUSIONS

Muscle strength and 2-PD in the paretic UE during the first month post-stroke were the best predictors of dextrous hand function recovery at 6 months.