Suzie Mudge

Circuit-Based Rehabilitation Improves Gait Endurance but Not Usual Walking Activity in Chronic Stroke: A Randomized Controlled Trial

UNLABELLED Mudge S, Barber PA, Stott NS. Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial. OBJECTIVE To determine whether circuit-based rehabilitation would increase the amount and rate that individuals with stroke walk in their usual environments. DESIGN Single-blind randomized controlled trial. SETTING Rehabilitation clinic. PARTICIPANTS Sixty participants with a residual gait deficit at least 6 months after stroke originally enrolled in the study. Two withdrew in the initial phase, leaving 58 participants (median age, 71.5y; range, 39.0-89.0y) who were randomized to the 2 intervention groups. INTERVENTIONS The exercise group had 12 sessions of clinic-based rehabilitation delivered in a circuit class designed to improve walking. The control group received a comparable duration of group social and educational classes. MAIN OUTCOME MEASURES Usual walking performance was assessed using the StepWatch Activity Monitor. Clinical tests were gait speed (timed 10-meter walk) and endurance (six-minute walk test [6MWT]), confidence (Activities-Based Confidence Scale), self-reported mobility (Rivermead Mobility Index [RMI]), and self-reported physical activity (Physical Activity and Disability Scale). RESULTS Intention-to-treat analysis revealed that the exercise group showed a significantly greater distance for the 6MWT than the control group immediately after the intervention (P=.030) but that this effect was not retained 3 months later. There were no changes in the StepWatch measures of usual walking performance for either group. The exercise and control groups had significantly different gait speed (P=.038) and scores on the RMI (P=.025) at the 3-month follow-up. These differences represented a greater decline in the control group compared with the exercise group for both outcome measures. CONCLUSIONS Circuit-based rehabilitation leads to improvements in gait endurance but does not change the amount or rate of walking performance in usual environments. Clinical gains made by the exercise group were lost 3 months later. Future studies should consider whether rehabilitation needs to occur in usual environments to improve walking performance.

Does clinic-measured gait speed differ from gait speed measured in the community in people with stroke?

Objective: To compare the extent to which gait speed measured in the clinic setting differs from that measured in the community. Design: Participants completed the 10-m walk test at a self-selected speed in a clinic setting. Following this they completed a 300-m community-based walking circuit that covered a variety of environmental conditions. Gait velocity was sampled at different points in the circuit. The same circuit and sampling points were used for all participants. Clinic gait velocity was compared to gait velocity measured on five occasions during the community-based circuit. Setting: Physiotherapy clinic and local shopping mall. Participants: Twenty-eight chronic stroke patients who regularly accessed the community divided into two groups based on their gait velocity in the clinic. Main outcome measures: Walking velocity. Results: Spearman rank correlation coefficient indicated that there was a strong correlation between the total time taken to walk the 300-m course and the clinic-based gait velocity (r=-0.88, P<0.0001). A linear mixed model with repeated measures analysis revealed significant interaction between community measures for group A versus group B (F4,26=4.49, P=0.0068) and significant differences across community conditions (F4,26=7.12, P=0.0005). Conclusion: The clinic-based 10-m walk test is able to predict walking velocity in a community setting in chronic stroke patients who score 0.8 m/s or faster. However, for those who score less than 0.8 m/s in the clinic test, gait velocity in the community may be overestimated.

Test—retest reliability of the StepWatch Activity Monitor outputs in individuals with chronic stroke

Objective: To examine the test—retest reliability of the StepWatch Activity Monitor outputs over two periods, a week apart, in participants with stroke. Design: Test—retest reliability study over monitoring periods of one, two and three days. Setting: Participants usual environment. Participants: Forty participants more than six months post stroke. Main measures: StepWatch outputs: total step count, number of steps at high medium and low stepping rates, sustained activity indices, peak activity index. Results: The intraclass correlation coefficients were high for all StepWatch outputs and all monitoring periods but were highest for the three-day monitoring period (0.930—0.989) and lowest for the one-day monitoring period (0.830—0.950). The coefficient of variation ranged from 6.7% to 48.7% over the monitoring periods, with higher variation shown for shorter monitoring periods. The most reliable four outputs had 95% limits of agreement between three-day periods that were less than 40%. These were total step count (±37.8%), highest step rate in 1 minute (±23.0%), highest step rate in 5 minutes (±38.6%) and peak activity index (±29.8%). The highest step rate in 1 minute was the only StepWatch output that had 95% limits of agreement less than 40% for the two-day (±31.2%) and one-day (±36.7%) monitoring periods. Conclusions: Total step count, highest step rate in 1 minute, highest step rate in 5 minutes and peak activity index have good test—retest reliability over a three-day monitoring period, with lower reliability shown by the other StepWatch outputs. In general, monitoring over one or two days is less reliable.

The effect of treadmill training on gait, balance and trunk control in a hemiplegic subject: a single system design

Purpose : The purpose of the study was to determine the effect of a period of body weight supported treadmill training on gait in a subject with chronic stroke and to see if there was a carry-over to balance, trunk control and function. Method : A male subject who had suffered a right CVA 30 months previously was selected for the study. A single system ABA design was used. Outcome measures were taken in the 4-week baseline period. This was followed by a 4-week period of body weight support treadmill training and a further 4 weeks of treatment withdrawal. Outcome measures used were the 10-m walk test, Berg Balance Scale (BBS), Trunk Control Test (TCT), a seated lateral reach test (LRT) and the Functional Independence Measure (FIM) and were collected in all phases of the study. Results : During the intervention phase, there were significant increases in the BBS and the LRT. No significant changes were found in the TCT or the 10-m walk test. The FIM showed a small improvement in the motor score. Conclusions : A period of treadmill training has significant carry-over to balance in a subject with chronic hemiplegia.

Are physiotherapists comfortable with person-centred practice? An autoethnographic insight.

Abstract Purpose: This study aimed to understand our shared conflicting response and discomfort to person-centred rehabilitation within the context of our physiotherapy rehabilitation culture by reflecting on our own experiences as research physiotherapists and clinicians. Method: This study used autoethnographical methods to explore the personal and professional experiences of two physiotherapists in neurological rehabilitation. Data were collected through ten written reflections and five joint discussions. The data were analysed collaboratively through focused conversations and writing. We looked for patterns in our data and the literature to triangulate our findings. Joint narratives were structured based on three headings: Where we have come from, Challenges to our position and Where we are now. Results: The four main topics of discussion were goal setting, hope, the physiotherapy paradigm and person-centred practice. Physiotherapy practice is typically underpinned by a biomechanical discourse, which separates the mind and the body. This paradigm limits our ability to manage aspects of person-centred practice, such as valuing patient preferences, fostering hope, managing expectation and building a positive therapeutic relationship. Conclusion: Awareness of existing influences on theory and practice is necessary to move the physiotherapy profession towards a greater degree of understanding and application of the principles of person-centred practice. Implications for Rehabilitation Physiotherapists need to recognise that our clinical practice is currently dominated by a biomechanical perspective, which limits our adoption of person-centred practice. Our usual way of working as an expert focuses on our own perspective that makes it difficult to work in a person-centred way. Strategies to incorporate a more person-centred approach include using communication strategies that help us actively seek patients’ perspectives.

Enabling Self-Directed Computer Use for Individuals with Cerebral Palsy: A Systematic Review of Assistive Devices and Technologies

Aim  The purpose of this study was to systematically review published evidence on the development, use, and effectiveness of devices and technologies that enable or enhance self‐directed computer access by individuals with cerebral palsy (CP).

Who is in control? Clinicians’ view on their role in self-management approaches: a qualitative metasynthesis

Objective To explore clinician perceptions of involvement in delivery of self-management approaches. Setting All healthcare settings. Design EBSCO, Scopus and AMED databases were searched, in July 2013, for peer-reviewed studies in English reporting original qualitative data concerning perceptions of clinicians regarding their involvement in or integration of a self-management approach. Of 1930 studies identified, 1889 did not meet the inclusion criteria. Full text of 41 studies were reviewed by two independent reviewers; 14 papers were included for metasynthesis. Findings and discussion sections were imported into Nvivo-10 and coded line-by-line. Codes were organised into descriptive themes and cross-checked against original sources to check interpretation, and refined iteratively until findings represented an agreed understanding. Studies were appraised for quality. Results Delivering self-management in practice appeared to be a complex process for many clinicians. The issue of ‘control’ arose in all studies, both in the qualitative data and authors’ interpretations. The first theme: Who is in control?—represented ways clinicians talked of exercising control over patients and the control they expected patients to have over their condition. The second theme: Changing clinician views—reflected what appeared to be an essential transformation of practice experienced by some clinicians in the process of integrating self-management approaches into the practice. A range of challenges associated with shifting towards a self-management approach were reflected in the third theme, Overcoming challenges to change. Tensions appeared to exist around forming partnerships with patients. Strategies found helpful in the process of change included: dedicating time to practice reciprocity in communication style, peer support and self-reflection. Conclusions A consistent finding across studies is that ‘control’ is a key feature of how self-management is viewed by clinicians. They described challenges associated with the paradigm shift required to share or let go of control. Future research should identify whether strategies described by clinicians are key to successful self-management.

Telerehabilitation to improve outcomes for people with stroke: study protocol for a randomised controlled trial

BackgroundIn New Zealand, around 45,000 people live with stroke and many studies have reported that benefits gained during initial rehabilitation are not sustained. Evidence indicates that participation in physical interventions can prevent the functional decline that frequently occurs after discharge from acute care facilities. However, on-going stroke services provision following discharge from acute care is often related to non-medical factors such as availability of resources and geographical location. Currently most people receive no treatment beyond three months post stroke. The study aims to determine if the Augmented Community Telerehabilitation Intervention (ACTIV) results in better physical function for people with stroke than usual care, as measured by the Stroke Impact Scale, physical subcomponent.Methods/designThis study will use a multi-site, two-arm, assessor blinded, parallel randomised controlled trial design. People will be eligible if they have had their first ever stroke, are over 20 and have some physical impairment in either arm or leg, or both. Following discharge from formal physiotherapy services (inpatient, outpatient or community), participants will be randomised into ACTIV or usual care. ACTIV uses readily available technology, telephone and mobile phones, combined with face-to-face visits from a physiotherapist over a six-month period, to help people with stroke resume activities they enjoyed before the stroke. The impact of stroke on physical function and quality of life will be assessed, measures of cost will be collected and a discrete choice survey will be used to measure preferences for rehabilitation options. These outcomes will be collected at baseline, six months and 12 months. In-depth interviews will be used to explore the experiences of people participating in the intervention arm of the study.DiscussionThe lack of on-going rehabilitation for people with stroke diminishes the chance of their best possible outcome and may contribute to a functional decline following discharge from formal rehabilitation. Best practice guidelines recommend a prolonged period of rehabilitation, however this is expensive and therefore not undertaken in most publicly funded centres. An effective, cost-effective, and preference-sensitive therapy using basic technology to assist programme delivery may improve patient autonomy as they leave formal rehabilitation and return home.Trial registrationACTRN12612000464864

Activity coaching to improve walking is liked by rehabilitation patients but physiotherapists have concerns: a qualitative study

QUESTION Does activity coaching add value to physiotherapy from the perspective of physiotherapists and patients in neurological rehabilitation? Is the use of activity coaching to promote walking and physical activity considered feasible by these physiotherapists and patients? DESIGN Qualitative study using interviews. PARTICIPANTS Five pairs of physiotherapists and their patients with neurological conditions. INTERVENTION A research physiotherapist trained in health coaching delivered an activity coaching intervention. This was provided in addition to standard physiotherapy. The treating physiotherapists observed the activity coaching session undertaken by their patients. RESULTS Observing the coaching interview was valuable for the treating physiotherapists in that it provided a way to refocus, step back, gain insight, and facilitate more active involvement for their patients in the rehabilitation process. Similarly patients valued the opportunity to focus on what was important and put into action their rehabilitation goals. Contrasting perceptions were evident, which limits the practical usefulness of this intervention due to the concerns voiced by some of the physiotherapists. CONCLUSION The activity coaching was perceived as providing a valuable addition to standard practice and was acceptable to patients but the mixed responses of physiotherapists limit the feasibility of this approach. Use of strategies and specific training for physiotherapists may be needed before approaches like activity coaching can be adopted successfully.

Interventions to improve real-world walking after stroke: a systematic review and meta-analysis

Objective: This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained. Data sources: EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies. Review methods: Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data. Results: Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3–6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (–0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were. Conclusions: A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.