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Tole G, Raymond MJ, Williams G, Clark RA, Holland AE. Strength training to improve walking after stroke: how physiotherapist, patient and workplace factors influence exercise prescription. Physiother Theory Pract 2020; 38:1198-1206. [PMID: 33210574 DOI: 10.1080/09593985.2020.1839986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background:Muscle weakness is well established as the primary impairment that affects walking after stroke and strength training is an effective intervention to improve this muscle weakness. Observation of clinical practice however has highlighted an evidence-practice gap in the implementation of evidence-based strength training guidelines. Objective: To explore perceived barriers and facilitators that influence Australian physiotherapy practices when prescribing strength training with stroke survivors undergoing gait rehabilitation. Methods: Semi-structured interviews were conducted with a convenience sample of physiotherapists currently providing rehabilitation services to patients following stroke in Australia. Interviews were transcribed verbatim and line-by-line thematic analysis was undertaken to create themes and sub-themes. Results: Participants were 16 physiotherapists (12 females) with 3 months - 42 years experience working with people after stroke. Major themes identified were1) patient factors influence the approach to strength training; 2) interpretation and implementation of strength training principles is diverse; and 3) workplace context affects the treatment delivered. Physiotherapists displayed wide variation in their knowledge, interpretation and implementation of strength training principles and strength training exercise prescription was seldom evidence or guideline based. Workplace factors included the clinical preference of colleagues, and the need to modify practice to align with workforce resources. Conclusions: Implementation of strength training to improve walking after stroke was diverse. Therapist-related barriers to the implementation of effective strength training programs highlight the need for improved knowledge, training and research engagement. Limited resourcing demonstrates the need for organizational prioritization of stroke education and skill development. Narrowing the evidence-practice gap remains a challenge.
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Affiliation(s)
- Genevieve Tole
- Department of Physiotherapy of Alfred Health, Melbourne, Australia.,Acquired Brain Injury Unit, Caulfield Hospital, Alfred Health, Caulfield, Australia.,Department of Physiotherapy, La Trobe University, Bundoora, Australia
| | | | - Gavin Williams
- Department of Physiotherapy, Epworth Hospital, Richmond, Australia.,Department of Physiotherapy, University of Melbourne, Carlton, Australia
| | - Ross A Clark
- School of Health and Sports Science, University of the Sunshine Coast, Sippy Downs, Australia
| | - Anne E Holland
- Department of Physiotherapy of Alfred Health, Melbourne, Australia.,Department of Physiotherapy, La Trobe University, Bundoora, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
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Williams G, Denehy L. Clinical education alone is sufficient to increase resistance training exercise prescription. PLoS One 2019; 14:e0212168. [PMID: 30811460 PMCID: PMC6392279 DOI: 10.1371/journal.pone.0212168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 01/29/2019] [Indexed: 11/19/2022] Open
Abstract
A large body of evidence demonstrates that resistance training has been ineffective for improving walking outcomes in adults with neurological conditions. However, evidence suggests that previous studies have not aligned resistance exercise prescription to muscle function when walking. The main aim of this study was to determine whether a training seminar for clinicians could improve knowledge of gait and align resistance exercise prescription to the biomechanics of gait and muscle function for walking. A training seminar was conducted at 12 rehabilitation facilities with 178 clinicians. Current practice, knowledge and barriers to exercise were assessed by observation and questionnaire prior to and immediately after the seminar, and at three-month follow-up. Additionally, post-seminar support and mentoring was randomly provided to half of the rehabilitation facilities using a cluster randomised controlled trial (RCT) design. The seminar led to significant improvements in clinician knowledge of the biomechanics of gait and resistance training, the amount of ballistic (t = -2.38; p = .04) and conventional (t = -2.30; p = .04) resistance training being prescribed. However, ongoing post-seminar support and mentoring was not associated with any additional benefits F(1, 9) = .05, p = .83, partial eta squared = .01. Further, improved exercise prescription occurred in the absence of any change to perceived barriers. The training seminar led to significant improvements in the time spent in ballistic and conventional resistance training. There was no further benefit obtained from the additional post-seminar support. The seminar led to improved knowledge and significantly greater time spent prescribing task-specific resistance exercises.
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Affiliation(s)
- Gavin Williams
- Epworth Hospital, Melbourne, Australia
- School of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Linda Denehy
- Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia
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Hendrey G, Clark RA, Holland AE, Mentiplay BF, Davis C, Windfeld-Lund C, Raymond MJ, Williams G. Feasibility of Ballistic Strength Training in Subacute Stroke: A Randomized, Controlled, Assessor-Blinded Pilot Study. Arch Phys Med Rehabil 2018; 99:2430-2446. [PMID: 29859180 DOI: 10.1016/j.apmr.2018.04.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/14/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To establish the feasibility and effectiveness of a 6-week ballistic strength training protocol in people with stroke. DESIGN Randomized, controlled, assessor-blinded study. SETTING Subacute inpatient rehabilitation. PARTICIPANTS Consecutively admitted inpatients with a primary diagnosis of first-ever stroke with lower limb weakness, functional ambulation category score of ≥3, and ability to walk ≥14 m were screened for eligibility to recruit 30 participants for randomization. INTERVENTIONS Participants were randomized to standard therapy or ballistic strength training 3 times per week for 6 weeks. MAIN OUTCOME MEASURES The primary aim was to evaluate feasibility and outcomes included recruitment rate, participant retention and attrition, feasibility of the exercise protocol, therapist burden, and participant safety. Secondary outcomes included measures of mobility, lower limb muscle strength, muscle power, and quality of life. RESULTS A total of 30 participants (11% of those screened) with mean age of 50 years (SD 18) were randomized. The median number of sessions attended was 15 of 18 and 17 of 18 for the ballistic and control groups, respectively. Earlier than expected discharge to home (n=4) and illness (n=7) were the most common reasons for nonattendance. Participants performed the exercises safely, with no study-related adverse events. There were significant (P<.05) between-group changes favoring the ballistic group for comfortable gait velocity (mean difference [MD] 0.31m/s, 95% confidence interval [CI]: 0.08-0.52), muscle power, as measured by peak jump height (MD 8cm, 95% CI: 3-13), and peak propulsive velocity (MD 64cm/s, 95% CI: 17-112). CONCLUSIONS Ballistic training was safe and feasible in select ambulant people with stroke. Similar rates of retention and attrition suggest that ballistic training was acceptable to patients. Secondary outcomes provide promising results that warrant further investigation in a larger trial.
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Affiliation(s)
- Genevieve Hendrey
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia; Discipline of Physiotherapy, La Trobe University, Melbourne, Victoria, Australia; Acquired Brain Injury Unit, Caulfield Hospital, Caufield, Melbourne, Victoria, Australia.
| | - Ross A Clark
- School of Health and Sports Science, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Anne E Holland
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia; Discipline of Physiotherapy, La Trobe University, Melbourne, Victoria, Australia
| | - Benjamin F Mentiplay
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia; Victorian Infant Brain Studies, Murdoch Children's Research Institute, Parkville, Melbourne, Victoria, Australia
| | - Carly Davis
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
| | - Cristie Windfeld-Lund
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia; Acquired Brain Injury Unit, Caulfield Hospital, Caufield, Melbourne, Victoria, Australia
| | - Melissa J Raymond
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
| | - Gavin Williams
- Department of Physiotherapy, Epworth Hospital, Richmond, Victoria, Australia; Department of Physiotherapy, The University of Melbourne, Parkville, Melbourne, Victoria, Australia
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Tarrant BJ, Holland A, Le Maitre C, Robinson R, Corbett M, Bondarenko J, Button B, Thompson B, Snell G. The timing and extent of acute physiotherapy involvement following lung transplantation: An observational study. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2018. [PMID: 29528538 DOI: 10.1002/pri.1710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Physiotherapy "standard care" for the acute post lung transplant recipient has not yet been documented. We aimed to analyse how soon patients commence exercise and how much time is dedicated to this during physiotherapy sessions acutely post lung transplantation. METHODS Prospective observational study of bilateral sequential and single lung transplant recipients for any indication, ≥18 years. Participants were observed during 6 physiotherapy sessions: 3 initial and 3 prior to acute inpatient discharge. Duration and content of each session was recorded, consisting of physical exercise and non-exercise tasks. RESULTS Thirty participants, 20 male, median age 58.5 (interquartile range 54.5-65.0) were observed over 173 sessions. Chronic obstructive pulmonary disease was the most common transplant indication (n = 12, 40%). Bilateral lung transplant was performed in 90% (n = 27) of participants. First time to mobilise was 2 (2-3) days. Participants received 14 (12.8-23.8) sessions over 18 (17-31) days. The mean duration of physiotherapy in the initial phase was 107.8 (standard deviation 21.8) min, with 22.9 (7.5) min spent exercising. In the final phase, exercise time increased to 28.1 (11.4) min out of 84.1 (24.6) min. Assessment was the most common non-exercise component, at 26.6 (7.9) and 22.1 (12.5) min across the three initial and final sessions. IMPLICATIONS FOR PHYSIOTHERAPY PRACTICE Lung transplant recipients spent 21-34% of observed sessions performing physical exercise beginning 48 hr following surgery. Remaining physiotherapist time was spent on assessment, respiratory interventions, education, and patient-specific duties. The use of physiotherapy assistants, structured, progressive exercise programs, and continued workplace innovation may enable a higher percentage of physiotherapist supervised physical exercise in the future.
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Affiliation(s)
- Benjamin James Tarrant
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
- Department of Rehabilitation, Nutrition and Sport, La Trobe University, Melbourne, Australia
| | - Anne Holland
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
- Department of Rehabilitation, Nutrition and Sport, La Trobe University, Melbourne, Australia
| | | | - Rebecca Robinson
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
| | - Monique Corbett
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
| | - Janet Bondarenko
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
| | - Brenda Button
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
- Cystic Fibrosis Service, Alfred Health, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Bruce Thompson
- Monash University, Melbourne, Australia
- Lung Function Laboratory, Alfred Health, Melbourne, Australia
| | - Greg Snell
- Monash University, Melbourne, Australia
- Lung Transplant, Alfred Health, Melbourne, Australia
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