Britt Normann

Responsiveness and Clinically Meaningful Improvement, According to Disability Level, of Five Walking Measures After Rehabilitation in Multiple Sclerosis A European Multicenter Study

Background. Evaluation of treatment effects on walking requires appropriate and responsive outcome measures. Objectives. To determine responsiveness of 5 walking measures and provide reference values for clinically meaningful improvements, according to disability level, in persons with multiple sclerosis (pwMS). Methods. Walking tests were measured pre- and postrehabilitation in 290 pwMS from 17 European centers. Combined anchor- and distribution-based methods determined responsiveness of objective short and long walking capacity tests (Timed 25-Foot Walk [T25FW] and 2- and 6-Minute Walk Tests [2MWT and 6MWT] and of the patient-reported Multiple Sclerosis Walking Scale–12 [MSWS-12]). A global rating of change scale, from patients’ and therapists’ perspective, was used as external criteria to determine the area under the receiver operating characteristic curve (AUC), minimally important change (MIC), and smallest real change (SRC). Patients were stratified into disability subgroups (Expanded Disability Status Scale score ≤4 [n = 98], >4 [n = 186]). Results. MSWS-12, 2MWT, and 6MWT were more responsive (AUC 0.64-0.73) than T25FW (0.50-0.63), especially in moderate to severely disabled pwMS. Clinically meaningful changes (MICs) from patient and therapist perspective were −10.4 and −11.4 for MSWS-12 (P < .01), 9.6 m and 6.8 m for 2MWT (P < .05), and 21.6 m (P < .05) and 9.1 m (P = .3) for 6MWT. In subgroups, MIC was significant from patient perspective for 2MWT (10.8 m) and from therapist perspective for MSWS-12 (−10.7) in mildly disabled pwMS. In moderate to severely disabled pwMS, MIC was significant for MSWS-12 (−14.1 and −11.9). Conclusions. Long walking tests and patient-reported MSWS-12 were more appropriate than short walking tests in detecting clinically meaningful improvement after physical rehabilitation, particularly the MSWS-12 for moderate to severely disabled pwMS.

Embodied-enactive clinical reasoning in physical therapy

Abstract Clinical reasoning is essential in physical therapy practice. Instrumental approaches and more recent narrative approaches to clinical reasoning guide physical therapists in their understanding of the patient’s movement disturbances and help them to plan strategies to improve function. To the extent that instrumental and/or narrative models of clinical reasoning represent impairments as mere physical disturbances, we argue that such models remain incomplete. We draw on a phenomenologically inspired approach to embodied cognition (termed “enactivism”) to suggest that the dynamics of lived bodily engagement between physical therapist and patient contribute to and help to constitute the clinical reasoning process. This article outlines the phenomenologically informed enactive perspective on clinical reasoning, with special reference to clinical work that addresses impairments as sequelae of neurological diseases.

Patient satisfaction and perception of change following single physiotherapy consultations in a hospital's outpatient clinic for people with multiple sclerosis

The aim of this study was to investigate satisfaction with physiotherapy and perception of change following single physiotherapy consultations in a hospitals outpatient service for people with multiple sclerosis (MS) (PwMS). The consultation included assessment, exploration of treatment, information, and instruction in self-assisted exercises based on the British guidelines for PwMS. Seventy-two PwMS were consecutively included, 54 women and 18 men with a mean age 45 (range 26–80). The Outpatient Experience Questionnaire (OPEQ) was used to record satisfaction; the Patient Global Impression of Change (PGIC) and the Borgs Rating Scale of Perceived Exertion (BRSPE) were used to investigate perceived changes in standing up, sitting down, and walking following the consultation. Sixty-four patients (89%) returned the OPEQ. The results showed strong satisfaction with physiotherapy regarding both interpersonal and clinical skills (mean 9.4, SD 1.0, best score 10) and no significant differences regarding the level of ambulatory independence, gender, or age. The PGIC indicated perceived short-term improvement for 35 (57%) patients, with no patients reporting deterioration. The BRSPE showed a significantly lower perception of exertion during walking after the consultation (Wilcoxon signed-rank test, Z–2.58, p = 0.010). The study indicates a high level of satisfaction regarding interpersonal and clinical skills, information, and instruction in self-assisted exercises and indicates that perceptions of short-term improvement may occur after single consultations. The study suggests an important role for physiotherapy in hospital outpatient services for PwMS, but further studies are necessary to deepen our understanding.

Embodiment and self in reorientation to everyday life following severe traumatic brain injury.

Abstract People with severe traumatic brain injury (sTBI) are often young and need long-term follow-up as many suffer complex motor, sensory, perceptual and cognitive impairments. This paper aims to introduce phenomenological notions of embodiment and self as a framework to help understand how people with sTBI experience reorientation to everyday life, and to inform clinical practice in neurological physiotherapy. The impairments caused by the sTBI may lead to a sense of alienation of ones own body and changes in operative intentionality and in turn disrupt the reorganization of self, identity, everyday life and integration/co-construction of meaning with others. Applying a first-person conception of the body may extend insights into the importance of an adapted and individualized approach to strengthen the sensory, perceptual and motor body functions, which underpin the pre-reflective and reflective aspects of the self. It seems important to integrate these aspects, while also paying attention to optimizing co-construction of meaning for the person with sTBI in the treatment context. This requires understanding the patient as an experiencing and expressive body, a lived body (body-as-subject) and not just the body-as-object as is favored in more traditional frameworks of physiotherapy.

Innovative Physiotherapy and Continuity of Care in People with MultipleSclerosis: A Randomized Controlled Trial and a Qualitative Study

Background: Individuals with Multiple Sclerosis (MS) frequently present balance and walking problems; in which reduced trunk stability, often termed core stability, is one essential aspect. A new group-based, individualized core stability training (GroupCoreSIT) is developed and will be evaluated in terms of effects, users’ perceptions, performance and coordination of care. Methods: The study consists of two related parts: 1) a prospective randomized controlled trial (RCT), and 2) a qualitative study. The RCT will be conducted in six municipalities to evaluate the effects of GroupCoreSIT on people with MS compared to standard care. The intervention addresses movement quality in core and balance training highlighting the following elements: dynamic stability, sensory stimulation, specificity, individualization, intensity, and teaching. GroupCoreSIT will be offered three hours per week for 6 weeks, complemented with unsupervised home exercises, with a 6-month follow-up. Seventy-to ambulant people with MS will be included, baseline tested and randomized to intervention and control group. Assessor blinded standardized outcome measurements will be carried at 1-week, 3-month and 6-month post-intervention. The qualitative study will include: i) qualitative interviews conducted twice with 12 participants from each group, at 1-week and 6-month post intervention, aimed to increase the knowledge about short and long-term experiences with GroupCoreSIT and standard care; ii) 12 observations and 12 qualitative interviews with physiotherapists conducting GroupCoreSIT, aimed to identify essential aspects of physiotherapy performance and perceptions related to delivery of intervention; and iii) qualitative interviews conducted twice with 16-20 health professionals in hospital and municipalities, focusing on intensive programs in the coordination of care for people with MS. Conclusion: Evaluation of the efficacy of GroupCoreSIT, participants’ perceptions, physiotherapists’ performance and reflections, and health professionals’ deliberations regarding coordination of intensive programs will provide information for evidence based selection of physiotherapy in ambulatory people with MS.

Group-based individualized core stability and balance training in ambulant people with multiple sclerosis: a pilot feasibility test–retest study

Abstract Group-based physiotherapy is underexplored in people with multiple sclerosis (MS) and interventions integrating underlying aspects of balance are required. This study aimed to investigate the feasibility of a new group-based individualized core stability intervention (GroupCoreSIT) and the short-term effects on balance and walking in people with MS. A test–retest design was chosen and 12 ambulant people with MS included. GroupCoreSIT was performed three times a week for 5 weeks. Outcomes were measured using the Trunk Impairment Scale – Norwegian Version (TIS-NV), Timed 25 Foot Walking (T25FW), Two-Minute Walk Test (2MWT), Six-Minute Walk Test (6MWT), MS Walking Scale 12 (MSWS-12), Multiple Sclerosis Impact Scale 29 – Norwegian Version (MSIS 29-NV), Patient Global Impression of Change (PGICwalking, PGICgeneral health) and Visual Analogue Scale balance and walking (VASbalance/VASwalking). Significant improvement was demonstrated in sitting balance, TIS-NV (p = 0.003*), and walking tests T25FW (usual speed, p = 0.008, fastest speed, p = 0.005*), 2MWT (p = 0.026*) and 6MWT (p = 0.006*). Self-reported outcomes showed significant improvements: MSWS-12 (p = 0.003*), MSIS 29-NV (p = 0.005*) and VASbalance (p = 0.017*), but VASwalking did not show significant improvement (p = 0.088) (*significant p values after Bonferroni correction). This study provides preliminary evidence for the feasibility and effectiveness of GroupCoreSIT. An assessor-blinded randomized controlled trial is required to confirm these findings.

Somatosensory impairments and upper limb function following stroke: Extending the framework guiding neurological physiotherapy

Abstract Disturbances in the somatosensory system are common following stroke but are often neglected during the rehabilitation of upper limb function. Physical therapists’ theoretical understanding of the body, including somatosensory capacities, is important for clinical decision making. In this article, we introduce theoretical notions based on phenomenology of the body to provide subjectivity status to the body and argue for the application of this understanding to improve clinical practice. Subjectivity status to the body implies a conception of the body as the centre of experience and expression simultaneously with it being a biological mechanism. Somatosensory modalities are considered as integral aspects of the experiencing and expressing body (the embodied self) and therefore need to be studied as integrated rather than isolated neurophysiological events. These body functions support intentionality, ownership and the sense of being in control of ones own movement to enable interaction with the surroundings and other people. Disturbances of the somatosensory system affect vital aspects of the embodied self, and training in these capacities may strengthen the experiencing and expressing body. We apply this framework to clinical examples and discuss the implications of a deeper understanding of somatosensory disturbances following stroke; we also discuss the potential of this framework to influence clinical decision making to further develop neurological physiotherapy.

Rehabilitation including treadmill therapy for patients with incomplete locked-in syndrome after stroke; a case series study of motor recovery

Primary objective: The aim of this study was to explore changes in motor function in patients with incomplete LIS referred to rehabilitation. Research design: A prospective, explorative, multiple case study design was applied. Methods and procedures: A multidisciplinary intervention programme was conducted including treadmill therapy (TT) with body weight support. Patients being able to stand upright supported by a standing frame were consecutively recruited to TT from 2001–2005. Physical performance was recorded on video and treadmill data were registered. Performances of transfer and walking were selected as the focus of observation. Two external observers described the performances independently, using an observational form and validated the joint and condensed descriptions. Outcomes and results: A total of nine patients fulfilled the intervention programme and no adverse events were noted. Personal assistance and body weight support were reduced during the TT period and all patients demonstrated improved physical performance. While five patients were able to practice some kind of walking activity at the end of rehabilitation, four patients demonstrated improvement in body functions, showing better postural control. Conclusion: This study indicates that TT can be a safe and useful method to intensify the rehabilitation programme for patients with incomplete LIS.

How is individualization in constraint-induced movement therapy performed? A qualitative observational study

Abstract The aim of the study was to investigate relationships between the design of tasks and impairments in constraint-induced movement therapy (CIMT) and significant principles of in situ individualization in group-based performance of the intervention, focusing on quality of performance versus compensatory strategies in the more affected upper limb. Non-participatory observations of four individuals undergoing CIMT group training with a physiotherapist were conducted, followed by theme-based content analysis using concepts from practice knowledge and movement analysis as analytical tools. The material was characterized by the physiotherapist focusing on the quality of movements by interacting and making a variety of adjustments. Most tasks were too challenging in terms of shoulder stability and were performed using compensatory strategies. It appeared essential that participants’ could solve the task with optimal movement quality in addition to experiencing meaning and success. In conclusion, the physiotherapist’s individualizations in situ appeared to be based on goal attainment through optimization of movement quality. Interlinking the design of tasks with the individual patient’s underlying impairments, elements from activities in daily life and sense-making seem essential. Impairments occurred owing to high demands of dynamic stability in the shoulder, which may be a reason why participants in CIMT often use compensatory strategies.

Comprehensive core stability intervention and coordination of care in acute and subacute stroke rehabilitation—a pilot study

Abstract Purpose: To investigate the feasibility and preliminary effects of new intervention emphasising core stability training integrated in functional activity (I-CoreDIST), supported by clinical Skype sessions to coordinate between health care levels among acute stroke patients. Methods: A baseline-, 4- and 12-week post-test design, including 13 individuals with acute stroke who received I-CoreDIST 5–6 day/week for 30–60 min as inpatients and three times a week as outpatients, for a total of 12 weeks. Primary outcomes: Trunk Impairment Scale-Norwegian Version (TIS-NV) and Swedish Postural Assessment Scale for Stroke-Norwegian Version (SwePASS-NV). Secondary outcomes: The Mini-BESTest, 10-m Walk Test, 2-min Walk Test, ActiGraphWgt3X-BT monitors and Questback. Linear mixed models and non-parametric tests were used for the analysis. Results: The TIS-NV demonstrated significant within-group improvements: mean difference 2.36 points at 4 weeks (p = .006) and 5.09 points at 12 weeks (p < .000) compared to baseline. The SwePASS-NV showed significant within-group improvements compared to baseline: mean difference 6.91 points at 4 weeks (p = .005) and 9.64 points at 12 weeks (p < .000). The secondary outcomes showed significant within-group improvements at 12 weeks. The Skype sessions are valuable but not applicable prior to discharge. Conclusions: I-CoreDIST is feasible, indicate effects, and Skype sessions should be re-scheduled. Randomised controlled trials are warranted.