Sharon Wood-Dauphinee

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.

Translating Health Status Questionnaires and Evaluating Their Quality : The IQOLA Project Approach

This article describes the methods adopted by the International Quality of Life Assessment (IQOLA) project to translate the SF-36 Health Survey. Translation methods included the production of forward and backward translations, use of difficulty and quality ratings, pilot testing, and cross-cultural comparison of the translation work. Experience to date suggests that the SF-36 can be adapted for use in other countries with relatively minor changes to the content of the form, providing support for the use of these translations in multinational clinical trials and other studies. The most difficult items to translate were physical functioning items, which used examples of activities and distances that are not common outside of the United States; items that used colloquial expressions such as pep or blue; and the social functioning items. Quality ratings were uniformly high across countries. While the IQOLA approach to translation and validation was developed for use with the SF-36, it is applicable to other translation efforts.

International quality of life assessment (IQOLA) project

The International Quality of Life Assesment (IQOLA) Project is a 4-year project to translate and adapt the widely used MOS SF-36 Health Survey Questionnaire in up to 15 countries and validate, norm, and document the new translations as required for their use in international studies of health outcomes. In addition to the eight-scale SF-36 health profile, the project will also validate psychometrically based physical and mental health summary scores, as well as health utility indexes incorporating SF-36 scales for use in cost-utility studies.

There’s No Place Like Home An Evaluation of Early Supported Discharge for Stroke

BACKGROUND AND PURPOSE Because stroke management is aimed at facilitating community reintegration, it would be logical that the sooner the patient can be discharged home, the sooner reintegration can commence. The purpose of this study was to determine the effectiveness of prompt discharge combined with home rehabilitation on function, community reintegration, and health-related quality of life during the first 3 months after stroke. METHODS A randomized trial was carried out involving patients who required rehabilitation services and who had a caregiver at home. When medically ready for discharge, persons with stroke were randomized to either the home intervention group (n=58) or the usual care group (n=56). The home group received a 4-week, tailor-made home program of rehabilitation and nursing services; persons randomized to the usual care group received services provided through a variety of mechanisms, depending on institutional, care provider, and personal preference. The main outcome measure was the Physical Health component of the Measuring Outcomes Study Short-Form-36 (SF-36). Associated outcomes measures included the Timed Up & Go (TUG), Barthel Index (BI), the Older Americans Resource Scale for instrumental activities of daily living (OARS-IADL), Reintegration to Normal Living (RNL), and the SF-36 Mental Health component. RESULTS The total length of stay for the home group was, on average, 10 days, 6 days shorter than that for the usual care group. There were no differences between the 2 groups on the BI or on the TUG at either 1 or 3 months after stroke; however, there was a significantly beneficial impact of the home intervention on IADL and reintegration (RNL). By 3 months after stroke, the home intervention group showed a significantly higher score on the SF-36 Physical Health component than the usual care group. The total number of services received by the home group was actually lower than that received by the usual care group. CONCLUSIONS Prompt discharge combined with home rehabilitation appeared to translate motor and functional gains that occur through natural recovery and rehabilitation into a greater degree of higher-level function and satisfaction with community reintegration, and these in turn were translated into a better physical health.

Disablement following stroke

PURPOSE Stroke is the most disabling chronic condition, newly affecting 35000 persons in Canada each year. Because of declining fatality, a growing number of persons will have to cope with stroke-related disability. The purpose of this paper is to describe the disabilities experienced by persons with stroke during the first year and explore the evolution of impairment, disability, handicap and health-related quality of life. SUBJECTS The data for this paper come from a series of longitudinal and cross-sectional studies, collectively known as the McGill Stroke Rehabilitation Research Program. RESULTS Within the first week post-stroke, getting out of bed and walking over a short distance, even with assistance, was a strong predictor of discharge home. Most of the improvement in measures of impairment and disability occurred during the first month and, by 3 months, there was still considerable room for improvement in all measures: 85% of persons were still impaired on gait speed, 78% had not reached age-specific norms for upper extremity function, 68% still demonstrated slow physical mobility, 37% needed some assistance with basic activities of daily living and 29% were still impaired on balance. By 1 year, 73% of persons scored the maximum for basic activities of daily living but 51 and 67% of persons reported their physical health and mental health to be lower than expected. Among a hardy group of stroke survivors, still living in the community 1 year post-stroke, the most striking area of difficulty was endurance, as measured by the 6 minute walk test. Those subjects well enough to complete this task (50% of sample) were able to walk, on average, only 250 metres, equivalent to 40% of their predicted ability. This series of snapshots taken at different points in time suggests that much of the improvement in impairment and disability occurs during the first month and then reaches a plateau. Handicap and quality of life continue to be issues later. Rehabilitation strategies need to consider the multifaceted nature of disablement, which in itself changes with time post-stroke.

Translating health status questionnaires and evaluating their quality: the IQOLA Project approach. International Quality of Life Assessment.

This article describes the methods adopted by the International Quality of Life Assessment (IQOLA) project to translate the SF-36 Health Survey. Translation methods included the production of forward and backward translations, use of difficulty and quality ratings, pilot testing, and cross-cultural comparison of the translation work. Experience to date suggests that the SF-36 can be adapted for use in other countries with relatively minor changes to the content of the form, providing support for the use of these translations in multinational clinical trials and other studies. The most difficult items to translate were physical functioning items, which used examples of activities and distances that are not common outside of the United States; items that used colloquial expressions such as pep or blue; and the social functioning items. Quality ratings were uniformly high across countries. While the IQOLA approach to translation and validation was developed for use with the SF-36, it is applicable to other translation efforts.

Task-specific physical therapy for optimization of gait recovery in acute stroke patients

A randomized controlled pilot trial was conducted to estimate the effects of early, intensive, gait-focused physical therapy on ambulatory ability in acute, stroke patients. Twenty-seven patients with middle cerebral artery infarct of thromboembolic origin confirmed by computed axial tomography scan were stratified and randomly assigned to the experimental group, to a control group that received early, intensive and conventional therapy, or to a group receiving routine conventional therapy that started later and was not intense. Assessments at entry, six weeks, and three and six months by independent evaluators permitted comparisons with reference to clinical measures of motor performance, balance, and functional capacity, and laboratory measures of gait movements. Group results at six weeks demonstrated that gait velocity was similar in the two conventional groups thereby eliminating the timing of the interventions as an important factor. At that point, gait velocity was faster in the experimental group. The difference translated into a moderate effect size of 0.58. The time dedicated to gait training but not to total therapy time was correlated (rs = 0.63) to gait velocity. This effect disappeared at three and six months after stroke. These pilot results justify planning a large trial to test the effectiveness of a therapeutic protocol that focuses on early and intense gait therapy in an effort to facilitate early ambulation following stroke.

A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial:

Objective: To evaluate the efficacy of a task-orientated intervention in enhancing competence in walking in people with stroke. Design: Two-centre observer-blinded stratified block-randomized controlled trial. Setting: General community. Subjects: Between May 2000 and February 2003, 91 individuals with a residual walking deficit within one year of a first or recurrent stroke consented to participate. Interventions: The experimental intervention comprised 10 functional tasks designed to strengthen the lower extremities and enhance walking balance, speed and distance. The control intervention involved the practice of upper extremity activities. Subjects in both groups attended sessions three times a week for six weeks. Main measures: Six-minute walk test (SMWT), 5-m walk (comfortable and maximum pace), Berg Balance Scale, timed ‘up and go’. Results: At baseline, subjects in the experimental (n = 44) and control (n = 47) groups walked an average distance of 209 m (SD = 126) and 204 m (SD = 131), respectively, on the SMWT. Mean improvements of 40 m (SD = 72), and 5 m (SD = 66) were observed following the experimental and control interventions, respectively. The between-group difference was 35 m (95% confidence interval (CI) 7, 64). Significant between-group effects of 0.21 m/s (95% CI 0.12, 0.30) and of 0.11 m/s (95% CI 0.03, 0.19) in maximum and comfortable walking speed, respectively, were observed. People with a mild, moderate or severe walking deficit at baseline improved an average of 36 (SD = 96), 55 (SD = 56) and 18 m (SD = 23), respectively, in SMWT performance following the experimental intervention. Conclusions: Study findings support the efficacy of a task-orientated intervention in enhancing walking distance and speed in the first year post stroke, particularly in people with moderate walking deficits.

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery

BackgroundMeasuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research.MethodsAn expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research.ResultsRandomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function.ConclusionsLaparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

Cross-cultural comparisons of the content of SF-36 translations across 10 countries : Results from the IQOLA project

Increasingly, translated and culturally adapted health-related quality of life measures are being used in cross-cultural research. To assess comparability of results, researchers need to know the comparability of the content of the questionnaires used in different countries. Based on an item-by-item discussion among International Quality of Life Assessment (IQOLA) investigators of the content of the translated versions of the SF-36 in 10 countries, we discuss the difficulties that arose in translating the SF-36. We also review the solutions identified by IQOLA investigators to translate items and response choices so that they are appropriate within each country as well as comparable across countries. We relate problems and solutions to ratings of difficulty and conceptual equivalence for each item. The most difficult items to translate were physical functioning items that refer to activities not common outside the United States and items that use colloquial expressions in the source version. Identifying the origin of the source items, their meaning to American English-speaking respondents and American English synonyms, in response to country-specific translation issues, greatly helped the translation process. This comparison of the content of translated SF-36 items suggests that the translations are culturally appropriate and comparable in their content.