Rachel C. Stockley

An investigation of the use of passive movements in intensive care by UK physiotherapists.

OBJECTIVES To investigate the current use of passive movements (PMs) by National Health Service (NHS) physiotherapists working with sedated and ventilated patients in critical care settings. DESIGN Postal questionnaire. SETTING All open NHS critical/intensive care units in England, Northern Ireland, Scotland and Wales. PARTICIPANTS Physiotherapists working in UK NHS critical/intensive care units. RESULTS Questionnaires were posted to 246 physiotherapists working in intensive care units; 165 (67%) were returned. One hundred and fifty-two respondents routinely treated ventilated and sedated patients, of which 151 (99%) reported utilising PMs. They were used most commonly (>70%) in patients admitted to critical care with medical, neurological or surgical problems. Respondents reported using a median of five repetitions of PMs once daily, and the majority of respondents took joints to the end of range (>78%). Joints most commonly treated included the shoulder, hip, knee, elbow and ankle. Heart rate and blood pressure were monitored by over 84% of respondents during treatment. CONCLUSIONS Whilst there is little empirical evidence to underpin the use of PMs, this study found that PMs were used regularly by 99% of respondents working in NHS critical care settings. Further work is now needed to evaluate the immediate and long-term effects of PMs in critically ill patients to inform and develop future practice.

Move it or lose it?: A survey of the aims of treatment when using passive movements in intensive care

OBJECTIVES To identify the aims of treatment when physiotherapists use passive movements (PMs) for ventilated and sedated patients on intensive care in the UK. METHOD Postal questionnaires distributed to senior physiotherapists working within all National Health Service (NHS) trusts with open level 3 ICU beds. Open questionnaire items surveyed the aims of using PMs in different clinical areas (neurology, cardiology, orthopaedics/trauma, general surgery, medicine, other). RESULTS The vast majority of respondents stated that the aim of using PMs was to maintain joint range of movement (ROM) in ventilated and sedated patients across all clinical areas. Respondents also identified additional uses of PMs for neurological patients. CONCLUSION There appears to be a high level of consensus amongst physiotherapists that PMs influence joint range and that there will be a loss of range if PMs are not carried out. Currently this is not supported by empirical evidence. Therefore, future research should investigate the actual physiological effects of PMs and the clinical reasoning underpinning their use in critically ill patients.

It's more than just physical therapy: reported utilization of physiotherapy services for adults with neuromuscular disorders attending a specialist centre

Purpose: The purpose of this study is to evaluate service users’ perceptions of their utilization of the physiotherapy service at a specialist Neuromuscular Centre and to identify their reasons for and barriers to attending. Method: A prospective survey design, consisting of a 13-item questionnaire was completed by 104 registered users of a physiotherapy service at a Neuromuscular Centre in northwest England. Descriptive statistics was employed to analyse data from Likert style questions and thematic analysis conducted on responses to open-ended questions. Results: Over 79% of respondents were satisfied with the frequency and duration of their treatment. Respondents attended physiotherapy to obtain physical therapy, for general wellbeing and to access specialized resources. Barriers to attendance included work commitments, travel cost and time, and lack of Centre resources. Clients attending physiotherapy valued the specialist service including advice from therapists, perceived benefit from social interaction with other clients and physical therapy. Conclusion: Adults with neuromuscular disorders identified psychosocial as well as physical benefits from attending physiotherapy at the Neuromuscular Centre. The findings highlight the importance of service users’ views in service provision and suggest that a collaborative commitment to patient management could by advantageous when developing physiotherapy services. Implications for Rehabilitation In this study adults with neuromuscular disorders appeared to value the availability of frequent and ongoing access to specialist physiotherapy. In addition to physical gains, this client group consistently reported benefits in psychosocial wellbeing from attendance at physiotherapy A collaborative commitment to patient management between physiotherapy providers and service users with neuromuscular disorders could lead to optimal utilization of physiotherapy services

A blended user centred design study for wearable haptic gait rehabilitation following hemiparetic stroke

Restoring mobility and rehabilitation of gait are high priorities for post-stroke rehabilitation. Cueing using metronomic rhythmic sensory stimulation has been shown to improve gait, but most versions of this approach have used auditory and visual cues. In contrast, we developed a prototype wearable system for rhythmic cueing based on haptics, which was shown to be highly effective in an early pilot study. In this paper we describe a follow-up study with four stroke survivors to inform design, and to identify issues and requirements for such devices to be used in home-based or out-door settings. To this end, we present a blended user-centred design study of a wearable haptic gait rehabilitation system. This study draws on the combined views of physiotherapists, nurses, interaction designers and stroke survivors. Many of the findings were unanticipated, identifying issues outside the scope of initial designs, with important implications for future design and appropriate use.

Acupuncture for joint symptoms related to aromatase inhibitor therapy in postmenopausal women with early-stage breast cancer: a narrative review

Background Aromatase inhibitor-induced musculoskeletal syndrome (AIMSS) leads to discontinuation of aromatase inhibitor therapy in a significant proportion of patients with breast cancer. Acupuncture is popular among cancer patients and has previously been shown to improve symptoms in a range of musculoskeletal complaints. Aim To determine the effectiveness and safety of acupuncture for the management of AIMSS in postmenopausal women with early-stage breast cancer. Methods A literature search was carried out for randomised controlled trials (RCTs) on acupuncture for AIMSS in postmenopausal women with early-stage breast cancer. Characteristics of trials and outcomes were extracted from the retrieved articles, which were also assessed for risk of bias and quality of reporting. Results Four RCTs were retrieved of sample size 32–67 (totalling 190 participants). Compliance with treatment was high and rates of adverse events were low. Of the three two-arm RCTs, two found no difference between acupuncture and sham acupuncture and one found that acupuncture was statistically superior to sham acupuncture. The fourth RCT, which incorporated three arms, found acupuncture and sham acupuncture to be statistically superior to usual care but there was no difference between true and sham acupuncture. Three trials that used non-penetrating sham as the control found no effect of acupuncture over sham, but the one trial that used superficial needle insertion found acupuncture to be superior. Conclusions Acupuncture is safe and results in improvement in AIMSS symptoms, but similar benefits are also elicited by non-penetrating sham acupuncture. Future research should seek to establish the durability of improvements.

The acute physiological and perceptual responses to blood-flow restriction applied during un-resisted knee exercise: a potential treatment adjunct for physiotherapists

Purpose: Blood-flow restriction [BfR] training involves the temporary, artificial reduction of blood flow through a limb. Evidence suggests that BfR combined with low-intensity resistance exercise can minimise the loss of thigh muscle size and strength during periods of impaired weight-bearing. However, evidence is scarce as to the specific utility of adding BfR to un-resisted or ‘no-load’ exercise during injury rehabilitation. Therefore, this case series examined the effects of applying BfR during a no-load lower-limb knee exercise completed by athletes recovering from significant lower limb injuries. Methods: Three professional rugby players provided consent to incorporate BfR training into their injury rehabilitation programmes. (Case one; four weeks post tibia and fibula fracture. Case two; five weeks post Achilles tendon rupture. Case three; immediately following MRI diagnosis of an osseous stress injury of the knee). During the control exercise session, players performed three sets of a seated, un-resisted, single-leg knee-extension exercise. At subsequent sessions, a 21.5 cm wide blood-pressure cuff was used to superimpose BfR over the same exercise. BfR was applied intermittently or continuously across the upper thigh via 100 mmHg or 120 mmHg cuff pressure. Near infra-red spectroscopy [NIRS] monitored tissue oxygen saturation [SmO2] and total haemoglobin mass [tHb] of the vastus lateralis muscle before and during the exercise of each lower-limb. The relative change in SmO2 and tHb generated during each exercise session was then calculated. Session rate of perceived exertion [RPE] was monitored via a 10-point visual scale. Descriptive statistics were then used to indicate trends among these variables. Results: BfR training was delivered four to five times per week for periods of 4 to 12 weeks. NIRS data from thirty BfRT sessions (five sessions per leg, per player) were obtained. Mean resting values for vastus lateralis SmO2 and tHb were 54.3% and 12.72 g/dL respectively. During the control exercise session, SmO2 increased by a mean of 4.68 points, whilst tHb decreased slightly (-0.04 g/dL). In contrast, the addition of continuous BfR at 120 mmHg generated a mean drop in SmO2 of 22.31 points, whilst tHb increased (+0.23 g/dL). No adverse events or pain occurred during any exercise session. The control session generated a mean session RPE of 0.94 out of 10. Session RPE during BfR training ranged between 3.6 and 4.9. Conclusion(s): In a case series of injured athletes, data indicated that adding BfR to a ‘no-load’ knee extension exercise generated oxygen desaturation of the vastus lateralis muscle and increased perceptual exertion. Lower-limb BfR training was delivered in a safe, tolerable way as part of a multi-modal, intensive injury rehabilitation programme. Implications: BfR training may provide Physiotherapists with a novel Method of generating exercise-induced physiological stress within muscle tissue during exercise, without the need to add any external resistance. Achieving sufficient physiological stress during the very early stages of injury rehabilitation via no-load BfR training may promote a muscular response that limits the longitudinal muscle disuse atrophy seen during periods of impaired weight-bearing. Further research is warranted to substantiate this and to explore the utility of no-load BfR training within non-athletic, clinical populations. Funding acknowledgements: This study was funded via a PhD studentship awarded by Manchester Metropolitan University.

Walk to the Beat: A Case Report of the Use of a Novel Haptic Device to Improve Walking after Stroke

Background: Stroke affects 15 million people worldwide every year and leaves two-thirds of survivors with signifi cant mobility defi cits including reduced walking speed, increased unevenness of step length and asymmetry. Haptic cues, which utilise sensory stimulation and so are unaffected by visual or auditory interference could discreetly improve the gait of people after stroke. Therefore, the objective of this single mixed methods case study was to evaluate the use of a novel haptic device in a single participant after stroke. Context and purpose: After initial familiarisation, gait symmetry, walking speed and cadence of a 69 year old male stroke survivor were recorded using a Qualisys Motion Capture system whilst he walked on a ten metre walkway, fi rstly without and then with a haptic device on each leg, which provided a metronomic rhythmical vibratory cue. The participant then provided a user evaluation of the devices using a semi structured interview. Results: The haptic device was evaluated positively by the participant although he noted it needed to be refi ned to increase its wear-ability and acceptability for everyday use. Whilst gait speed and cadence remained unaltered, there was a 14% improvement in temporal gait symmetry when wearing the haptic device, suggesting it improved this aspect of gait. Conclusion: Whilst limited by its design, the fi ndings of this single case study indicate that the haptic device could be a novel technology-based therapeutic adjunct to improve gait symmetry after stroke. It also provides key understanding of user needs which can be used to guide the development of a new prototype device for stroke survivors. Brief summary: Many stroke survivors have residual mobility problems. Haptic cueing may improve walking by providing a tactile cue that the participant follows to improve symmetry. This single case study suggests that gait symmetry could be improved by haptic cueing and indicates factors affecting the wear ability of such a device.

To sit or stand? A preliminary, cross sectional study to investigate if there is a difference in glenohumeral subluxation in sitting or standing in people following stroke

BackgroundGlenohumeral subluxation (GHS) is a common symptom following stroke. Many therapists postulate that GHS may be reduced if the base of support (BOS) is reduced and the centre of mass (COM) is raised as this requires greater postural muscle activity. However, there is little empirical evidence to support this practice.ObjectiveThe aim of this preliminary study was to investigate if the amount of GHS alters from sitting to standing.Study designA cross sectional, within-subject design in a convenience sample of 15 stroke patients with GHS was utilised.MethodsA prospective design was used with a single blinded tester who assessed GHS using the calliper method in sitting, standing and on return to sitting. Friedman and post hoc Wilcoxon tests showed that GHS was significantly reduced in standing compared to sitting (p <0.05) but this reduction was not maintained on return to sitting (p = 0.25).ConclusionsThe results of this study are limited by its small size. However, these results indicate that reducing BOS during rehabilitation may improve GHS after stroke. Whilst the maintenance of benefit is not established, these findings suggest that reducing BOS as part of treatment may help patients with GHS. Further research is now required to replicate these results in a larger sample and to directly examine shoulder muscle activity to investigate which muscles may influence GHS in response to changing BOS. Future work could also aim to determine whether the reduction in GHS was directly attributable to a reduced BOS or the effort associated with moving from sitting to standing.