Ruth Parry

Randomized, Controlled Trial to Evaluate Increased Intensity of Physiotherapy Treatment of Arm Function After Stroke

BACKGROUND AND PURPOSE Many patients have impaired arm function after stroke, for which they receive physiotherapy. The aim of the study was to determine whether increasing the amount of physiotherapy early after stroke improved the recovery of arm function and to compare the effects of this therapy when administered by a qualified therapist or a trained, supervised assistant. The physiotherapy followed a typical British approach, which is Bobath derived. Ten hours of additional therapy were given over a 5-week period. METHODS The study design was a single-blind, randomized, controlled trial. Stroke patients were recruited from those admitted to the hospital in the 5 weeks after stroke. They were randomly allocated to routine physiotherapy, additional treatment by a qualified physiotherapist, or additional treatment by a physiotherapy assistant. Outcome was assessed after 5 weeks of treatment and at 3 and 6 months after stroke on measures of arm function and of independence in activities of daily living. RESULTS There were 282 patients recruited to the study. The median initial Barthel score was 6.5, and the median age of the patients was 73 years. The median initial Rivermead Motor Assessment Arm score was 1. There were no significant differences between the groups at randomization or on any of the outcome measures. Only half of the patients allocated to the 2 additional-therapy groups completed the program. CONCLUSIONS This increase in the amount of physiotherapy for arm impairment with a typical British approach given early after stroke did not significantly improve the recovery of arm function in the patients studied. A number of other studies of interventions aimed at rehabilitation of arm function have reported positive results. Such findings may have been due to the content of these interventions, to the greater intensity of the interventions, or to the selection of patients to whom the treatments were applied.

Effect of severity of arm impairment on response to additional physiotherapy early after stroke

Objective: To investigate effect of initial severity of arm impairment on response to additional physiotherapy for the arm after stroke. Design: In this controlled trial, patients were randomized into one of three groups: routine physiotherapy (RPT) patients received no additional physiotherapy; qualified physiotherapy (QPT) patients received additional treatment from a qualified physiotherapist; assistant physiotherapy (APT) patients received additional treatment from a trained supervised assistant. Comparisons between the whole groups found no significant differences and have been reported elsewhere. In a post hoc analysis, the groups were subdivided according to severity of initial arm impairment. The subgroups were then compared. Setting: A general hospital with acute and rehabilitation facilities for stroke patients. Subjects: Patients (n= 282) between one and five weeks after stroke. Interventions: Ten hours additional physiotherapy were given over a five-week period. The treatment approach reflected current usual British practice. ‘Blind’ outcome assessment was performed after intervention, and at three and six months after stroke. Main outcome measures: Rivermead Motor Assessment Arm Scale, Action Research Arm Test. Results: In more severe patients, no benefits of additional treatment were detected. In less severe patients, significant benefits were found in those who completed treatment with the trained assistant. However, a considerable number of patients did not complete the additional treatment. The content of treatment differed between the QPT and APT groups. Treatment of less severe APT patients emphasized repetitive supervised practice of movements and functional tasks. No significant effects of additional treatment were found in terms of shoulder pain or spasticity. Conclusions: Regardless of whether additional physiotherapy was given or not, patients with severe arm impairment improved very little in arm function. Enabling adaptation to loss of arm function may be an appropriate rehabilitation strategy for some patients. Trends in the data confirm findings of some previous studies that intensive treatment for patients with some motor recovery of the upper limb is effective. Following patient assessment and treatment planning by a qualified physiotherapist, it may be appropriate for guidance of repetitive practice of motor and functional tasks to be delegated to trained and closely supervised assistant staff.

How to communicate with patients about future illness progression and end of life: a systematic review

Background Conversation and discourse analytic research has yielded important evidence about skills needed for effective, sensitive communication with patients about illness progression and end of life. Objectives To: ▸ Locate and synthesise observational evidence about how people communicate about sensitive future matters; ▸ Inform practice and policy on how to provide opportunities for talk about these matters; ▸ Identify evidence gaps. Design Systematic review of conversation/discourse analytic studies of recorded interactions in English, using a bespoke appraisal approach and aggregative synthesis. Results 19 publications met the inclusion criteria. We summarised findings in terms of eight practices: ‘fishing questions’—open questions seeking patients’ perspectives (5/19); indirect references to difficult topics (6/19); linking to what a patient has already said—or noticeably not said (7/19); hypothetical questions (12/19); framing difficult matters as universal or general (4/19); conveying sensitivity via means other than words, for example, hesitancy, touch (4/19); encouraging further talk using means other than words, for example, long silences (2/19); and steering talk from difficult/negative to more optimistic aspects (3/19). Conclusions Practices vary in how strongly they encourage patients to engage in talk about matters such as illness progression and dying. Fishing questions and indirect talk make it particularly easy to avoid engaging—this may be appropriate in some circumstances. Hypothetical questions are more effective in encouraging on-topic talk, as is linking questions to patients’ cues. Shifting towards more ‘optimistic’ aspects helps maintain hope but closes off further talk about difficulties: practitioners may want to delay doing so. There are substantial gaps in evidence.

Teaching and learning communication skills in physiotherapy: What is done and how should it be done?

OBJECTIVES To survey practice and opinion regarding school-based teaching of communication skills, to summarise relevant research evidence from physiotherapy and beyond, to reflect on practice in light of evidence, and to propose associated recommendations. DESIGN Survey using customised questionnaires. Basic descriptive statistical analysis and thematic content analysis were used. The results were compared with evidence from systematic reviews to derive recommendations. SURVEY PARTICIPANTS AND SETTING: Educators in all UK centres delivering physiotherapy qualifying programmes in 2006. RESULTS A response rate of 69% was achieved. The majority of respondents reported delivering communication-specific modules. Lecturing was common, and more experiential methods were also used. Assessment was mainly by written work. Educators commented on challenges and strategies involved in student engagement, provision of authentic experiences, availability of teaching time and expertise, and physiotherapy-specific teaching resources. Evidence from allied health profession, medical and nursing education research emphasises the importance of experiential teaching, formative feedback, observational assessment and a substantial evidence base on which to ground course content. In physiotherapy, the latter is emerging but incomplete. There are also gaps in direct evidence about advantages or otherwise of stand-alone modules and benefits of pre-qualification communication training. Evidence suggests that effective training requires substantial teaching time, expertise and a body of empirical research on specific communication practices and their effects. CONCLUSION Curriculum designers and educators should endeavour to maximise the degree to which training in this area is experiential, provide training when students have already had some contact with patients, and assess students by observation if at all possible. Due to gaps in the evidence, some important questions about optimal practice remain unanswered.

Interventions to reduce dependency in personal activities of daily living in community dwelling adults who use homecare services: a systematic review

Objectives: To identify interventions that aim to reduce dependency in activities of daily living (ADL) in homecare service users. To determine: content; effectiveness in improving ability to perform ADL; and whether delivery by qualified occupational therapists influences effectiveness. Data sources: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, OTseeker, PEDro, Web of Science, CIRRIE, and ASSIA. Review methods: We included: randomised controlled trials, non-randomised controlled trials and controlled before and after studies. Two reviewers independently screened studies for inclusion, assessed risk of bias and extracted data. A narrative synthesis of the findings was conducted. Results: Thirteen studies were included, totalling 4975 participants. Ten (77%) were judged to have risk of bias. Interventions were categorised as those termed ‘re-ablement’ or ‘restorative homecare’ (n=5/13); and those involving separate components which were not described using this terminology (n=8/13). Content of the intervention and level of health professional input varied within and between studies. Effectiveness on ADL: eight studies included an ADL outcome, five favoured the intervention group, only two with statistical significance, both these were controlled before and after studies judged at high risk of bias. ADL outcome was reported using seven different measures. Occupational therapy: there was insufficient evidence to determine whether involvement of qualified occupational therapists influenced effectiveness. Conclusion: There is limited evidence that interventions targeted at personal ADL can reduce homecare service users’ dependency with activities, the content of evaluated interventions varies greatly.

“What do you expect from physiotherapy?”: a detailed analysis of goal setting in physiotherapy

Abstract Purpose: Health care practice guidelines require physiotherapists to include patients in goal-setting. However, not much is known about how this process is accomplished in practice. The purpose of this study is to analyse patient–physiotherapist consultations and to identify how physiotherapists enquire about goals and how patients respond to these enquiries. Method: 37 consenting patients and their physiotherapist from outpatient physiotherapy practice settings were videotaped. Conversation analysis was used to transcribe and analyse the data. Results: In 11 cases, physiotherapists enquire explicitly about goals. Patients’ responses indicate that problems can arise when therapists’ questions treat it as expected that the patient has a goal already in mind, and has sufficient understanding about “physiotherapy-relevant” goals. Patients’ difficulties with stating a goal are related to patients’ knowledge to propose a goal and whether they treat consultations as one in which it is appropriate to claim knowledge about goals. Conclusions: Goal-setting is not a straightforward process. Practices that entail asking patients to state their goals neither take into consideration the fact that patients may not know what an achievable goal is nor do they consider so-called social reasons for patients not to make claims to their physiotherapist about what the goals should be. Implications for Rehabilitation Patients respond to explicit goal enquiries using an open question with delayed responses indicating some communication problem. Goal-setting should not be treated as a predetermined process, but as negotiated in consultations. Goal-setting is a complex interaction in which participants manage knowledge about goals.

Physiotherapy for the Arm and Hand after Stroke

Summary Evaluations of physiotherapy for stroke patients have been criticised for their lack of description of the content of treatments. The purpose of this paper is to describe in detail the physiotherapy approach employed in a recent trial ( Lincoln et al, 1999 ). The trial evaluated effects of early additional physiotherapy for the arm. The main outcome measures were the Rivermead Motor Assessment Arm Scale and the Action Research Arm Test. The trial included a comparison between treatments administered by a qualified physiotherapist and treatments delegated to a trained and closely supervised physiotherapy assistant. A post hoc subgroup analysis of the data from this trial suggested benefits in a small group of less severely impaired patients who had completed additional treatment in the assistant group ( Parry et al, 1999 ). This paper will discuss this finding in the light of differences in the content of treatment which was applied by the qualified and assistant therapists. Design The study was a randomised controlled trial. Outcome was compared between additional and routine amounts of physiotherapy, and between treatment given by a qualified physiotherapist and treatment given by a trained and supervised assistant. During the trial, descriptive data concerning the content of treatments were recorded. Following post hoc analysis which subdivided the patients into those who were more and less impaired, content of the treatments applied by the qualified therapist and by the trained supervised assistant were compared. Finding Treatment content differed between the assistant and qualified groups. Treatment in the less severe assistant subgroup included a greater proportion of repetitive supervised practice of movements and functional tasks. For all but one of the 93 patients randomised to the assistants group, it was possible to construct a programme of treatment activities suitable for administration by a trained supervised assistant. There was no significant difference between the assistant and qualified groups in the number of patients who completed the treatment. Conclusions The findings from the subgroup analysis were the result of post hoc analysis of small groups and must therefore be viewed as speculative. However, previous research supports an argument that benefits in the milder patients treated by the assistant may have resulted from the emphasis on repetitive supervised practice in their therapy. We argue that it is appropriate to delegate this sort of treatment to trained and supervised physiotherapy assistants.

Acceptability and design of video-based research on healthcare communication: Evidence and recommendations

OBJECTIVES To contribute to understandings about acceptability and risks entailed in video-based research on healthcare communication. To generate recommendations for non-covert video-based research on healthcare communication - with a focus on maximising its acceptability to participants, and managing and reducing its risks. METHODS A literature review and synthesis of (a) empirical research on participant acceptability and risks of video recording; (b) regulations of professional and governmental bodies; (c) reviews and commentaries; (d) guidance and recommendations. These were gathered across several academic and professional fields (including medical, educational, and social scientific). RESULTS 36 publications were included in the review and synthesis (7 regulatory documents, 7 empirical, 4 reviews/commentaries, 18 guidance/recommendations). In the context of research aiming in some way to improve healthcare communication: CONCLUSION AND PRACTICE IMPLICATIONS The recommendations are designed to support deliberations and decisions about individual studies and to support ethical scrutiny of proposed research studies. Whilst preliminary, it is nevertheless the most comprehensive and detailed currently available.

Determining the feasibility of ambulance-based randomised controlled trials in patients with ultra-acute stroke: Study protocol for the “Rapid Intervention with GTN in Hypertensive Stroke Trial” (RIGHT, ISRCTN66434824)

Background. Time from acute stroke to enrolment in clinical trials needs to be reduced to improve the chances of finding effective treatments. No completed randomised controlled trials of ambulance-based treatment for acute stroke have been reported in the UK, and the practicalities of recruiting, consenting, and treating patients are unknown. Methods. RIGHT is an ambulance based, single-blind, randomised controlled trial with blinded-outcome assessment. The trial will assess feasibility of using ambulance services to deliver ultra-acute stroke treatments; a secondary aim is to assess the effect of glyceryl trinitrate (GTN) on haemodynamic variables and functional outcomes. Initial consent, randomisation, and treatment are performed by paramedics prior to hospitalisation. Patients with ultra-acute stroke (≤4 hours of onset) are randomised to transdermal GTN (5 mg/24 hours) or gauze dressing daily for 7 days. The primary outcome is systolic blood pressure at 2 hours. Secondary outcomes include feasibility, haemodynamics, dependency, and other functional outcomes. A nested qualitative study is included. Trial Status. The trial has all relevant ethics and regulatory approvals and recruitment started on February 15, 2010. The trial stopped recruitment in December 2011 after 41 patients were recruited. Trial Registration. The trial registration number is ISRCTN66434824 and EudraCT number is 2007-004766-40.

Giving Reasons for Doing Something Now or at Some Other Time

Physiotherapists often have to ask their clients to move in a certain way, and they sometimes accompany such instructions with explanations. It turns out that these practitioners have an interesting resource—they can design their explanation to bear either upon the exact movement currently in play or on a more general or future case. I show that they make this distinction largely by how they deploy explanatory connectives like because, so, and so on—and, counterintuitively, how they omit such connectives. I finish by considering other datasets and discussing the pedagogical benefits, in any interaction, of being able to construct and convey different temporal domains that the account is meant to bear on.