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

Sensory Stimulation of the Foot and Ankle Early Post-stroke: A Pilot and Feasibility Study

Background: Somatosensory stimulation of the lower extremity could improve motor recovery and walking post-stroke. This pilot study investigated the feasibility of a subsequent randomized controlled trial (RCT) to determine whether task-specific gait training is more effective following either (a) intensive hands-on somatosensory stimulation or (b) wearing textured insoles. Objectives: Determine recruitment and attrition rates, adherence to intervention, acceptability and viability of interventions and outcome measures, and estimate variance of outcome data to inform sample size for a subsequent RCT. Methods: Design: randomized, single-blinded, mixed-methods pilot study. Setting: In-patient rehabilitation ward and community. Participants: n = 34, 18+years, 42-112 days following anterior or posterior circulation stroke, able to follow simple commands, able to walk independently pre-stroke, and providing informed consent. Intervention: Twenty 30-min sessions of task-specific gait training (TSGT) (delivered over 6 weeks) in addition to either: (a) 30-60 min mobilization and tactile stimulation (MTS); or (b) unlimited textured insole (TI) wearing. Outcomes: Ankle range of movement (electrogoniometer), touch-pressure sensory thresholds (Semmes Weinstein Monofilaments), motor impairment (Lower Extremity Motricity Index), walking ability and speed (Functional Ambulation Category, 5-m walk test, pressure insoles) and function (modified Rivermead Mobility Index), measured before randomization, post-intervention, and 1-month thereafter (follow-up). Adherence to allocated intervention and actual dose delivered (fidelity) were documented in case report forms and daily diaries. Focus groups further explored acceptability of interventions and study experience. Analysis: Recruitment, attrition, and dose adherence rates were calculated as percentages of possible totals. Thematic analysis of daily diaries and focus group data was undertaken. Standard deviations of outcome measures were calculated and used to inform a sample size calculation. Results: Recruitment, attrition, and adherence rates were 48.57, 5.88, and 96.88%, respectively. Focus groups, daily-diaries and case report forms indicated acceptability of interventions and outcome measures to participants. The 5-m walk was selected as primary outcome measure for a future trial [mean (SD) at end of intervention: 16.86 (11.24) MTS group and 21.56 (13.57) TI group]; sample size calculation indicated 60 participants are required per group. Conclusion: Recruitment, attrition and adherence rates and acceptability of interventions and outcomes justify a subsequent powered RCT of MTS+TSGT compared with TI+TSGT.

Description of interventions is under-reported in physical therapy clinical trials

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A clear definition and description of the interventions in randomized controlled trials are pre-requisites for implementation in clinical practice.

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There is a trend among investigators to describe control group interventions poorly compared to the experimental group.

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The readers would not be able to apply the findings of the trial to their clinical practice if the interventions are poorly described.

Background

Amongst several barriers to the application of quality clinical evidence and clinical guidelines into routine daily practice, poor description of interventions reported in clinical trials has received less attention. Although some studies have investigated the completeness of descriptions of non-pharmacological interventions in randomized trials, studies that exclusively analyzed physical therapy interventions reported in published trials are scarce.

Objectives

To evaluate the quality of descriptions of interventions in both experimental and control groups in randomized controlled trials published in four core physical therapy journals.

Methods

We included all randomized controlled trials published from the Physical Therapy Journal, Journal of Physiotherapy, Clinical Rehabilitation, and Archives of Physical Medicine and Rehabilitation between June 2012 and December 2013. Each randomized controlled trial (RCT) was analyzed and coded for description of interventions using the checklist developed by Schroter et al.

Results

Out of 100 RCTs selected, only 35 RCTs (35%) fully described the interventions in both the intervention and control groups. Control group interventions were poorly described in the remaining RCTs (65%).

Conclusions

Interventions, especially in the control group, are poorly described in the clinical trials published in leading physical therapy journals. A complete description of the intervention in a published report is crucial for physical therapists to be able to use the intervention in clinical practice.

Functional strength training and movement performance therapy produce analogous improvement in sit-to-stand early after stroke: early-phase randomised controlled trial

OBJECTIVES

Restoring independence in the sit-to-stand (STS) task is an important objective for stroke rehabilitation. It is not known if a particular intervention, strength training or therapy focused on movement performance is more likely to improve STS recovery. This study aimed to compare STS outcomes from functional strength training, movement performance therapy and conventional therapy.

DESIGN

Randomised controlled trial.

SETTING

Acute stroke units.

PARTICIPANTS

Medically well patients (n=93) with recent (<42 days) stroke. The mean age of patients was 68.8 years, mean time post ictus was 33.5 days, 54 (58%) were male, 20 showed neglect (22%) and 37 (40%) had a left-sided brain lesion.

INTERVENTIONS

Six weeks of either conventional therapy, functional strength training or movement performance therapy. Subjects were allocated to groups on a random basis.

MAIN OUTCOME MEASURES

STS ability, timing, symmetry, co-ordination, smoothness and knee velocity were measured at baseline, outcome (after 6 weeks of intervention) and follow-up (3 months after outcome).

RESULTS

No significant differences were found between the groups. All three groups improved their STS ability, with 88% able to STS at follow-up compared with 56% at baseline. Few differences were noted in quality of movement, with only symmetry when rising showing significantly greater improvement in the movement performance therapy group; this benefit was not evident at follow-up.

CONCLUSIONS

Recovery of the STS movement is consistently good during stroke rehabilitation, irrespective of the type of therapy experienced. Changes in quality of movement did not differ according to group allocation, indicating that the type of therapy is less important. Clinical trial registration number NCT00322192.

Kick with the finger: symbolic actions shape motor cortex excitability

A large body of research indicates that observing actions made by others is associated with corresponding motor facilitation of the observer's corticospinal system. However, it is still controversial whether this matching mechanism strictly reflects the kinematics of the observed action or its meaning. To test this issue, motor evoked potentials induced by single-pulse transcranial magnetic stimulation were recorded from hand and leg muscles while participants observed a symbolic action carried out with the index finger, but classically performed with the leg (i.e., a soccer penalty kick). A control condition in which participants observed a similar (but not symbolic) hand movement was also included. Results showed that motor facilitation occurs both in the observer's hand (first dorsal interosseous) and leg (quadriceps femoris) muscles. The present study provides evidence that both the kinematics and the symbolic value of an observed action are able to modulate motor cortex excitability. The human motor system is thus not only involved in mirroring observed actions but is also finely tuned to their symbolic value.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

OBJECTIVES

To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

OBJECTIVES

To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

Development of the Occupational Therapy Stroke Arm and Hand Record: An Upper Limb Treatment Schedule

Introduction:

This study aimed to develop a comprehensive occupational therapy treatment schedule of upper limb interventions for stroke survivors with reduced upper limb function.

Method:

In a three-phased qualitative consensus study, 12 occupational therapists from acute and community settings in North West England contributed to interviews and subsequently group discussions to design and pilot a treatment schedule. Interview data were analysed using thematic analysis; the themes were used to develop a framework for the schedule that was supported by and reflected the International Classification of Functioning, Disability and Health framework. A draft schedule was the subject of a focus group and the resultant schedule was piloted in clinical practice by eight local occupational therapists working in neurological rehabilitation.

Findings:

Consensus was reached on three themes summarizing aspects of function: interventions that address preparation for activity, functional skills (that is, an aspect of function), and function. Three additional themes summarized other aspects of therapy: advice and education, practice outside therapy sessions, and psychosocial interventions. These themes became the main headings of the treatment schedule. The Occupational Therapy Stroke Arm and Hand Record treatment schedule was piloted and found to be comprehensive and potentially beneficial to clinical practice.

Conclusion:

The Occupational Therapy Stroke Arm and Hand Record treatment schedule provides a tool for use in stroke research and clinical practice.

The SWIFT Cast trial protocol: a randomized controlled evaluation of the efficacy of an ankle-foot cast on walking recovery early after stroke and the neural-biomechanical correlates of response

RATIONALE

An ankle-foot cast may enable people to repeatedly practice walking with a more normal movement pattern early after stroke.

AIMS

To evaluate the clinical efficacy of using an ankle-foot cast [soft scotch ankle-foot (SWIFT) Cast] to enhance walking recovery and to find whether site of stroke lesion and/or baseline biomechanical characteristics predict response to a SWIFT Cast.

DESIGN

Randomized, controlled, observer-blind trial.

STUDY

Participants (n = 120), 3-42 days after stroke with walking difficulty. All will receive conventional physical therapy. Those allocated to the experimental group will also receive a SWIFT Cast for up to six-weeks. During therapy sessions, the SWIFT Cast will be worn for retraining of walking as clinically appropriate. Outside therapy sessions, participants will initially wear the SWIFT Cast for the whole of their waking day, and this will be adjusted as clinically appropriate.

OUTCOMES

Measures will be undertaken before randomization, six-weeks thereafter and six-months after stroke. Primary outcome will be walking speed. Secondary outcomes will include the Functional Ambulation Category and efficiency of gait (e.g. step-time symmetry). Structural brain imaging using magnetic resonance imaging (standard fluid attenuated inversion recovery and T1-weighted high-resolution 'volume' spoiled gradient) will be undertaken at baseline. The clinical efficacy analysis will use analysis of covariance. The relationship between clinical response to therapy and biomechanical data will use correlation and multivariate regression techniques as required. For neuroimaging data, the relationship to clinical response to therapy will be computed using voxel-based lesion-symptom mapping. An interaction test across groups will identify which voxels are associated with different mean levels of treatment efficacy.

Quality of descriptions of treatments: a review of published randomised controlled trials

OBJECTIVES

To be useable in clinical practise, treatments studied in trials must provide sufficient information to enable clinicians and researchers to replicate. We sought to assess the completeness of treatment descriptions in published randomised controlled trials (RCTs) using a checklist and to determine the extent to which peer reviewers and editors comment on the quality of reporting of treatments.

DESIGN

A cross-sectional study.

SETTING

Trials published in the BMJ, a general medical journal.

PARTICIPANTS

Fifty-one trials published in the BMJ were independently evaluated by two raters using a checklist. Reviewers' and editors' comments were also assessed for statements on treatment descriptions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of trials rated as replicable (primary outcome).

RESULTS

For 57% (29/51) of the papers, published treatment descriptions were not considered sufficient to allow replication. Most poorly described aspects were the actual procedures involved including the sequencing of the technique (what happened and when) and the physical or informational materials used (eg, training materials): 53% and 43% not clear, respectively. For a third of treatments, the dose/duration of individual sessions was not clear and for a quarter the schedule (interval, frequency, duration or timing) was not clear. Although the majority of problems were not picked up by reviewers and editors, when they were detected only about two-thirds were fixed before publication.

CONCLUSIONS

Journals wanting to publish the research of use to practising healthcare professionals need to pay more attention to descriptions of treatments. Our checklist, may be useful for reviewers, and editors and could help ensure that important details of treatments are provided before papers are in the public domain.

Clinical efficacy and prognostic indicators for lower limb pedalling exercise early after stroke: study protocol for a pilot randomised controlled trial

Background

It is known that repetitive, skilled, functional movement is beneficial in driving functional reorganisation of the brain early after stroke. This study will investigate a) whether pedalling an upright, static exercise cycle, to provide such beneficial activity, will enhance recovery and b) which stroke survivors might be able to participate in pedalling.

Methods/Design

Participants (n = 24) will be up to 30 days since stroke onset, with unilateral weakness and unable to walk without assistance. This study will use a modified exercise bicycle fitted with a UniCam crank. All participants will give informed consent, then undergo baseline measurements, and then attempt to pedal. Those able to pedal will be entered into a single-centre, observer-blinded randomised controlled trial (RCT). All participants will receive routine rehabilitation. The experimental group will, in addition, pedal daily for up to ten minutes, for up to ten working days.

Prognostic indicators, measured at baseline, will be: site of stroke lesion, trunk control, ability to ambulate, and severity of lower limb paresis.

The primary outcome for the RCT is ability to voluntarily contract paretic lower limb muscle, measured by the Motricity Index. Secondary outcomes include ability to ambulate and timing of onset and offset of activity in antagonist muscle groups during pedalling, measured by EMG.

Discussion

This protocol is for a trial of a novel therapy intervention. Findings will establish whether there is sufficient evidence of benefit to justify proceeding with further research into clinical efficacy of upright pedalling exercise early after stroke. Information on potential prognostic indicators will suggest which stroke survivors could benefit from the intervention.

Trial Registration

ISRCTN: ISRCTN45392701

Black-white disparities in motor function outcomes taking into account patient characteristics, nontherapy ancillaries, therapy activities, and therapy interventions

OBJECTIVE

To assess black-white differences in functional outcomes, controlling for patient characteristics, use of nontherapy ancillaries (NTAs), and use of physical (PT) and occupational therapy (OT) activities and interventions.

DESIGN

Multicenter prospective observational cohort study of poststroke rehabilitation.

SETTING

Six U.S. inpatient rehabilitation facilities.

PARTICIPANTS

Patients (N=732) subdivided into case-mix subgroups (CMGs; CMGs 104-107 for moderate strokes [n=397], CMGs 108-114 for severe strokes [n=335]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Discharge Motor FIM.

RESULTS

Taking into account patient characteristics, NTAs, and therapy activities, multivariate regressions explained (R(2)) 54% and 69% of variation in outcomes between patients with moderate and severe stroke, respectively. Black race was associated with lower outcomes than white race in the severe group. However, race was no longer associated with outcomes after including interventions used within PT and OT activities. Including interventions within therapy activities increased R(2) to 64% and 74% for moderate and severe strokes, respectively. Some PT and OT activities were provided more to blacks than whites and vice versa. Greater intensity sometimes was associated with better and sometimes with poorer functional outcomes.

CONCLUSIONS

After controlling for interventions within activities, no racial differences were found in functional outcomes at discharge despite racial differences in rehabilitation care, possibly because each racial group received a mixture of interventions that were negatively and positively associated with outcome. Clinicians should provide therapies associated with better outcomes with high and similar intensities for black and white patients poststroke.

Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation

OBJECTIVE

To describe racial differences in patient characteristics, nontherapy ancillaries, physical therapy (PT), occupational therapy (OT), and functional outcomes at discharge in stroke rehabilitation.

DESIGN

Multicenter prospective observational cohort study of poststroke rehabilitation.

SETTING

Six U.S. inpatient rehabilitation facilities.

PARTICIPANTS

Black and white patients (n=732), subdivided in case-mix subgroups (CMGs): CMGs 104 to 107 for moderate strokes (n=397), and CMGs 108 to 114 for severe strokes (n= 335).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

FIM.

RESULTS

Significant black-white differences in multiple patient characteristics and intensity of rehabilitation care were identified. White subjects took longer from stroke onset to rehabilitation admission and were more ambulatory prior to stroke. Black subjects had more diabetes. For patients with moderate stroke, black subjects were younger, were more likely to be women, and had more hypertension and obesity with body mass index greater than or equal to 30. For patients with severe stroke, black subjects were less sick and had higher admission FIM scores. White subjects received more minutes a day of OT, although black subjects had significantly longer median PT and OT session duration. No black-white differences in unadjusted stroke rehabilitation outcomes were found.

CONCLUSIONS

Reasons for differences in rehabilitation care between black and white subjects should be investigated to understand clinicians' choice of treatments by race. However, we did not find black-white differences in unadjusted stroke rehabilitation outcomes.

Motor imagery to enhance recovery after subcortical stroke: who might benefit, daily dose, and potential effects

BACKGROUND

Motor imagery may enhance motor recovery after stroke.

OBJECTIVES

To estimate the proportion of patients able to perform motor imagery, the feasibility of delivery of motor imagery training (MIT), and the effects of MIT on motor recovery in an exploratory study.

METHODS

An immediate pretreatment and posttreatment single-group design was used to study 10 patients after subcortical stroke with neuromuscular weakness in the upper limb. MIT that included upper limb activities reflecting everyday tasks was provided for 10 consecutive working days. Measures included assessment of chaotic motor imagery, patient report of tolerability of MIT, Motricity Index (MI), Nine Hole Peg Test (9HPT), and quality of movement (MAL-QOM). MIT dose was changed in response to patient feedback. Graphed motor function scores were inspected visually for clinically important changes.

RESULTS

Four of the 10 patients were unable to perform motor imagery. Patient opinion was positive about the content and shaped daily dose of MIT given in two 20-minute periods separated by a 10-minute rest. Clinically important changes in motor scores were found. Four patients increased MI score (range 8-16), 3 patients increased 9HPT score (range 0.02-0.04 pegs/second), and 4 patients increased MAL-QOM score (range 0.63-1.29).

CONCLUSIONS

MIT was received positively by patients, but 40% were unable to perform imagery and interindividual variations were found on motor function.

An approach to standardize, quantify and record progress of routine upper limb therapy for stroke subjects: The Action Medical Research Upper Limb Therapy protocol

Introduction.

Explicitly describing therapy for research purposes, in terms of content and quantity, improves the validity of research and facilitates evidence-based clinical practice. However, such descriptions are not common in therapy research. The aim was to develop an upper limb therapy protocol which reflected local clinical practice in the stroke unit, and a recording form to document the content, quantity and progression of therapy.

Methods.

This was a multi-method study. A list of interventions commonly used for the rehabilitation of the stroke upper limb was compiled following a systematic literature search. This was then refined into the Action Medical Research Upper Limb Therapy (AMRULT) protocol in a two-stage process involving a survey and a group discussion. Six physical therapists and three occupational therapists supported its development. The AMRULT protocol was then piloted in a two-arm randomized controlled trial with 90 stroke patients for therapy and recording purposes.

Results.

The protocol classified therapies based on therapy input as passive, active assisted, active/strengthening and functional. Using this form it was possible to not only summarize the content of therapy but also objectively document progression (e.g. 14% of the participants progressed to functional exercises between the 5th and 8th weeks after stroke onset).

Discussion.

The AMRULT protocol and associated recording form were useful in both standardizing the delivery and quantification (content and progression) of therapy. While the AMRULT protocol was devised for a specific purpose, the method used can be adapted to develop protocols to support other research studies.

Efficacy of Functional Strength Training on Restoration of Lower-Limb Motor Function Early After Stroke: Phase I Randomized Controlled Trial

After stroke, physiotherapy can promote brain reorganization and motor recovery. Combining muscle strength and functional training (functional strength training, FST) may be beneficial. The aim of the authors was to compare FST with conventional physiotherapy (CPT) while controlling for the potential confounder of therapy intensity in a multicenter, randomized controlled observer-blind trial. The mean age of the participants was 68.3 (standard deviation [SD] = 12.03) years at a mean of 34 (SD = 20) days after stroke, with mean peak paretic knee extension torque (torque) of 22 (SD = 25) Nm. The estimated sample size was 102 to detect a between-group difference of 0.2 m/s in walking speed. After baseline measures, participants were allocated randomly to CPT or CPT + CPT or CPT + FST for 6 weeks. Additional experimental therapy was provided for up to 1 hour a day, 4 times each week. Outcomes were measured 6 weeks after baseline and at follow-up 12 weeks thereafter. Measures included walking speed, knee extensor torque, and functional mobility (Rivermead). At outcome, both extraintensity groups showed greater increases in walking speed than the CPT group, but this reached significance only for the CPT + CPT group ( P = .031). The CPT + CPT group also had a greater number of participants who walked at 0.8 m/s or above. No significant differences were observed for torque about the knee or for the Rivermead score. At follow-up, no significant differences were observed. These phase I results justify a subsequent trial of CPT + CPT versus CPT + FST.

Progressive Staging of Pilot Studies to Improve Phase III Trials for Motor Interventions

Based on the suboptimal research pathways that finally led to multicenter randomized clinical trials (MRCTs) of treadmill training with partial body weight support and of robotic assistive devices, strategically planned successive stages are proposed for pilot studies of novel rehabilitation interventions. Stage 1, consideration-of-concept studies, drawn from animal experiments, theories, and observations, delineate the experimental intervention in a small convenience sample of participants, so the results must be interpreted with caution. Stage 2, development-of-concept pilots, should optimize the components of the intervention, settle on most appropriate outcome measures, and examine dose-response effects. A well-designed study that reveals no efficacy should be published to counterweight the confirmation bias of positive trials. Stage 3, demonstration-of-concept pilots, can build out from what has been learned to test at least 15 participants in each arm, using random assignment and blinded outcome measures. A control group should receive an active practice intervention aimed at the same primary outcome. A third arm could receive a substantially larger dose of the experimental therapy or a combinational intervention. If only 1 site performed this trial, a different investigative group should aim to reproduce positive outcomes based on the optimal dose of motor training. Stage 3 studies ought to suggest an effect size of 0.4 or higher, so that approximately 50 participants in each arm will be the number required to test for efficacy in a stage 4, proof-of-concept MRCT. By developing a consensus around acceptable and necessary practices for each stage, similar to CONSORT recommendations for the publication of phase III clinical trials, better quality pilot studies may move quickly into better designed and more successful MRCTs of experimental interventions.

Effects of Conventional Physical Therapy and Functional Strength Training on Upper Limb Motor Recovery After Stroke: A Randomized Phase II Study

Background. Functional training and muscle strength training may improve upper limb motor recovery after stroke. Combining these as functional strength training (FST) might enhance the benefit, but it is unclear whether this is better than conventional physical therapy (CPT). Comparing FST with CPT is not straightforward. Objective. This study aimed at assessing the feasibility of conducting a phase III trial comparing CPT with FST for upper limb recovery. Methods. Randomized, observer-blind, phase II trial. Subjects had upper limb weakness within 3 months of anterior circulation infarction. Subjects were randomized to CPT (no extra therapy), CPT + CPT, and CPT + FST. Intervention lasted 6 weeks. Primary outcome measure was the Action Research Arm Test (ARAT). Measurements were taken before treatment began, after 6 weeks of intervention, and 12 weeks thereafter. Attrition rate was calculated and differences between groups were interpreted using descriptive statistics. ARAT data were used to inform a power calculation. Results. Thirty subjects were recruited (8% of people screened). Attrition rate was 6.7% at outcome and 40% at follow-up. At outcome the CPT + FST group showed the largest increase in ARAT score and this was above the clinically important level of 5.7 points. Median (interquartile range) increases were 11.5 (21.0) for CPT; 8.0 (13.3) for CPT + CPT; and 19.5 (22.0) for CPT + FST. The estimated sample size for an adequately powered subsequent phase III trial was 279 subjects at outcome. Conclusion. Further work toward a phase III clinical trial appears justifiable.

Training and exercise to drive poststroke recovery

To make practical recommendations regarding therapeutic strategies for the rehabilitation of patients with hemiparetic stroke, it is important to have a general understanding of the fundamental mechanisms underlying the neuroplasticity that is induced by skills training and by exercise programs designed to increase muscle strength and cardiovascular fitness. Recent clinical trials have provided insights into methods that promote adaptations within the nervous system that correlate with improved walking and upper extremity function, and that can be instigated at any time after stroke onset. Data obtained to date indicate that patients who have mild to moderate levels of impairment and disability can benefit from interventions that depend on repetitive task-oriented practice at the intensity and duration necessary to reach a plateau in a reacquired skill. Studies are underway to lessen the consequences of more-severe motor deficits by drawing on medications that augment plasticity, biological interventions that promote neural repair, and strategies that employ electrical stimulation and robotics.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

BACKGROUND

There are a number of different approaches to physiotherapy treatment following stroke that, broadly speaking, are based on neurophysiological, motor learning and orthopaedic principles. Some physiotherapists base their treatment on a single approach, while others use a mixture of components from a number of different approaches.

OBJECTIVES

To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched May 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and CINAHL (1982 to May 2005). We contacted experts and researchers with an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function in adult participants with a clinical diagnosis of stroke. Outcomes included measures of disability, motor impairment or participation.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised the identified trials according to the inclusion and exclusion criteria, documented their methodological quality, and extracted the data.

MAIN RESULTS

Twenty-one trials were included in the review, five of which were included in two comparisons. Eight trials compared a neurophysiological approach with another approach; eight compared a motor learning approach with another approach; and eight compared a mixed approach with another approach. A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardised mean difference (SMD) 0.94, 95% confidence intervals (CI) 0.08 to 1.80). There was no significant evidence that any single approach had a better outcome than any other single approach or no treatment control.

AUTHORS' CONCLUSIONS

There is evidence that physiotherapy intervention, using a mix of components from different approaches, is significantly more effective than no treatment or placebo control in the recovery of functional independence following stroke. There is insufficient evidence to conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of clearly described individual techniques and task-specific treatments, regardless of their historical or philsophical origin.