G. Kwakkel

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

Objective: To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke. Methods: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a bestresearch synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score). Results: In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2–8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% CI 0.03–0.23) for effects of high intensity of exercise training to 0.92 (95% CI 0.54–1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% CI 0.07–0.91), treadmill training with or without body weight support, respectively 0.70 (95% CI 0.29–1.10) and 1.09 (95% CI 0.56–1.61), aerobics (SES 0.39; 95% CI 0.05–0.74), external auditory rhythms during gait (SES 0.91; 95% CI 0.40–1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% CI 0.76–2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema. Conclusions: This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.

Cueing training in the home improves gait-related mobility in Parkinson’s disease: the RESCUE trial

Objectives: Gait and mobility problems are difficult to treat in people with Parkinson’s disease. The Rehabilitation in Parkinson’s Disease: Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity. Methods: A single-blind randomised crossover trial was set up, including 153 patients with Parkinson’s disease aged between 41 and 80 years and in Hoehn and Yahr stage II–IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain. Results: Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p<0.001) and timed balance tests (p = 0.003) improved in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up. Conclusions: Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson’s disease.

Effects of external rhythmical cueing on gait in patients with Parkinson's disease: a systematic review

Objective: To critically review studies evaluating the effects of external rhythmical cueing on gait in patients with Parkinsons disease. Methods: Articles published from 1966 to January 2005 were searched by two physiotherapists in MEDLINE, PiCarta, PEDRo, Cochrane, DocOnline, CINAHL and SUMSEARCH. To be included, articles had to investigate the effects of external rhythmical cueing (i.e., auditory, visual or tactile cueing) on gait parameters in patients with idiopathic Parkinsons disease. Both controlled and noncontrolled studies were included. Based on the type of design and methodological quality a meta-analysis or best-evidence synthesis was applied. Results: Twenty-four studies (total number of patients = 626) out of the 159 screened studies were evaluated in this systematic review. Two out of 24 were randomized controlled trails (RCT), both of high methodological quality. One RCT did not focus specifically on external rhythmical cueing of individual patients with Parkinsons disease, but on group exercises in general, including walking with cues. All other studies were pre-experimental studies. Best-evidence synthesis showed strong evidence for improving walking speed with the help of auditory cues. Insufficient evidence was found for the effectiveness of visual and somatosensory cueing. Conclusion: Only one high-quality study, specifically focused on the effects of auditory rhythmical cueing, suggesting that the walking speed of patients with Parkinsons disease can be positively influenced. However, it is unclear whether positive effects identified in the laboratory can be generalized to improved activities of daily living (ADLs) and reduced frequency of falls in the community. In addition, the sustainability of a cueing training programme remains uncertain.

Effectiveness of exercise therapy: A best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinsons disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Rehabilitation, exercise therapy and music in patients with Parkinson's disease: a meta-analysis of the effects of music-based movement therapy on walking ability, balance and quality of life

Recent evidence suggests that music-based movement (MbM) therapy may be a promising intervention to improve gait and gait-related activities in Parkinsons disease (PD) patients, because it naturally combines cognitive movement strategies, cueing techniques, balance exercises and physical activity while focussing on the enjoyment of moving on music instead of the current mobility limitations of the patient. A meta-analysis of RCTs on the efficacy of MbM-therapy, including individual rhythmic music training and partnered dance classes, was performed. Identified studies (K = 6) were evaluated on methodological quality, and summary effect sizes (SES) were calculated. Studies were generally small (total N= 168). Significant homogeneous SESs were found for the Berg Balance Scale, Timed Up and Go test and stride length (SESs: 4.1,2.2,0.11; P-values <0.01; I(2) 0,0,7%, respectively). A sensitivity analysis on type of MbM-therapy (dance- or gait-related interventions) revealed a significant improvement in walking velocity for gait-related MbM-therapy, but not for dance-related MbM-therapy. No significant effects were found for UPDRS-motor score, Freezing of Gait and Quality of Life. Overall, MbM-therapy appears promising for the improvement of gait and gait-related activities in PD. Future studies should incorporate larger groups and focus on long-term compliance and follow-up.

Effects of visual feedback therapy on postural control in bilateral standing after stroke: a systematic review.

OBJECTIVE To establish whether bilateral standing with visual feedback therapy after stroke improves postural control compared with conventional therapy and to evaluate the generalization of the effects of visual feedback therapy on gait and gait-related activities. DESIGN A systematic review. METHODS A computer-aided literature search was performed. Randomized controlled trials and controlled clinical trials, comparing visual feedback therapy with conventional balance treatments were included up to April 2005. The methodological quality of each study was assessed with the the Physiotherapy Evidence Database scale. Depending on existing heterogeneity, studies with a common variable of outcome were pooled by calculating the summary effect-sizes using fixed or random effects models. RESULTS Eight out of 78 studies, presenting 214 subjects, were included for qualitative and quantitative analysis. The methodological quality ranged from 3 to 6 points. The meta-analysis demonstrated non-significant summary effect-sizes in favour of visual feedback therapy for weight distribution and postural sway, as well as balance and gait performance, and gait speed. CONCLUSION The additional value of visual feedback therapy in bilateral standing compared with conventional therapy shows no statistically significant effects on symmetry of weight distribution between paretic and non-paretic leg, postural sway in bilateral standing, gait and gait-related activities. Visual feedback therapy should not be favoured over conventional therapy. The question remains as to exactly how asymmetry in weight distribution while standing is related to balance control in patients with stroke.

Training with inspiratory pressure support in patients with severe COPD.

This study evaluates the effects of training with noninvasive ventilatory support in patients with chronic obstructive pulmonary disease in a randomised, controlled, observer-blinded trial. Twenty-nine patients with chronic obstructive pulmonary disease and with a ventilatory limited exercise capacity (forced expiratory volume in one second <60% predicted, breathing reserve at maximal exercise <20% of maximally voluntary ventilation, resting arterial oxygen tension ≥8 kPa (60 mmHg), end-exercise arterial oxygen saturation measured by pulse oximetry ≥85%) completed an 8-week supervised outpatient cycle exercise programme. Fourteen patients were randomised to training with inspiratory pressure support of 10 cmH2O and 15 patients to training with control (sham) inspiratory pressure support of 5 cmH2O. Outcome measures were the incremental shuttle walking test and a constant-load cycle endurance test at 75% of peak work rate including the measurement of physiological responses, and health status measured using the St. Georges Respiratory Questionnaire. Statistically significant between-group differences were found in favour of the inspiratory pressure support of 10 cmH2O group for improvement in shuttle walking distance (16±17 versus 3±13%), cycle endurance (164±124 versus 88±128%), and the reduction in minute ventilation during exercise (-11±10 versus -2±9%). It was concluded that exercise training with inspiratory pressure support of 10 cmH2O resulted in statistically significantly larger improvements in exercise performance than training with inspiratory pressure support of 5 cmH2O in patients with chronic obstructive pulmonary disease suffering from a ventilatory limited exercise capacity. Inspiratory pressure support of 10 cmH2O may be considered as adjunct during high-intensity exercise training.

The effect of rhythmic somatosensory cueing on gait in patients with Parkinson's disease

BACKGROUND AND AIMS Gait and gait related activities in patients with Parkinsons disease (PD) can be improved with rhythmic auditory cueing (e.g. a metronome). In the context of a large European study, a portable prototype cueing device was developed to provide an alternative for rhythmic auditory cueing: rhythmic somatosensory cueing (RSC, a miniature vibrating cylinder attached to the wrist). We investigated whether PD patients could adapt their walking pattern using RSC under conditions of changing walking speed and the presence of potentially distracting visual flow while walking on a treadmill. METHODS A total of 17 patients with PD participated (mean age 63.4+/-10.3 years; Hoehn-Yahr score 2.5+/-0.9, mean Unified Parkinsons Disease Rating Scale score 49.8+/-13.7, mean disease duration 7.7+/-5.1 years). They performed systematic walking speed manipulations under 4 conditions in a random order: (1) no cue, no visual flow, (2) no cue, visual flow, (3) cue, no visual flow and (4) cue, visual flow. Visual flow in the form of a virtual corridor that moved at the current walking speed was projected on a 2 x 2 m rear-projection screen. The cueing rhythm was set at -10% of preferred stride frequency at each speed. Stride frequency was assessed using peaks in the trajectories of thigh sagittal plane segmental angles. RESULTS Walking with RSC resulted in lower stride frequencies, and thus larger step lengths (p-values <0.05), regardless of walking speed. The presence of visual flow did not impair the use of RSC, as evidenced by the lack of differences between conditions 3 and 4 (p>0.05). CONCLUSION Rhythmic somatosensory cueing may be a viable alternative for auditory cueing and is robust to changes in walking speed and visual distractors.

Measuring fatigue in patients with multiple sclerosis: reproducibility, responsiveness and concurrent validity of three Dutch self-report questionnaires

Purpose. To determine the reproducibility, responsiveness and concurrent validity of Dutch versions of the Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), and Checklist Individual Strength (CIS20R) in patients with multiple sclerosis (MS). Method. Forthy-three ambulatory patients with MS (mean age 48.7 years; SD 7 years; 30 women; median Expanded Disability Status Scale score 3.5) completed the questionnaires twice within 1 week. The Intraclass Correlation Coefficients (ICCs), Bland and Altman analysis, the smallest detectable change (SDC) and the minimal detectable change (MDC) were calculated. Concurrent validity was determined by Pearsons correlation coefficients. Results. ICCs ranged from 0.76 (FSS), to 0.85 (MFIS) to 0.81 (CIS20R). Bland and Altman analysis showed no significant systematic differences between assessments. MDCs were 20.7% (FSS), 19.23% (MFIS), and 17.7% (CIS20R). Pearson correlation coefficients were r = 0.66 (FSS–MFIS), r = 0.54 (MFIS–CIS20R) and r = 0.42 (CIS20R–FSS). Conclusion. Despite good test–retest reliability of FSS, MFIS and the CIS20R, the present study shows that fatigue questionnaires are not very responsive for change in patients with MS. This finding suggests that future trials should monitor profiles of fatigue by repeated measurements rather than pre-post assessments alone. The moderate associations suggest that the three questionnaires largely measure different aspects of perceived fatigue.

Acute effects of inspiratory pressure support during exercise in patients with COPD

The aim of the present study was to evaluate the acute effects of inspiratory pressure support (IPS) of 5 cmH2O (IPS5) and 10 cmH2O (IPS10) on exercise endurance. Forty-five patients with COPD (mean forced expiratory volume in one second (FEV1)=39±14% pred) performed three constant-load endurance tests on a cycle ergometer at 75% of maximal workload. One test was without IPS, one test with IPS5, and one with IPS10. No statistically significant difference was found in exercise endurance between tests without IPS and IPS5 (4.2±2.6 versus 4.4±2.9 min). In contrast, IPS10 resulted in a statistically significant increase in endurance compared with exercise without IPS (6.3±6.7 versus 4.2±2.6 min), as well as compared with exercise with IPS5 (6.3±6.7 versus 4.4±2.9 min). A wide scatter in individual responses to IPS was found, ranging from a deterioration of 1.6 min (−36%) to an improvement of 16.3 min (+445%). In only 15 patients, the increase in endurance exceeded the upper limit of the 95% confidence interval. Stepwise multiple regression analysis showed that maximal inspiratory pressure was the most important determinant of the increase in exercise endurance due to the application of IPS10. It was concluded that in contrast to inspiratory pressure support of 5 cmH2O, the application of inspiratory pressure support of 10 cmH2O during exercise resulted in a statistically significant improvement in exercise endurance in patients with COPD compared with exercise without inspiratory pressure support. However, on an individual basis, large differences in responses were found. Inspiratory muscle weakness was revealed as a determinant of improvement in exercise endurance due to the application of inspiratory pressure support of 10 cmH2O, explaining only 24% of the variance in outcome.