The effects of position on oxygen saturation in acute stroke: a systematic review

Objective: To investigate the effect of body position on oxygen saturation in the acute stages post stroke.

Design: Systematic review.

Methods: Databases: PREMEDLINE and MEDLINE, Psychinfo, EMBASE, CINAHL, PEDro, all EBM Reviews and Scottish Intercollegiate Guidelines Network (SIGN). Keywords: combinations of cerebrovascular accident/stroke/hemiplegia/ cerbrovascular disorders and position or posture or sitting or standing/lying/supine/ side lying, with oxygen saturation/oxygen levels/blood gas analysis/hypoxia/sleep apnea syndrome/obstructive sleep disorder/Cheyne Stokes breathing. Limits: English language, human, adults and clinical trials. The quality of relevant papers was independently reviewed using criteria based on the SIGN guidelines for randomized controlled trials and methods described by Rywdik et al.

Results: There were four relevant studies involving 183 patients: three high quality and one poor quality. Heterogeneity in the testing positions, selection criteria, outcome measures and analysis methods prevented meta-analysis. There was strong evidence that body position did not affect oxygen saturation in acute stroke patients without relevant (respiratory) co-morbidities. There was limited evidence that sitting in a chair had a beneficial effect and lying positions had a deleterious effect on oxygen saturation in acute stroke patients with respiratory co-morbidities.

Conclusions: Acute stroke patients without respiratory co-morbidities can adopt any body position, people with respiratory co-morbidities should be positioned as upright as possible.

The effect of a slider shoe on hemiplegic gait

Objective: To assess the effect of a slider shoe on the gait speed and energy efficiency of hemiplegic gait.

Design: A–B–A single-case design to compare walking with and without the slider shoe. Results were assessed graphically using the 2SD method.

Setting: Stroke unit of an NHS general hospital in the UK.

Subjects: Four acute stroke patients undergoing gait rehabilitation.

Intervention: Walking practice with and without a slider shoe worn over the real shoe of the weak leg.

Main outcome measures: Gait speed (10-m walk test) and energy efficiency (Physiological Cost Index).

Results: All subjects showed an improvement in speed and efficiency when wearing the slider shoe compared with the baseline phase (A1). Three subjects showed a sustained improvement in efficiency and two showed a sustained improvement in speed in the second baseline phase (A2).

Conclusion: A slider shoe may improve the speed and efficiency of hemiplegic gait for people in the early stages of gait rehabilitation. Further investigation is warranted.

The effect of a structured programme to increase patient activity during inpatient stroke rehabilitation: a Phase I cohort study

OBJECTIVE

To develop an intervention and undertake a proof-of-concept evaluation of its feasibility, acceptability, and impact on recorded patient activity levels during inpatient stroke rehabilitation.

DESIGN

A longitudinal cohort design.

SETTING

Three inpatient stroke rehabilitation services.

SUBJECTS

Stroke survivors receiving inpatient rehabilitation.

INTERVENTION

A programme designed to increase patient activity, including individualised patient timetables, independent practice, therapeutic group work, and structured social activities was developed and implemented without additional resource.

MAIN MEASURES

Patients' recorded activity levels were compared for two weeks before and after implementation of the programme. Data regarding the estimated time spent in different types of activity were extracted from patient treatment records, patients' and therapists' diaries, or timetables (if used) to measure patient activity levels

RESULTS

At baseline, recorded activity levels were low; patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation of the programme, recorded activity levels significantly increased to a mean of 123 minutes (SD = 88) per day (p = 0.0001). The time spent in all types of recorded activity increased (p = 0.0001-0.002), except psychology where the increase did not reach significance (p = 0.670).

CONCLUSIONS

A structured programme can significantly increase recorded patient activity levels during inpatient stroke rehabilitation without additional resource.

The impact of a toolkit on use of standardised measurement tools in stroke rehabilitation

Objective:

To evaluate the impact of a toolkit of psychometrically robust measurement tools, the Greater Manchester Assessment for Stroke Rehabilitation (G-MASTER) toolkit, on the use of measurement tools during stroke rehabilitation

Design:

Mixed methods cohort design using non-participant observation of multi-disciplinary team meetings and semi-structured interviews with members of the team over three months before and three months after implementation of the assessment toolkit. Development and implementation of the toolkit are also described.

Setting:

Ten in-patient stroke services in a large UK city.

Subjects:

Members of the participating multi-disciplinary stroke teams.

Results:

Before implementation standardised measures were seldom used in team meetings. After implementation, use of all measurement tools significantly increased (36% to 81% of occasions, P<0.000). Staff were generally positive about the toolkit and felt it enabled more accurate problem identification, effective progress monitoring, timely decision-making, communication and promoted inter-team relationships.

Conclusions:

A toolkit of standardised measurement tools can be feasibly and acceptably implemented into stroke rehabilitation. It increases the use of measurement tools by the multi-disciplinary team and improves the processes and quality of care.

Effects of dual task on turning ability in stroke survivors and older adults

BACKGROUND

Turning is an integral component of independent mobility in which stroke survivors frequently fall.

OBJECTIVE

This study sought to measure the effects of competing cognitive demands on the stepping patterns of stroke survivors, compared to healthy age-match adults, during turning as a putative mechanism for falls.

METHODS

Walking and turning (90°) was assessed under single (walking and turning alone) and dual task (subtracting serial 3s while walking and turning) conditions using an electronic, pressure-sensitive walkway. Dependent measures were time to turn, variability in time to turn, step length, step width and single support time during three steps of the turn. Turning ability in single and dual task conditions was compared between stroke survivors (n=17, mean ± SD: 59 ± 113 months post-stroke, 64 ± 10 years of age) and age-matched healthy counterparts (n=15).

RESULTS

Both groups took longer, were more variable, tended to widen the second step and, crucially, increased single support time on the inside leg of the turn while turning and distracted.

CONCLUSIONS

Increased single support time during turning may represent biomechanical mechanism, within stepping patterns of turning under distraction, for increased risk of falls for both stroke survivors and older adults.

Multi-disciplinary team meetings in stroke rehabilitation: an observation study and conceptual framework

Objective:

To explore how multi-disciplinary team meetings operate in stroke rehabilitation.

Design:

Non-participant observation of multi-disciplinary team meetings and semi-structured interviews with attending staff.

Setting and participants:

Twelve meetings were observed (at least one at each site) and 18 staff (one psychologist, one social worker; four nurses; four physiotherapists four occupational therapists, two speech and language therapists, one stroke co-ordinator and one stroke ward manager) were interviewed in eight in-patient stroke rehabilitation units.

Results:

Multi-disciplinary team meetings in stroke rehabilitation were complex, demanding and highly varied. A model emerged which identified the main inputs to influence conduct of the meetings were personal contributions of the members and structure and format of the meetings. These were mediated by the team climate and leadership skills of the chair. The desired outputs; clinical decisions and the attributes of apparently effective meetings were identified by the staff. A notable difference between the meetings that staff considered effective and those that were not, was their structure and format. Successful meetings tended to feature a set agenda, structured documentation; formal use of measurement tools; pre-meeting preparation and skilled chairing. These features were often absent in meetings perceived to be ineffective.

Conclusions:

The main features of operation of multi-disciplinary team meetings have been identified which will enable assessment tools and interventions to improve effectiveness to be developed.

A systematic review and meta-analysis of the effect of an ankle-foot orthosis on gait biomechanics after stroke

OBJECTIVE

To systematically review the evidence on the effects of an ankle-foot orthosis on gait biomechanics after stroke.

DATA SOURCES

The following databases were searched; AMED, CINHAL, Cochrane Library (Stroke section), Medline, PubMed, Science Direct and Scopus. Previous reviews, reference lists and citation tracking of the selected articles were screened and the authors of selected trials contacted for any further unpublished data.

REVIEW METHODS

Controlled trials of an ankle-foot orthosis on gait biomechanics in stroke survivors were identified. A modified PEDro score evaluated trial quality; those scoring 4/8 or more were selected. Information on the trial design, population, intervention, outcomes, and mean and standard deviation values for the treatment and control groups were extracted. Continuous outcomes were pooled according to their mean difference and 95% confidence intervals in a fixed-effect model.

RESULTS

Twenty trials involving 314 participants were selected. An ankle-foot orthosis had a positive effect on ankle kinematics (P < 0.00001-0.0002); knee kinematics in stance phase (P < 0.0001-0.01); kinetics (P = 0.0001) and energy cost (P = 0.004), but not on knee kinematics in swing phase (P = 0.84), hip kinematics (P < 0.18-0.89) or energy expenditure (P = 0.43). There were insufficient data for pooled analysis of individual joint moments, muscle activity or spasticity. All trials, except one, evaluated immediate effects only.

CONCLUSIONS

An ankle-foot orthosis can improve the ankle and knee kinematics, kinetics and energy cost of walking in stroke survivors.

Measures of sensation in neurological conditions: a systematic review

Objective: To systematically review the psychometric properties and clinical utility of measures of sensation in neurological conditions to inform future research studies and clinical practice.

Data sources: Electronic databases (MEDLINE, CINAHL, EMBASE and AMED) were searched from their inception to December 2010.

Review methods: Search terms were used to identify articles that investigated any sensory measures in neurological conditions. Data about their psychometric properties and clinical utility were extracted and analyzed independently. The strength of the psychometric properties and clinical utility were assessed following recommendations. 1

Results: Sixteen sensory measures were identified. Inter-rater reliability and redundancy of testing protocols are particular issues for this area of assessment. Eleven were rejected because they were not available for a researcher or clinician to use. Of the remaining five measures, the Erasmus MC modifications of the Nottingham Sensory Assessment and the Sensory section of the Fugl–Meyer Assessment showed the best balance of clinical utility and psychometric properties.

Conclusion: Many measures of sensory impairment have been used in research but few have been fully developed to produce robust data and be easy to use. At present, the sensory section of the Fugl–Meyer Assessment and the Erasmus MC modifications of the Nottingham Sensory Assessment show the most effective balance of usability and robustness, when delivered according to the operating instructions.

How to measure balance in clinical practice. A systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions

OBJECTIVE

To identify psychometrically robust and clinically feasible measurement tools of balance activity in people with neurological conditions to recommend for use in clinical practice.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, PEDro and AMED.

REVIEW METHODS

Independent reviewers selected and extracted data from articles that assessed the reliability, validity, sensitivity to change and clinical utility of measures of balance activity in adult neurological conditions. Quality assessment was based on Jorstad et al. Measures with 'good' psychometrics and > or =9/10 clinical utility scores were recommended.

RESULTS

Nineteen measurement tools were selected. Of these, the Brunel Balance Assessment, Berg Balance Scale, Trunk Impairment Scale, arm raise and forward reach tests in sitting and standing, weight shift, step/tap and step-up tests reached the required standards and are usable in clinical practice. The Brunel Balance Assessment and its associated functional performance tests have the additional advantages of being a hierarchical scale with established lack of redundancy.

CONCLUSION

The measurement tools identified above are psychometrically robust and feasible to use in clinical practice. Future objective measure development should consider the theoretical construct of the measure, the minimal detectable change and use in clinical populations other than stroke.

Functional balance and mobility tests in healthy participants: reliability, error and influencing factors

BACKGROUND AND PURPOSE

Knowledge of the measurement error and reliability of measurement tools is required to judge whether true changes in performance have occurred. How a patient's performance relates to that of a healthy individual, and which factors would influence performance, also need to be considered to assess whether a patient's performance is 'normal'. The aim of the present study was to assess within-session and test-retest reliability, and measurement error, of a hierarchical series of functional tests of balance and walking in healthy participants. Obtaining indicative data in a group of healthy participants was an additional aim.

METHOD

Forty healthy participants aged 20-60 years were recruited from staff and students of Cardiff University. The participants completed eight functional balance and mobility tests on two occasions on the same day. Intra-class correlation co-efficients (ICCs), assessed within-session, and test-retest reliability and measurement error were calculated from the mean squares error term of a repeated measures analysis of variance (ANOVA). The relationship to the overall mean score was calculated and linear regression investigated the factors influencing performance.

RESULTS

Within-session and test-retest reliability for each of the tests was moderate to high (ICCs = 0.88-0.98 and 0.77-0.94, respectively). The overall measurement error was 3% to 11% of the mean scores. Age was the most frequent factor influencing performance; level of activity and body mass index (BMI) did not influence performance on any of the tests.

CONCLUSIONS

Functional balance and mobility tests are reliable but are subject to random error up to 11% of the mean. The present study provides initial reference data for physiotherapists in clinical practice. It is important to begin to develop a database of a standard range of scores to give a context with which to judge more accurately the importance and relevance of clinical measurements from patients.

The effect of perceived adherence to the Bobath concept on physiotherapists' choice of intervention used to treat postural control after stroke

PURPOSE

The Bobath concept is the predominant stroke physiotherapy approach in the UK but there is little literature about its operationalization. The aim of this study was to assess the effect of perceived adherence to the Bobath concept on interventions used by physiotherapists to treat postural control problems after stroke. The physiotherapists' experience, clinical grade and the type of patients treated were also compared.

METHODS

The design was a cross sectional survey involving 11 NHS Trusts. The participants were 35 stroke physiotherapists who recorded the treatment of 132 patients in 644 sessions using the Stroke Physiotherapy Intervention Recording Tool. Descriptive statistics, independent t-tests and Chi-squares were used in the analysis to describe the physiotherapists and patients, and compare the effects of perceived adherence to the Bobath concept on intervention choice, clinical grade, experience and the type of patient treated.

RESULTS

Most physiotherapists perceived their practice to be eclectic but the interventions used followed a traditional Bobath model. Perceived adherence to the Bobath concept had little effect on the choice of intervention. The only significant difference was that 'preparation for treatment' techniques were used more frequently by 'strongly Bobath' physiotherapists then 'eclectic' physiotherapists. There were no other significant differences, nor were there any differences in the physiotherapists' clinical grade, post-graduate training or the type of patient treated except that 'eclectic' physiotherapists' patients were older. Most of the 'strongly Bobath' physiotherapists were experienced and most of the 'eclectic' physiotherapists were novices (p<0.023).

CONCLUSIONS

Although most physiotherapists perceived themselves to be eclectic, their actual practice followed a traditional Bobath model; recent developments of the Bobath concept were not incorporated into clinical practice. The reasons for the mismatch between physiotherapists' perception and their actual practice are discussed.

A clinical model for the assessment of posture and balance in people with stroke

PURPOSE

The lack of models to define and describe rehabilitation processes have often been identified as limiting research and the development of clinical practice. This study describes the development of a clinical model to address a key aspect of stroke physiotherapy--the assessment of posture and balance.

METHOD

Twenty seven experienced neurological physiotherapists (PT) in six focus groups were used. Participants were shown photographs of a typical stroke patient in sitting and standing positions and were asked 'What would you note if you were assessing the posture and balance of this patient?' Answers were displayed on flip charts to allow immediate feedback about the accuracy and completeness of data. Thematic content analysis was then used.

RESULTS

A complex reasoning process emerged to answer three main questions: What can the patient do? How does s/he do it? Why does s/he do it that way? To answer these questions physiotherapists established balance disability (by observing the patient's ability to perform a series of increasingly demanding balance tasks), identified postural and movement impairments (by observing alignment and movement of body segments relative to each other and to the expected norm for that patient) and assessed muscle activity (by observation and palpation).

CONCLUSIONS

Focus groups have been used to elicit a clinical model for the assessment of posture and balance, the content of which will be used to inform a new outcome measure.

The immediate effect of handling technique on range of movement in the hemiplegic shoulder

PURPOSE

To assess the immediate effect of two different handling. techniques on range of flexion in the hemiplegic shoulder.

METHOD

A randomized controlled design with within-subject comparison was used. Range of shoulder flexion was measured using a bubble goniometer. Range of passive movement was compared as the weak arm was lifted using an 'axilla hold' (when the gleno-humeral joint is supported and held in external rotation) and a 'distal hold' (when the arm is lifted at the forearm without shoulder support). Twenty-two people with arm weakness following stroke were recruited. They were inpatients or attending a day hospital in two NHS trusts, with no previous limitation of range or function of their arm. A paired t-test was used for analysis.

RESULTS

Mean shoulder flexion for the axilla hold was 115.2 degrees (SD 38.45), and 97.7 degrees (SD 44.7) for the distal hold. This difference was significant at p < 0.001 (95% confidence interval (95% CI) 7.96, 26.88).

CONCLUSIONS

Lifting the hemiplegic arm by holding the humerus under the axilla and maintaining external rotation produces greater range of flexion at the hemiplegic shoulder than a 'distal hold'.

The effect of a hinged ankle foot orthosis on hemiplegic gait: objective measures and users' opinions

OBJECTIVE

To assess the effect of a hinged ankle foot orthosis (AFO) on functional mobility and gait impairments in people with a severe hemiplegia undergoing rehabilitation, and to investigate the patients' views of the hinged AFO.

DESIGN

With/without group comparison, and face-to-face questionnaire.

SUBJECTS AND SETTING

Twenty-five subjects over 18 years, with a hemiplegia following cerebrovascular accident (CVA) undergoing rehabilitation in a regional rehabilitation unit.

OUTCOME MEASURES

Functional Ambulation Categories as a measure of disability. Paper walkways to measure gait impairments--stride length, step length, symmetry, cadence and velocity. Face-to-face questionnaire to determine the users' opinion of the hinged AFO.

RESULTS

Comparison of gait with and without the hinged AFO showed significant improvements in functional mobility (p = 0.000) and in some gait impairments; stride length of the weak (p < 0.005, 95% CI -8.1, -1.6) and sound legs (p < 0.014, 95% CI -8, -1), velocity (p = 0.00, 95% CI -0.1, -0.03) and cadence (p < 0.002, 95% CI -15.1, -3.8). No effect was found for step length in the weak or sound leg or symmetry. The subjects' response was positive, 24 (96%) felt they walked better with the AFO and found it comfortable. Twenty-three (92%) were unbothered by the appearance and 16 (64%) could doff and don it.

CONCLUSION

The hinged AFO improved objective measures of gait impairments and disability and patients were positive about it.

The process of stroke rehabilitation: what happens and why

OBJECTIVE

To assess the process of hospital-based stroke rehabilitation.

DESIGN

A criterion-based process audit, combined with surveys of patient and staff opinions and basic outcome measures.

SETTING

All wards and units treating stroke patients in a health care district, including an acute and a community National Health Service (NHS) trust.

SUBJECTS

Process audit: documented notes of 115 stroke patients admitted over a four-month period. Patient satisfaction survey: 93 surviving stroke patients. Staff opinion survey: Hospital doctors, therapists and nurses treating stroke patients throughout the district.

RESULTS

A disappointingly poor level of service. The main shortcomings were poor assessment of impairment (pass rate, 46%), inadequate communication between staff and with patients and carers (pass rate, 43%), and an absence of rehabilitation beyond the basic of activities of daily living and indoor mobility (pass rate for assessment of disability and emotional need, 50%). Thirty-three per cent of patients were dissatisfied with the hospital-based service they received, particularly lack of therapy, information and recovery. The main reasons for these shortcomings were low priority given to stroke patients, lack of time, shortage of staff, and lack of knowledge and awareness of stroke amongst the staff. Rehabilitation units and elderly care tended to perform better than general medical units in areas of assessment of impairment, self-care skills and mobility, and wheelchair provision.

CONCLUSIONS

Evidence from previous publications suggests that this service was no worse than in other districts, but this audit methodology, by comprehensively examining many aspects of a service together, is better able to reveal inadequacies.

Trunk kinematics in hemiplegic gait and the effect of walking aids

OBJECTIVE

To establish baseline measurements of trunk movements during hemiplegic gait, to assess the relationship between trunk movements and walking ability, and to investigate the effect of walking aids on the trunk movements.

METHOD

Twenty subjects with a chronic hemiplegia from a stroke, who could walk independently, were recruited. Lateral and vertical movements of the pelvis, and symmetry of these movements were measured using CODA (a three-dimensional movement analysis system) as the subjects walked at their own pace without an aid. They were also tested as they walked with a stick and a tripod to assess the effect of different walking aids. Mean values for the trunk movements and symmetry were calculated, Pearson's correlations assessed the relationship between each trunk movement and gait velocity (a measure of overall walking ability), and the influence of the different aids was assessed using a one-way repeated measures ANOVA.

RESULTS

Lateral displacement was large (mean = 9.9 cm, SD 3.9) and orientated to the sound side, vertical displacement was small (mean = 2.45 cm, SD 1.4). The movements showed marked asymmetry which favoured the hemiplegic side in that there was less movement of, or towards this side. There was a significant relationship (at 5% level) between walking ability and lateral movements (r = 0.6), but not vertical movements (r= 0.41). No significant differences were found with the different aids.

CONCLUSION

These results give baseline values for trunk movements during hemiplegic gait and the relationship between the movements and walking ability. The use of walking aid and the type of walking aid did not affect the subjects' trunk movements or walking ability.

The support taken through walking aids during hemiplegic gait

OBJECTIVE

To assess the effect of different aids on the amount of support hemiplegic subjects took from them. The relationship between the amount of support, severity of hemiplegia and walking ability were also assessed.

DESIGN

Hemiplegic subjects' gait and the amount of support they took from the aid were measured as they walked with a normal height stick, a high stick and a tripod.

SUBJECTS

Fifteen subjects with a hemiplegia of more than three months' duration who could walk independently were recruited.

OUTCOME MEASURES

Velocity, the gross function section of the Rivermead Motor Assessment, percentage bodyweight taken through the aid, the aid contact time, the placement of the aid, and the lateral shift of the pelvis when weight bearing were assessed.

RESULTS

No differences in the amount of support or walking ability were found with the different aids. There was a significant relationship between severity of hemiplegia and the percentage of bodyweight taken through the aid (r= -0.67), between aid contact time and severity of hemiplegia (-0.53) and between aid contact time and walking ability (-0.53). No relationship between walking ability and other measures of the amount of support was found.

CONCLUSIONS

Different types of aid did not influence the amount of support taken by hemiplegic subjects. These results contradict the beliefs of many neurological physiotherapists in Britain and the clinical implications are discussed.