Pitfalls in effectiveness research: a comparative analysis of treatment goals and outcome measures in stroke rehabilitation

Distinguishing theories of dysfunction, treatment and care. Reflections on ‘Describing rehabilitation interventions’

Background: An editorial by Wade (Clinical Rehabilitation 2005; 19: 811-18. suggested a method for describing rehabilitation interventions.

Objective: To review the editorial critically, and to suggest a more complete theory.

Editorial: The editorial develops a model identifying factors that should be considered when analysing a complex rehabilitation problem, and provides a high-level description of the rehabilitation process. It explicitly does not address theories of behaviour change.

New ideas: Three additional theoretical models are needed. The first considers the mechanisms that link the factors identified in Wade's model. For example how does self-esteem (in personal context) actually influence activity performance? This is a theory of dysfunction. The second needs to discuss how treatments alter their target. For example how does cognitive behavioural therapy alter pain perception and/or alter activity performance? This is a theory of treatment. It may be related to the theory of dysfunction. The third, which is less certain, needs to consider the process of giving support (maintaining the status quo). For example, how should one offer continuing opportunities for meaningful social role performance to someone with major cognitive losses? This is a theory of care.

Conclusion: The two models that Wade integrated in his conceptual framework (the World Health Organization's International Classification of Functioning (WHO ICF) and the rehabilitation process) should primarily be considered as descriptive in character. Theories are still needed to understand how activity limitation arises and how treatments alter activity limitation, and possibly how a patient is supported to maintain a certain level of activity.

Pediatric physical therapy in infancy: from nightmare to dream? A two-arm randomized trial

BACKGROUND

Systematic reviews have suggested that early intervention by means of specific motor training programs and general developmental programs in which parents learn how to promote infant development may be the most promising ways to promote infant motor and cognitive development of infants with or at high risk for developmental motor disorders.

OBJECTIVE

The purpose of this study was to investigate the effects of a recently developed pediatric physical therapy intervention program ("Coping With and Caring for Infants With Special Needs" [COPCA]) on the development of infants at high risk for developmental disorders using a combined approach of a 2-arm randomized trial and process evaluation.

SETTING

The study was conducted at the University Medical Center Groningen in the Netherlands.

PARTICIPANTS AND INTERVENTION

Forty-six infants at high risk for developmental disorders were randomly assigned to receive COPCA (a family-centered program) (n=21) or traditional infant physical therapy (TIP) (n=25) between 3 to 6 months corrected age (CA). Developmental outcome was assessed by blinded assessors at 3, 6, and 18 months CA with a neurological examination, the Alberta Infant Motor Scales, the Pediatric Evaluation of Disability Inventory, and the Mental Developmental Index (MDI) of the Bayley Scales of Infant Development. Contents of the intervention were analyzed by a quantitative video analysis of therapy sessions. Quantified physical therapy actions were correlated to evaluate associations between intervention and developmental outcome components.

RESULTS

The trial revealed that developmental outcome in both groups was largely identical. Process evaluation showed that typical COPCA actions-(1) family involvement and educational actions, (2) application of a wide variation in challenging the infant to produce motor behavior by himself or herself and allowing the infant to continue this activity, and (3) stimulation of motor behavior at the limit of the infant's capabilities-had positive correlations with developmental outcome at 18 months CA. The use of handling techniques was negatively associated with the Pediatric Evaluation of Disability Inventory outcome at 18 months CA.

LIMITATIONS

Major limitations were the limited size of the groups studied and the differences between the groups in frequency and duration of physical therapy sessions.

CONCLUSION

Extending the randomized trial with process evaluation was needed to obtain insight into associations between the components of intervention and developmental outcome. Specific therapist behaviors of parent coaching are associated with improved developmental outcome measures. Further studies are needed to examine whether these associations are caused by therapist behavior or whether therapist behavior is modified by children's motor skills.

Rehabilitation interventions for vegetative and minimally conscious patients

Brain injury rehabilitation is a complex and challenging task for all members of the multidisciplinary team. Medical advances have allowed more severely impaired patients to survive and consequently the number of patients in the vegetative and minimally conscious states have proportionately increased. Thus, the need for evidence-based practice and further research demonstrating the effects of specific rehabilitation interventions is required. This article reviews the current research and consensus on rehabilitation for patients in the vegetative and minimally conscious states.

Does an early increased-intensity interdisciplinary upper limb therapy programme following acute stroke improve outcome?

OBJECTIVE

To determine whether an early increased-intensity upper limb therapy programme following acute stroke improves outcome.

DESIGN

A randomized controlled trial.

SETTING

A stroke unit which provides acute care and rehabilitation for all stroke admissions.

SUBJECTS

One hundred and twenty-three patients who had had a stroke causing upper limb impairment within the previous 10 days.

INTERVENTION

The intervention group received stroke unit care plus enhanced upper limb rehabilitation provided jointly by a physiotherapist and occupational therapist, commencing within 10 days of stroke, and available up to 30 minutes/day, five days/week for six weeks. The control group received stroke unit care.

MAIN OUTCOME MEASURES

The primary outcome measure was the Action Research Arm Test (ARAT) three months after stroke.

SECONDARY OUTCOME MEASURES

Motricity Index; Frenchay Arm Test; upper limb pain; Barthel ADL Index; Nottingham E-ADL Scale; and costs to health and social services at three and six months after stroke.

RESULTS

There were no differences in outcomes between the intervention and control groups three and six months after stroke. During the intervention period the intervention group received a median of 29 minutes of enhanced upper limb therapy per working day as inpatients. The total amount of inpatient physiotherapy and occupational therapy received by the intervention group was a median of 52 minutes per working day during the intervention period and 38 minutes per working day for the control group (p = 0.001). There were no differences in service costs.

CONCLUSIONS

An early increased-intensity interdisciplinary upper limb therapy programme jointly provided by a physiotherapist and occupational therapist did not improve outcome after stroke. The actual difference in the amount of therapy received by intervention and control groups was less than planned due to a competitive therapy bias.