Treadmill training to improve mobility for people with sub-acute stroke: a phase II feasibility randomized controlled trial.

OBJECTIVE: This phase II study investigated the feasibility and potential effectiveness of treadmill training versus normal gait re-education for ambulant and non-ambulant people with sub-acute stroke delivered as part of normal clinical practice. DESIGN: A single-blind, feasibility randomized controlled trial. SETTING: Four hospital-based stroke units. SUBJECTS: Participants within three months of stroke onset. INTERVENTIONS: Participants were randomized to treadmill training (minimum twice weekly) plus normal gait re-education or normal gait re-education only (control) for up to eight weeks. MAIN MEASURES: Measures were taken at baseline, after eight weeks of intervention and at six-month follow-up. The primary outcome was the Rivermead Mobility Index. Other measures included the Functional Ambulation Category, 10-metre walk, 6-minute walk, Barthel Index, Motor Assessment Scale, Stroke Impact Scale and a measure of confidence in walking. RESULTS: In all, 77 patients were randomized, 39 to treadmill and 38 to control. It was feasible to deliver treadmill training to people with sub-acute stroke. Only two adverse events occurred. No statistically significant differences were found between groups. For example, Rivermead Mobility Index, median (interquartile range (IQR)): after eight weeks treadmill 5 (4-9), control 6 (4-11) p = 0.33; or six-month follow-up treadmill 8.5 (3-12), control 8 (6-12.5) p = 0.42. The frequency and intensity of intervention was low. CONCLUSION: Treadmill training in sub-acute stroke patients was feasible but showed no significant difference in outcomes when compared to normal gait re-education. A large definitive randomized trial is now required to explore treadmill training in normal clinical practice.

A systematic review and meta-analysis of selected motor learning principles in physiotherapy and medical education.

BACKGROUND: Learning of procedural skills is an essential component in the education of future health professionals. There is little evidence on how procedural skills are best learnt and practiced in education. There is a need for educators to know what specific interventions could be used to increase learning of these skills. However, there is growing evidence from rehabilitation science, sport science and psychology that learning can be promoted with the application of motor learning principles. The aim of this review was to systematically evaluate the evidence for selected motor learning principles in physiotherapy and medical education. The selected principles were: whole or part practice, random or blocked practice, mental or no additional mental practice and terminal or concurrent feedback. METHODS: CINAHL, Cochrane Central, Embase, Eric and Medline were systematically searched for eligible studies using pre-defined keywords. Included studies were evaluated on their risk of bias with the Cochrane Collaboration's risk of bias tool. RESULTS: The search resulted in 740 records, following screening for relevance 15 randomised controlled trials including 695 participants were included in this systematic review. Most procedural skills in this review related to surgical procedures. Mental practice significantly improved performance on a post-acquisition test (SMD: 0.43, 95% CI 0.01 to 0.85). Terminal feedback significantly improved learning on a transfer test (SMD: 0.94, 95% CI 0.18 to 1.70). There were indications that whole practice had some advantages over part practice and random practice was superior to blocked practice on post-acquisition tests. All studies were evaluated as having a high risk of bias. Next to a possible performance bias in all included studies the method of sequence generation was often poorly reported. CONCLUSIONS: There is some evidence to recommend the use of mental practice for procedural learning in medical education. There is limited evidence to conclude that terminal feedback is more effective than concurrent feedback on a transfer test. For the remaining parameters that were reviewed there was insufficient evidence to make definitive recommendations.

Inter- and Intrarater Reliability of the Infant Motor Profile in 3- to 18-Month-Old Infants.

PURPOSE: To investigate inter- and intrarater reliability scoring the Infant Motor Profile (IMP). METHODS: A total of 20 infants at risk for motor developmental delay were assessed using the IMP. Six infants were born at term (gestational age: 38-42 weeks), and 14 infants were preterm (gestational age: 24-35 weeks). Videos were analyzed twice with an interval of 1 month by 4 assessors after 2 days of IMP training. RESULTS: Spearman rank scores demonstrated strong interrater and intrarater reliability for total IMP scores (inter: r = 0.80-0.96; intra: r = 0.85-0.97) and the domain of performance (r = 0.95-0.99). Reliability for the domains of variation, variability, and fluency was satisfactory (inter: r = 0.15-0.85; intra: r = 0.30-0.92). The weakest agreement was found in the domain of symmetry (inter: r = 0.20-0.69; intra: r = 0.33-0.65). CONCLUSION: Therapists naive to the IMP demonstrate good intra and interrater reliability (after 2 days of training) for most domains with the exception of symmetry.

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.

Experience of an upper limb training program with a non-immersive virtual reality system in patients after stroke: a qualitative study.

OBJECTIVES: The YouGrabber (YG) is a new virtual reality training system that focuses on unilateral and bimanual activities. This nested study was part of a larger multicenter randomized controlled trial and explored experiences of people with chronic stroke during a 4 weeks intensive upper limb training with YG. DESIGN: A qualitative design using semi-structured, face-to-face interviews. A phenomenological descriptive approach was used, with data coded, categorized and summarized using a thematic analysis. Topics investigated included: the experience of YG training, perceived impact of YG training on arm function, and the role of the treating therapist. RESULTS: Five people were interviewed (one female, age range 55 to 75 years, 1 to 6 years poststroke). Seven main themes were identified: (1) general experience, (2) expectations, (3) feedback, (4) arm function, (5) physiotherapist's role, (6) fatigue, (7) motivation. Key experiences reported included feelings of motivation and satisfaction, with positive factors identified as challenge, competition, fun and effort. The YG training appeared to trigger greater effort, however fatigue was experienced at the end of the training. Overall, patients described positive changes in upper limb motor function and activity level, e.g. automatic arm use. While the opportunity for self-practice was appreciated, input from the therapist at the start of the intervention was deemed important for safety and confidence. CONCLUSIONS: Reported experiences were mostly positive and the participants were motivated to practice intensively. They enjoyed the challenging component of the games.

Acquisition of Procedural Skills in Preregistration Physiotherapy Education Comparing Mental Practice Against No Mental Practice: The Learning of Procedures in Physiotherapy Education Trial - A Development of Concept Study.

INTRODUCTION: Procedural skills are a central element in the education of physiotherapists. Procedural skills relate to the execution of a practical task. An educational intervention, which can be used to support skill acquisition of procedural skills, is mental practice (MP). Several studies have investigated the use of MP or imaging in medical education. This pilot study evaluated the application of MP on the acquisition of procedural skills in physiotherapy education. METHODS: This pilot randomised controlled study recruited a convenience sample of 37 BSc physiotherapy student participants. Two different complex task procedures (transfer and vestibular rehabilitation) were trained during this study. Participants in both the transfer (task procedure 1) and the vestibular rehabilitation (task procedure 2) arm of the study were randomly assigned to either MP or no MP. RESULTS: For the transfer task, median performance at post-acquisition testing showed a moderate effect size in favour of the group using MP (r: -0.3), but the findings were not statistically significant (P: 0.2). Similar results were found for the vestibular rehabilitation task (r: 0.29; P: 0.21). In addition, the self-reported confidence was higher in the MP group. CONCLUSION: Moderate effect sizes were identified in favour of MP at post-acquisition testing. In addition, the between-group difference was higher than the minimally important difference. The feasibility of the study was high based on quantitative feasibility measures such as the recruitment rate. Both these findings suggest larger well-powered studies should be considered to confirm the findings of this pilot study.

The assessment of procedural skills in physiotherapy education: a measurement study using the Rasch model.

BACKGROUND: Procedural skills are a key element in the training of future physiotherapists. Procedural skills relate to the acquisition of appropriate motor skills, which allow the safe application of clinical procedures to patients. In order to evaluate procedural skills in physiotherapy education validated assessment instruments are required. Recently the assessment of procedural skills in physiotherapy education (APSPT) tool was developed. The overall aim of this study was to establish the structural validity of the APSPT. In order to do this the following objectives were examined: i) the fit of the items of APSPT to the Rasch-model, ii) the fit of the overall score to the Rasch model, iii) the difficulty of each test item and iv) whether the difficulty levels of the individual test items cover the whole capacity spectrum of students in pre-registration physiotherapy education. METHODS: For this observational cross-sectional measurement properties study a convenience sample of 69 undergraduate pre-registration physiotherapy students of the HES-SO Valais-Wallis was recruited. Participants were instructed to perform a task procedure on a simulated patient. The performance was evaluated with the APSPT. A conditional maximum likelihood approach was used to estimate the parameters of a partial credit model for polytomous item responses. Item fit, ordering of thresholds, targeting and goodness of fit to the Rasch model was assessed. RESULTS: Item fit statistics showed that 25 items of the APSPT showed adequate fit to the Rasch model. Disordering of item thresholds did not occur and the targeting of the APSPT was adequate to measure the abilities of the included participants. Undimensionality and subgroup homogeneity were confirmed. CONCLUSION: This study presented evidence for the structural validity of the APSPT. Undimensionality of the APSPT was confirmed and therefore presents evidence that the latent dimension of procedural skills in physiotherapy education consists of several subcategories. However, the results should be interpreted with caution given the small sample size.

A comparison of treadmill walking and overground walking in independently ambulant stroke patients: a pilot study.

Purpose. The purpose of the study was to compare the spatio-temporal and joint kinematic gait parameters of stroke patients walking on a treadmill and overground, to examine the assumption that patients walking on a treadmill will approximate the requirements of walking overground. Methods. Ten independently ambulant chronic stroke patients were included in the study. Vicon was used to collect spatio-temporal and joint kinematic data during overground walking at comfortable speed and at matched speed on the treadmill. Results. Walking on the treadmill demonstrated statistically significantly lower cadence, and longer step times of the non-hemiplegic and hemiplegic limbs. Absolute stance times of both limbs, absolute double support time, relative stance time and relative double support time were significantly longer during treadmill walking. Compared to overground walking, the inter-limb symmetries of step time, stance time, and stance/swing time ratio were significantly greater on the treadmill. During treadmill walking, joint kinematic data showed statistically significant changes with greater flexion of the nonhemiplegic knee and hip at initial contact, and less hip extension of the hemiplegic limb. Maximal ankle plantarflexion and knee extension of the hemiplegic limb occurred later in the gait cycle on the treadmill. Conclusion. These differences suggest it may be useful to use treadmill in conjunction with overground walking to focus on improving specific walking deficits in patients with stroke.

Stepping onto a single step: a kinematic study.

BACKGROUND AND PURPOSE: To describe the timings and ranges of linear displacements of the pelvis and feet occurring in a healthy older population when stepping up onto a step, and to describe variations noted in a small sample of subjects with hemiplegia. METHOD: An observational case series study design was used and the study took place in a gait laboratory in a general hospital. A convenience sample of 54 healthy volunteers (mean age 57.6 years, range 40-90 years; 26 males, 28 females) and six subjects with chronic hemiplegia (mean age 61.7 years, range 47-70 years; five males, one female) was recruited. Participants stepped up onto an 18 cm step. The following outcome measures were made: kinematic measures of stepping up cycle time; pelvic lateral displacement; width of foot base; and height of heel clearance by use of CODA (a three-dimensional movement analysis system). RESULTS: The mean (standard deviation, SD) stepping up cycle of healthy subjects was 1.68 seconds (+/- 0.22 seconds). The total range of pelvic lateral displacement during one stepping up cycle was 70 mm. Pelvic lateral displacement was asymmetrical, being significantly greater towards the initial weightbearing leg (p<0.0001). Older subjects (aged 60+ years) had less heel clearance (p<0.03) than younger subjects (aged <60 years). Stepping up performance by subjects with hemiplegia showed wide inter-subject variability, and was observed to be as much as three times slower to use as much as four times the range of pelvic lateral displacement and twice the foot base, and to be asymmetrical in timing of the stepping up cycle. CONCLUSIONS: This kinematic study describes a healthy stepping up pattern not previously reported. Age and hemiplegia influenced the amount and speed of movement adopted during the task. Information about the movement strategies used by the elderly and those with hemiplegia should guide physiotherapists in their management of physical function.

User involvement in a Cochrane systematic review: using structured methods to enhance the clinical relevance, usefulness and usability of a systematic review update.

BACKGROUND: This paper describes the structured methods used to involve patients, carers and health professionals in an update of a Cochrane systematic review relating to physiotherapy after stroke and explores the perceived impact of involvement. METHODS: We sought funding and ethical approval for our user involvement. We recruited a stakeholder group comprising stroke survivors, carers, physiotherapists and educators and held three pre-planned meetings during the course of updating a Cochrane systematic review. Within these meetings, we used formal group consensus methods, based on nominal group techniques, to reach consensus decisions on key issues relating to the structure and methods of the review. RESULTS: The stakeholder group comprised 13 people, including stroke survivors, carers and physiotherapists with a range of different experience, and either 12 or 13 participated in each meeting. At meeting 1, there was consensus that methods of categorising interventions that were used in the original Cochrane review were no longer appropriate or clinically relevant (11/13 participants disagreed or strongly disagreed with previous categories) and that international trials (which had not fitted into the original method of categorisation) ought to be included within the review (12/12 participants agreed or strongly agreed these should be included). At meeting 2, the group members reached consensus over 27 clearly defined treatment components, which were to be used to categorise interventions within the review (12/12 agreed or strongly agreed), and at meeting 3, they agreed on the key messages emerging from the completed review. All participants strongly agreed that the views of the group impacted on the review update, that the review benefited from the involvement of the stakeholder group, and that they believed other Cochrane reviews would benefit from the involvement of similar stakeholder groups. CONCLUSIONS: We involved a stakeholder group in the update of a Cochrane systematic review, using clearly described structured methods to reach consensus decisions. The involvement of stakeholders impacted substantially on the review, with the inclusion of international studies, and changes to classification of treatments, comparisons and subgroup comparisons explored within the meta-analysis. We argue that the structured approach which we adopted has implications for other systematic reviews.

Challenges in integrating international evidence relating to stroke rehabilitation: experiences from a Cochrane systematic review.

There are many randomized controlled trials relating to stroke rehabilitation being carried out in China, which are often published in Chinese-language journals. A recent update to our Cochrane systematic review of physical rehabilitation to improve function and mobility after stroke included 96 trials; over half (51) were conducted in China; 37 of these included studies were published in Chinese. Analyses within this Cochrane review support the conclusion that physical rehabilitation, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke. The inclusion of the Chinese studies had a substantial impact on the volume of evidence and, consequently, the conclusions. In this paper, we explore whether it is appropriate to draw implications for clinical practice throughout the world from evidence relating to a complex rehabilitation intervention delivered within one particular geographical healthcare setting. We explore the unique challenges associated with incorporating the body of evidence from China, particularly the Chinese-language publications, and identify the ongoing debate about the quality of Chinese research publications. We conclude that the growing body of evidence from China has important implications for future systematic reviews and evidence-based stroke care, but analysis and interpretation raise challenges, and improved reporting is critical.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke: a systematic review.

OBJECTIVES: To determine whether there is a difference in global dependency and functional independence in patients with stroke associated with different approaches to physiotherapy treatment. DATA SOURCES: We searched the Cochrane Stroke Group Trials Register (last searched May 2005), Cochrane Central Register of Controlled Trials (CENTRAL) (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. REVIEW METHODS: Inclusion criteria were: (a) randomized or quasi-randomized controlled trials; (b) adults with a clinical diagnosis of stroke; (c) physiotherapy treatment approaches aimed at promoting postural control and lower limb function; (d) measures of disability, motor impairment or participation. Two independent reviewers categorized identified trials according to the inclusion/exclusion criteria, documented the methodological quality and extracted the data. RESULTS: Twenty trials (1087 patients) were included in the review. Comparisons included: neurophysiological approach versus other approach; motor learning approach versus other approach; mixed approach versus other approach for the outcomes of global dependency and functional independence. A mixed approach was significantly more effective than no treatment control at improving functional independence (standardized mean difference (SMD) 0.94, 95% confidence interval (CI) 0.08 to 1.80). There were no significant differences found for any other comparisons. CONCLUSIONS: Physiotherapy intervention, using a 'mix' of components from different 'approaches' is more effective than no treatment control in attaining functional independence following stroke. There is insufficient evidence to conclude that any one physiotherapy 'approach' is more effective in promoting recovery of disability than any other approach.

Establishing the reliability of Mobility Milestones as an outcome measure for stroke.

UNLABELLED: Baer GD, Smith MT, Rowe PJ, Masterton L. Establishing the reliability of mobility milestones as an outcome measure for stroke. Arch Phys Med Rehabil 2003;84:977-81. OBJECTIVE: To establish intrarater, interrater, and test-retest reliability of a standardized measure of mobility, "mobility milestones," incorporating sitting balance, standing balance, and walking ability. DESIGN: Repeated-measures reliability study by using video data of patients with stroke. SETTING: Physiotherapy and rehabilitation departments in Scotland. PARTICIPANTS: Forty physiotherapists recruited from within the Lothian region: 20 senior physiotherapists with at least 3 years of experience working with neurologic patients and 20 staff grade physiotherapists with less than 12 months of experience working with neurologic patients. INTERVENTION: Videotape comprising 40 clips (36 original clips, 4 repeated clips) of stroke patients of differing levels of ability attempting the mobility milestones was produced. After a short training session in the interpretation and application of the mobility milestones, each physiotherapist viewed the tape separately and scored whether the milestone had been achieved or not. This was repeated at a separate test session 2 weeks later. MAIN OUTCOME MEASURE: Score for each mobility milestone. RESULTS: Kappa statistics were used to determine interrater reliability and showed good (.61-.80) to very good (.81-1.0) reliability for 3 of 4 milestones. Intraclass correlation coefficients (ICCs) were used to determine intrarater reliability of the 4 repeated clips and showed 75% of all subjects had high (ICC(2,1)=.91-1.0) reliability. The ICC(2,1) for test-retest reliability showed a similar pattern, with 70% of subjects showing good (.81-.90) or high (.91-1.0) reliability. CONCLUSIONS: The mobility milestones showed favorable levels of reliability when used by experienced or novice physiotherapists. The milestones can be adopted as a simple clinical outcome measure for use with stroke. Further research is required to establish reliability levels when the measure is used by different rehabilitation professionals.