Clinical Rehabilitation

Objective: Little is known about the long-term effectiveness after stroke of interventions for behaviour modification and ensuring concordance with therapies. We describe a follow-up study of a previous randomized controlled trial of a brief period of behaviour modification. The aim of this study was to determine outcomes three years after the initial intervention.

Design: Survivors of the original cohort were contacted and asked to attend for follow-up interview, within a geriatric day hospital. This study was carried out in the Geriatric Day Hospital at Stobhill Hospital, Balornock Road, Glasgow.

Interventions: Details of risk factor control, including blood pressure, cholesterol levels and diabetic control, were assessed. Questionnaires used in the initial study were repeated including the Geriatric Depression Scale score, Euroqol Perceived Health Status and Stroke Services Satisfaction Questionnaire.

Main measures: Primary outcome was collective risk factor control. Clinical outcomes including recurrent cerebrovascular events, medication persistence and perceived health status were also recorded.

Results: Mean length of follow-up was 3.6 years (SD 0.43). Of the 205 patients enrolled in the initial study, 102 patients attended for repeat interview

(49 intervention/53 control). There were no significant differences in the percentage of controlled risk factors between groups (intervention 51.7% versus control 55.9%, P = 0.53). Similarities were observed in the number of recurrent clinical events and medication persistence between groups. No overall difference was observed in perceived health status, satisfaction with care or depression scores.

Conclusions: Brief intervention with respect to behaviour modification and risk factor control does not appear to have any long-term benefit. These results must be cautiously interpreted in light of the small study number and further research is required.

Background and purpose: We describe our attempts to evaluate the effectiveness of a virtual environment developed to rehabilitate stroke patients in the task of making a hot drink.

Methods: Single case studies were performed in 13/138 (9%) stroke patients undergoing rehabilitation in a UK stroke unit. Participants in AB/BA (n = 5) and ABA (n = 2) design studies received 5 one-hour sessions of attention control training (A phase) and 5 one-hour sessions of virtual environment training (B phase). An AB design with random duration of A and B phases (minimum duration of A and B phases 3 and 5 days respectively, with total duration of 3 weeks) was used in 6 participants.

Results: Visual inspection of scores across all cases showed a trend towards improvement over time in both real and virtual hot drink making ability in both control and intervention phases. There was no significant difference (Wilcoxon, p > 0.05) in the improvements in real and virtual hot drink making ability during all control and intervention phases in the 13 cases. Ceiling effects limited the evaluation of effectiveness in 5 of the 8 cases in which daily performance measures were used.

Conclusions: Few people in this setting were suitable for this intervention. The case studies showed no evidence of a strong effect of this intervention, but we had great difficulty in performing single case studies. We conclude that more testing and development of this system is required before it is subjected to rigorous testing of clinical effectiveness.

Objective: To compare the long-term efficacy of pneumatic compression and low-level laser therapies in the management of postmastectomy lymphoedema.

Design: Randomized controlled trial.

Setting: Department of Physical Medicine and Rehabilitation of Cukurova University, Turkey.

Subjects: Forty-seven patients with postmastectomy lymphoedema were enrolled in the study.

Interventions: Patients were randomly allocated to pneumatic compression (group I, n=24) and low-level laser (group II, n=23) groups. Group I received 2 hours of compression therapy and group II received 20 minutes of laser therapy for four weeks. All patients were advised to perform daily limb exercises.

Main measures: Demographic features, difference between sum of the circumferences of affected and unaffected limbs (▵C), pain with visual analogue scale and grip strength were recorded.

Results: Mean age of the patients was 48.3 (10.4) years. ▵C decreased significantly at one, three and six months within both groups, and the decrease was still significant at month 12 only in group II (P = 0.004). Improvement of group II was greater than that of group I post treatment (P = 0.04) and at month 12 after 12 months (P = 0.02). Pain was significantly reduced in group I only at posttreatment evaluation, whereas in group II it was significant post treatment and at follow-up visits. No significant difference was detected in pain scores between the two groups. Grip strength was improved in both groups, but the differences between groups were not significant.

Conclusions: Patients in both groups improved after the interventions. Group II had better long-term results than group I. Low-level laser might be a useful modality in the treatment of postmastectomy lymphoedema.

Objective: To test the effects of pulmonary rehabilitation on fatigue, functional status and health perceptions in patients with chronic obstructive pulmonary disease.

Design: Randomized controlled trial.

Setting: Pulmonary outpatient department.

Subjects: Thirty patients randomly assigned to a rehabilitation (3 men, 9 women, mean age 66 (±2) years) or a control group (10 men, 4 women, mean age 64 (±2) years).

Interventions: The patients in the rehabilitation group participated in a multidisciplinary rehabilitation programme comprising exercise training twice weekly, for a 12-week period, nutritional and self-care advice, and education about disease and energy conservation strategies.

Main measures: Fatigue, functional limitations due to fatigue, functional performance and satisfaction, six-minute walking distance, hand grip strength and health perception were assessed at baseline and after 12 weeks.

Results: At baseline there were no significant differences between the groups, except for gender. The six-minute walking distance was 312.6 (±79.3) m for the rehabilitation group and 360.3 (±84.7) m for the control group. After 12 weeks, the rehabilitation group improved their walking distance by 40.6 (±27.2) m (P<0.05). The rehabilitation group improved in performance (from 4.8 (±2.0) to 6.0 (±1.5) scores, P<0.01) and satisfaction (from 4.6 (±2.2) to 6.0 (±2.1) scores, P<0.001) with regard to own selected daily activities. No statistically significant differences were seen between the changes within the rehabilitation group and changes within the control group at the 12-week follow-up.

Conclusions: Although the pulmonary rehabilitation programme had an immediate effect, it was not sustained.

Objective: To evaluate the feasibility and effects of using motor imagery during therapeutic stretching in individuals with spasticity.

Design: Randomized single-blind controlled pilot trial.

Setting: Chronic day care unit, neurological rehabilitation unit and in the community.

Subjects: Eleven individuals with spasticity in the arm requiring stretching as part of their normal routine.

Interventions: In addition to their normal stretching routine, subjects in the experimental group received motor imagery during their stretches (n = 6). The control group received progressive muscle relaxation during their stretches (n = 5). The dose varied between 8 and 56 sessions over eight weeks.

Main measures: Resistance to passive movement, measured with a torque transducer, passive range of movement, measured with an electro-goniometer, Modified Ashworth Scale (MAS) and level of discomfort during the MAS were assessed at baseline and after eight weeks by an independent assessor. These measures were recorded before and after a stretch intervention on both assessments.

Results: Participants, therapists and carers tolerated the techniques well. Compliance was variable and adherence was good. Mixed ANOVA showed no difference over time and no difference between the motor imagery and progressive muscle relaxation group on the primary and secondary outcome measures (P>0.05).

Conclusions: It is feasible to use motor imagery during therapeutic stretching. Statistical power was low due to the large variability in the population and the small sample size. Post-hoc sample size calculation suggests that future studies of this subject should include at least 54 participants per group. Further research is warranted.

Objective: To investigate the feasibility, acceptability and potential efficacy of group exercise for residents in care homes.

Design: Exploratory cluster randomized controlled trial.

Setting: Five randomly selected care homes in South Birmingham, UK.

Participants: Fifty-six care home residents (mean age 84.5, 71% female), 39 (70%) with cognitive impairments.

Intervention: Two homes (n = 28) were randomized to group exercise held twice weekly for five weeks. The remaining three homes (n = 28) formed the control group and received usual care, with no person specifically responsible for exercise training.

Outcome measures: Assessments were conducted at zero (pre-intervention), three (post-intervention) and six months (follow-up) using the Rivermead Mobility Index and Hospital Anxiety and Depression Scale or Stroke Aphasic Depression Questionnaire (depending on cognitive impairment). Adherence to group exercise and retention to the study were also documented.

Results: No statistically significant improvements in mobility or depression were found in favour of group exercise. Retention to the study was high with 46 (82%) participants completing all assessments. Adherence to group exercise was somewhat lower with participants attending a mean of 3.61 out of 8.5 prescribed sessions (42.5%).

Conclusions: Group exercise can be delivered to care home residents with reduced mobility but it is not suitable for residents with severe cognitive impairment. An estimated sample size of 240 participants would be required to detect a clinically significant difference in the Rivermead Mobility Index with 90% power.

Objective: To investigate and compare the impact of hospital and home exercise programmes on aerobic capacity, fatigue, and quality of life in patients with post-polio syndrome.

Design: A prospective, randomized controlled trial.

Setting: Department of Physical Medicine and Rehabilitation, University Hospital. Subjects: Thirty-two patients were divided into two groups for either hospital- or home-based aerobic exercise programme.

Main outcome measures: Patients were assessed before and after the rehabilitation programme, with respect to functional capacity (pVo₂), fatigue (Fatigue Severity Scale, Fatigue Impact Scale) and quality of life (Nottingham Heath Profile).

Results: After the exercise programme, improvement was observed in the hospital exercise group compared to a pre-exercise period in all Nottingham Heath Profile scores (except sleep scores), pVo₂, Fatigue Severity Scale and Fatigue Impact Scale (cognitive, physical, psychosocial, total) (P<0.05). In contrast, in the home exercise group a decrease was observed in pVo₂ scores after the rehabilitation programme, compared to a pre-rehabilitation period (P<0.05). In addition, a significant improvement was observed in the home exercise group after the rehabilitation programme in all parameters excluding Fatigue Impact Scale—physical, Fatigue Impact Scale—psychosocial, and Nottingham Heath Profile—sleep (P<0.05). When the two exercise groups were compared, improvement was observed in the hospital exercise group compared to the home exercise group in pVo₂ and Fatigue Severity Scale—total, Fatigue Impact Scale—physical, Fatigue Impact Scale—psychosocial, Fatigue Impact Scale—total, and Nottingham Heath Profile—energy scores (P<0.05).

Conclusion: Fatigue and quality of life were both improved in the home and hospital exercise groups. An increase was also found in the functional capacity in the hospital exercise group. A regular exercise programme is beneficial to patients with post-polio syndrome.

Objective: To assess the interobserver reliability of the Manual Ability Classification System (MACS) in young children (age 1—5 years) with cerebral palsy.

Design: Interobserver reliability study.

Setting: A cross-sectional study of a hospital-based population of children with cerebral palsy.

Subjects: Thirty children, 18 boys and 12 girls between 1 and 5 years of age (mean age 2.5 years ± 14.2 SD, Gross Motor Function Classification System level I—IV). Measures: the children were classified by means of the MACS by two independent observers. Interobserver reliability was analysed using Cohen's kappa.

Results: Overall interobserver reliability of the MACS for children aged 1—5 years was moderate, with a linear weighted kappa (κ) of 0.62 (95% confidence interval (CI) 0.49—0.76). According to the generally accepted categories of agreement, reliability was moderate for children under 2 years of age (κ = 0.55), and good for children between 2 and 5 years of age (κ = 0.67).

Conclusion: Classification of manual ability of young children with cerebral palsy is possible between 2 and 5 years of age. For children younger than 2 years old, it should be done with caution. Further development of the MACS for children under 5 years of age is recommended with an emphasis on age-appropriate descriptions of manual abilities.

Objective: To examine the accuracy of measuring step counts using a pedometer in participants with neurological conditions and healthy volunteers in relation to a manual step count tally.

Setting: Oxford Centre for Enablement, Nuffield Orthopaedic Centre NHS Trust, Oxford, UK.

Subjects: Healthy adults (n = 13, age: mean 29, SD = 12) and adults with neurological conditions (n=20 stroke, n=16 multiple sclerosis, n=5 muscular dystrophy, n=1 spinal cord injury, n=1 traumatic brain injury; age: mean 54, SD=13).

Main measures: Individuals walked for 2 minutes at self-selected walking speeds (SSWS) wearing a pedometer. Healthy individuals were then asked to walk at slow walking speeds (SWS). Step counts were recorded manually and using a pedometer.

Results: In healthy individuals there was no difference between manually measured and pedometer counts during walking (P>0.05). In adults with neurological conditions the pedometers undercounted (P = 0.003); bias (random error): 27 (111); percentage variability 30% and intraclass correlation coefficient (ICC) 0.66. In neurological adults, from regression analysis the relationship between error and walking speed was cubic, with walking speed accounting for 29% of pedometer error. Healthy individuals showed greater variability and undercounting at SWS bias (random error): 10 (31), percentage variability 8% and ICC 0.73, compared with SSWS bias (random error): —3 (13), percentage variability 3% and ICC 0.84.

Conclusions: Pedometers may undercount when used for people with neurological conditions. There may be variability in pedometer accuracy but this was not strongly related to walking speed. The suitability of pedometer use for exercise monitoring should be individually determined.

Objectives: To assess the incidence and circumstances of falls among stroke patients in a rehabilitation ward, the frequency of fall-related fractures, the relationship between falls and rehabilitation outcomes, and risk factors for falls.

Design: Prospective observational study.

Setting: Neurological rehabilitation ward.

Patients: In total 1155 patients (56% men; mean age 61.5 ± 14.3 years) admitted to the neurological rehabilitation ward after a stroke. Median (interquartile range) time since stroke onset was 36.5 (68) days.

Main measures: Patients' falls were registered during hospitalization (1—74 days) and variables relating to the type and symptoms of stroke, current medications, neurological deficit (Scandinavian Stroke Scale) and disability (Barthel Index) were collected from medical records.

Results: A total of 252 falls were recorded for 189 (16.3%) patients and 45 patients experienced 108 repeated falls. The incidence rate for falls was 7.6/1000 patient-days (95% confidence interval (CI) 6.6—8.5). Most patients fell while being transferred (33.9%) and while seated (21.5%), and 1.2% of falls resulted in fractures (n = 3). Increased risk of both first and multiple falls was strongly associated with initial Barthel score below 15 (hazard ratio (HR) 5.2 and 4.5, respectively) and time since stroke onset ≥12 weeks (HR 2.3 and 2.3, respectively). First falls were significantly associated with visuo-spatial neglect (HR 1.5). Repeated falls were related to age greater than 65 years (HR 1.4).

Conclusions: Patients with severe stroke-related disability in the early period after stroke are prone to falls during rehabilitation. Multiple falls are most frequent in patients over 65 years of age.