Body awareness therapy in persons with stroke: a pilot randomized controlled trial

An Overview of the Bodily Awareness Representation and Interoception: Insights and Progress in the Field of Neurorehabilitation Research

In the last two decades, the scientific literature on so-called body representations has been increasing, and the notion of body awareness (BA) is particularly interesting for neurorehabilitation. In this article, we present results derived from recent studies on this representation, considering the different definitions and explicative models proposed as well as the empirical settings used to test it, providing an extensive overview of these issues. This article discusses the challenge of understanding how we integrate the sensory experiences of proprioception (knowing where our body is in space) and interoception (sensing internal bodily sensations, like hunger of thirst) with our perception of self. This is a difficult problem to analyze because our awareness of our body is inherently linked to our perspective, since the body is the means through which we interact with the world. Presenting the different viewpoints offered by recent theories on this concern, we highlighted that the neurorehabilitation and psychiatric settings offer two important fields useful for the study of BA because in them it is possible to analyze bodily representations by inducing/observing a controlled discrepancy between dysfunctional content and sensory inputs.

Key constructs of body awareness impairments post-stroke: a scoping review of assessment tools and interventions

PURPOSE

To summarise body awareness assessment tools and interventions relevant for stroke rehabilitation using a framework that categorises key body awareness constructs, disorders and impairments.

MATERIALS AND METHODS

Online electronic databases and trial registries were searched from inception until July 2021, in addition to hand searching reference lists of included studies and reviews. Study selection included any study design where the investigation involved assessing and/or intervening in body awareness following stroke. Data were extracted based on predefined criteria by two independent reviewers and mapped to the emergent framework.

RESULTS

The final analysis included 144 papers that reported 43 assessment tools and 8 types of interventions for body awareness. Consensus was reached on a synthesised body awareness framework. This comprised specific impairments and disorders, constructs, sub-categories and main categories leading to the overarching term of body awareness. Clinical and psychometric properties of the assessment tools were not reported or poorly evaluated, and the interventions lacked robust study designs and rigorous methods.

CONCLUSIONS

The framework produced will enable future research and clinical practice to be based on consistent concepts and definitions. Clinicians can also use this information to cautiously select assessment tools and/or interventions but are reminded of the limitations identified in this review.Implications for rehabilitationThere is limited understanding, compounded by inconsistent terminology and definitions regarding body awareness after stroke.A synthesized framework to define key constructs and definitions of body awareness is proposed.Assessment tools and interventions reported in the literature are mapped to the proposed framework.Psychometric properties of available tools are reported.Significant work remains to refine concepts of body awareness, develop and evaluate assessment tools and interventions.

Effect of physical exercise on fear of falling in patients with stroke: A systematic review and meta-analysis

OBJECTIVE

To consolidate the evidence on the effect of physical exercise on fear of falling in individuals with stroke.

DATA SOURCES

PubMed, CINAHL, Cochrane Database and MEDLINE.

METHODS

An extensive database search was conducted to identify the randomised controlled trials that examined the effect of physical exercise on fear of falling post-stroke. Grading of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for each meta-analysis.

RESULTS

Fourteen trials totalling 1211 participants were included in this review. Thirteen of these (1180 participants) were included in the meta-analyses. In the primary analysis, very low-quality evidence suggested that exercise reduced fear of falling post-stroke (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.23 to 0.72). The effect was diminished at three- to six-month follow-up after exercise training ended (SMD -0.09; 95% CI -0.27 to 0.10; high-quality evidence). In the sensitivity analyses, the treatment effect was more pronounced in individuals with a lower baseline Berg balance score (BBS ≤45; SMD 0.53; 95%CI 0.17 to 0.88) and for those trials with exercise frequency of ≥3 sessions per week (SMD 0.70; 95%CI 0.39 to 1.01). Compared with circuit-based training consisting of a combination of walking, balance and strengthening exercises (SMD 0.27; 95% CI -0.09 to 0.63), walking programmes seemed to generate a larger effect on fear of falling (SMD 1.06; 95%CI 0.43 to 1.70).

CONCLUSION

Physical exercise was beneficial for reducing fear of falling in individuals with stroke, particularly those with poorer balance ability.

Interventions for perceptual disorders following stroke

BACKGROUND

Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non-invasive brain stimulation, pharmacological and surgical approaches.

OBJECTIVES

To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living.  SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain.

DATA COLLECTION AND ANALYSIS

One review author assessed titles, with two review authors independently screening abstracts and full-text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB-1 tool, and quality of evidence using GRADE.  A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update.

MAIN RESULTS

We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch-somatosensory disorders. None addressed stroke-related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non-invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL):  Somatosensory disorders: one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure.  Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention.  Visual perception disorders: no trials measuring ADL compared an intervention with no treatment or control.  In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials).   AUTHORS' CONCLUSIONS: Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high-quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer-term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines.

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.

Recovery of Body Awareness After Stroke: An Observational Study

Background: Body awareness (BA) is a process that involves sensory awareness originating from the body's physiological states, processes and actions, and is shaped by one's attitudes, perceptions, beliefs and experience of social and cultural context. Impairments in body awareness after stroke are believed to be common and may be an important influence on recovery outcomes. However, recovery of body awareness is poorly understood and receives little consideration in rehabilitation.

Aims: To investigate if body awareness changes over time following stroke; and identify if body awareness after stroke is associated with sensation, motor impairment, self-efficacy and quality of life.

Methods: An exploratory longitudinal observational study was performed. Participants with a stroke diagnosis and associated motor impairment were recruited from an acute stroke unit. An assessment battery consisting of sensory and motor impairment and function, body awareness, self-efficacy and quality of life measures were used at baseline, 1, 3 and 6 months.

Results: A total of 105 people with stroke were recruited. Most recovery in sensation and body awareness occurred within the first month after stroke (all p < 0.01). Sensation and body awareness were correlated with other clinical outcomes (motor impairment, self-efficacy and quality of life), demographics, and stroke specific clinical characteristics (all p < 0.01).

Conclusions: This is the first study to track recovery of body awareness after stroke and investigate the relationship it may have in recovery of sensation, motor impairment and function, self-efficacy and quality of life. Further research is now warranted to continue investigation of body awareness and to develop effective stroke-specific assessment and intervention strategies.

Motor-cognitive intervention concepts can improve gait in chronic stroke, but their effect on cognitive functions is unclear: A systematic review with meta-analyses

Motor-cognitive intervention concepts are promising to counteract residual gait and cognitive impairments in chronic stroke. There is, however, considerable variation in motor-cognitive intervention types, which may lead to different effects. This systematic review strived to summarize and compare the effects of different motor-cognitive intervention concepts on gait and cognitive functions in chronic stroke. The systematic search identified twenty-nine articles, which were allocated to three types of motor-cognitive training concepts; SEQUENTIAL, SIMULTANEOUS-ADDITIONAL, and SIMULTANEOUS-INCORPORATED. Random-effects meta-analyses revealed that motor-cognitive interventions may be better than non-combined training approaches for improving gait function in chronic stroke (e.g. gait speed: g = 0.43, 95 % CI [0.22, 0.64], p < 0.0001). SIMULTANEOUS-INCORPORATED motor-cognitive training seems the most promising concept. As very few articles measured both, spatiotemporal gait parameters and cognitive outcomes, future studies are warranted to investigate the effects of motor-cognitive intervention concepts on gait control and cognitive functions in chronic stroke.

Physical Therapy for a Patient with Essential Tremor and Prolonged Deep Brain Stimulation: A Case Report

Background

There is a lack of evidence examining the role of physical therapy (PT) to address movement dysfunction for individuals with essential tremor (ET).

Case Report

A 61-year-old male with ET and prolonged bilateral deep brain stimulation (DBS) completed 14 sessions of outpatient PT that emphasized balance, functional movements, and proximal stability training with an integration of principles of body awareness training and visual motor coordination. Improvements were noted in all outcome measures.

Discussion

This report describes a novel PT approach that offers a promising means of improving functional mobility and balance while decreasing falls risk in patients with ET.

Basic Body Awareness Therapy for patients with stroke: Experiences among participating patients and physiotherapists

BACKGROUND

After a stroke many patients have muscle weakness, spasticity and compromised sensation leading to decreased postural stability. Basic Body Awareness Therapy includes slow movements that challenge postural control.

AIM

The aim was to describe experiences of 8 weeks of Basic Body Awareness Therapy from the perspective of both patients with stroke and physiotherapists.

METHOD

This study had a qualitative design. Twenty-one patients and four physiotherapists were interviewed. The interviews were analysed using manifest and latent content analysis.

RESULTS

One overall theme emerged "Simple yet challenging" which was based on six categories: "Facing one's limitations", "Individualized movements", "A feeling of harmony", "Improved balance", "Integrated knowledge" and "Frustration and doubt". The patients described improvement in balance and stability, as well as increased wellbeing.

CONCLUSION

The patients and physiotherapists related that Basic Body Awareness Therapy challenges balance but also provides an opportunity to reflect on the body.

Effect of body awareness training on balance and walking ability in chronic stroke patients: a randomized controlled trial

[Purpose] To investigate the effects of body awareness training on balance and walking ability in chronic stroke patients. [Subjects] The subjects were randomly assigned to a body awareness training group (n=6) and a control group (n=6). [Methods] Patients in the body awareness training group received body awareness training for 20 minutes, followed by walking training for 30 minutes a day, 5 days a week for 4 weeks. The control group received walking training for 30 minutes a day, 5 days a week for 4 weeks. [Results] After the intervention, both groups showed significant improvements in the Berg Balance Scale, Timed Up and Go Test, and 10 m walk test compared with baseline results. The body awareness training group showed more significant improvements in the Berg Balance Scale and Timed Up and Go Test than the control group. There was no significant difference in the 10 m walk test between the groups. [Conclusion] The results of this study suggest that body awareness training has a positive effect on balance in patients with chronic stroke.

The effect of interventions on balance self-efficacy in the stroke population: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review of clinical trials that examined the effectiveness of interventions on balance self-efficacy among individuals with stroke.

DESIGN

Systematic review.

SUMMARY OF REVIEW

Searches of the following databases were completed in December 2014: MEDLINE (1948-present), CINAHL (1982-present), EMBASE (1980-present) and PsycINFO (1987-present) for controlled clinical trials that measured balance self-efficacy in adults with stroke. Reference lists of selected articles were hand-searched to identify further relevant studies.

REVIEW METHODS

Two independent reviewers performed data extraction and assessed the methodological quality of the studies using the Physical Therapy Evidence Database Scale. Standardized mean differences (SMD) were calculated.

RESULTS

A total of 19 trials involving 729 participants used balance self-efficacy as a secondary outcome. Study quality ranged from poor (n = 3) to good (n = 8). In the meta-analysis of 15 trials that used intensive physical activity interventions, a moderate beneficial effect on balance self-efficacy was observed immediately following the programs (SMD 0.44, 95% CI 0.11-0.77, P = 0.009). In the studies that included follow-up assessments, there was no difference between groups across retention periods (eight studies, SMD 0.32, 95% CI -0.17-0.80, P = 0.20). In the four studies that used motor imagery interventions, there was no between-group difference in change in balance self-efficacy (fixed effects SMD 0.68, 95% CI -0.33-1.69, P = 0.18).

CONCLUSIONS

Physical activity interventions appear to be effective in improving balance self-efficacy after stroke.

Effects of body awareness training on mild visuospatial neglect in patients with acute stroke: a pilot randomized controlled trial

[Purpose] This study aimed to investigate the effects of body awareness training (BAT) on mild visuospatial neglect in patients following acute stroke. [Subjects] The subjects were 12 stroke patients randomly assigned to either the experimental group (n₁=6) or control group (n₂=6). [Methods] The experimental group underwent BAT for 15 minutes and then task-oriented training for 30 minutes a day, five times a week for three weeks. The control group underwent task-oriented training for 30 minutes a day, five times a week for three weeks. Assessments were made using the Motor-free Visual Perception Test (MVPT), Line Bisection Test (LBT), and modified Barthel index (MBI). [Results] Following the interventions, the experimental group showed a significant change in MVPT, LBT, and MBI scores. [Conclusion] The results of this study suggest the feasibility and suitability of BAT with task-oriented training for mild visuospatial neglect in patients with acute stroke.