Clinical Rehabilitation

Objective: To summarize the current evidence on the effects of preoperative exercise therapy in patients awaiting invasive surgery on postoperative complication rate and length of hospital stay.

Data sources: A primary search of relevant key terms was conducted in the electronic databases of PubMed, EMBASE, PEDro and CINAHL.

Review methods: Studies were included if they were controlled trials evaluating the effects of preoperative exercise therapy on postoperative complication rate and length of hospital stay. The methodological quality of included studies was independently assessed by two reviewers using the PEDro scale. Statistical pooling was performed when studies were comparable in terms of patient population and outcome measures. Results were separately described if pooling was not possible.

Results: Twelve studies of patients undergoing joint replacement, cardiac or abdominal surgery were included. The PEDro scores ranged from 4 to 8 points. Preoperative exercise therapy consisting of inspiratory muscle training or exercise training prior to cardiac or abdominal surgery led to a shorter hospital stay and reduced postoperative complication rates. By contrast, length of hospital stay and complication rates of patients after joint replacement surgery were not significantly affected by preoperative exercise therapy consisting of strength and/or mobility training.

Conclusion: Preoperative exercise therapy can be effective for reducing postoperative complication rates and length of hospital stay after cardiac or abdominal surgery. More research on the utility of preoperative exercise therapy and its long-term effects is needed as well as insight in the benefits of using risk models.

Objective: To give an overview of the physical activity level of patients with chronic fatigue syndrome in comparison with asymptomatic controls.

Data sources: MEDLINE, Web of Science, EMBASE, PsycINFO, Picarta, the Cochrane Controlled Trial Register that is included in the Cochrane Library and reference tracking.

Review methods: A systematic literature search was conducted focusing on studies concerning physical activity levels of patients with chronic fatigue syndrome compared to controls. A meta-analysis was performed to pool data of the studies.

Results: Seventeen studies were included with 22 different comparisons between patients with chronic fatigue syndrome and controls. Fourteen studies, including 18 comparisons, showed lower physical activity levels in patients with chronic fatigue syndrome as compared to controls. Four studies, including four comparisons, showed no differences between both groups. The meta-analysis included seven studies and showed a daily physical activity level in patients with chronic fatigue syndrome of only 68% of the physical activity level observed in control subjects. The pooled mean coefficient of variation in patients with chronic fatigue syndrome was higher as compared to control subjects (34.3% versus 31.5%), but this difference did not reach significance.

Conclusion: Patients with chronic fatigue syndrome appear to be less physically active compared with asymptomatic controls. There is no difference in variation of physical activity levels between patients with chronic fatigue syndrome and healthy control subjects, but the validity and reliability of some methods of measuring physical activity is questionable or unknown.

Objective: To compare the effect of visual and kinesthetic locomotor imagery training on walking performance and to determine the clinical feasibility of incorporating auditory step rhythm into the training.

Design: Randomized crossover trial.

Setting: Laboratory of a Department of Physical Therapy.

Subjects: Fifteen subjects with post-stroke hemiparesis.

Intervention: Four locomotor imagery trainings on walking performance: visual locomotor imagery training, kinesthetic locomotor imagery training, visual locomotor imagery training with auditory step rhythm and kinesthetic locomotor imagery training with auditory step rhythm.

Main outcome measures: The timed up-and-go test and electromyographic and kinematic analyses of the affected lower limb during one gait cycle.

Results: After the interventions, significant differences were found in the timed up-and-go test results between the visual locomotor imagery training (25.69 ± 16.16 to 23.97 ± 14.30) and the kinesthetic locomotor imagery training with auditory step rhythm (22.68 ± 12.35 to 15.77 ± 8.58) (P<0.05). During the swing and stance phases, the kinesthetic locomotor imagery training exhibited significantly increased activation in a greater number of muscles and increased angular displacement of the knee and ankle joints compared with the visual locomotor imagery training, and these effects were more prominent when auditory step rhythm was integrated into each form of locomotor imagery training. The activation of the hamstring during the swing phase and the gastrocnemius during the stance phase, as well as kinematic data of the knee joint, were significantly different for posttest values between the visual locomotor imagery training and the kinesthetic locomotor imagery training with auditory step rhythm (P<0.05).

Conclusions: The therapeutic effect may be further enhanced in the kinesthetic locomotor imagery training than in the visual locomotor imagery training. The auditory step rhythm together with the locomotor imagery training produces a greater positive effect in improving the walking performance of patients with post-stroke hemiparesis.

Objective: This study compared two modes of physiotherapy service over 12 months in community-dwelling people with stroke, either following a train—wait train paradigm by providing bouts of intense physiotherapy, or a continuous less intense programme.

Design: Randomized trial.

Setting: Community-dwelling people with stroke.

Interventions: Fifty patients, first-time stroke, discharged home, following inpatient rehabilitation, allocated to two groups, A and B. Over 12 months, Group A (n = 25) received three two-month blocks of therapy at home, each block contained four 30 to 45 minute sessions per week, totalling 96 sessions. Group B (n = 25) continuously received two 30 to 45 minute sessions per week, totalling 104 sessions.

Main outcome measures: Primary Rivermead Mobility Index (0—15), secondary upper- and lower-limb motor functions, Activities of Daily Living competence, tone and number of falls.

Results: Both groups were comparable at onset, the mean age in Group A (B) was 62.4 (61.9) years. A and B patients equally improved functions over time, between group differences did not occur. The initial (terminal) Rivermead Mobility Index was 9.4 ± 2.8 (12.2 ± 2.1) in Group A, and 8.5 ± 3.5 (11.2 ± 2.7) in Group B. More Group B patients fell seriously (7 versus 1).

Conclusions: The intermittent high-intensity and continuous low-intensity therapy protocols were equally effective, the sheer intensity seems more important than the time-mode of application. The relatively young patients functionally improved in the first year after stroke, the reduced risk of serious falls in the intermittent high-intensity group should be validated.

Objective: To study the effect of pedometer-based gait training on changing gait parameters in children with spastic hemiparetic cerebral palsy.

Design: Two group randomized controlled trial with pre-treatment and posttreatment measures.

Setting: Rehabilitation clinics.

Subjects: Thirty spastic hemiparetic children with cerebral palsy of both sexes (13 females and 17 males) ranging in age from six to eight years old with mean age 7.05 ± 0.78 years.

Interventions: Children were randomized equally to receive pedometer-based gait training or a traditional gait training programme three times per week for three successive months.

Main measures: Assessment was done before and after three months of treatment application using 3D motion analysis system with six pro-reflex cameras to evaluate spatiotemporal gait parameters. The primary outcome measure was the walking velocity while the secondary outcome measures were stride length, cadence and cycle duration.

Results: There was a high statistically significant improvement in favour of the study group more than the control group concerning all the measured gait parameters. T-test results showed that velocity was 0.68 ± 0.09 m/sec (0.26 ± 0.07 change score) for study group and 0.42 ± 0.11 m/sec (0.06 ± 0.05 change score) for control group (t = 6.2) (P<0.0001) while cadence was much less significant 124.3 ± 4.3 step/min (-5.8 ± 2.1 change score) for study group and 128.7 ± 4.1 step/min (-0.86 ± 0.05 change score) for control group (t = 2.8) (P<0.008).

Conclusion: Pedometer-based gait training is a useful tool that can be used in improving gait parameters in children with spastic hemiparetic cerebral palsy.

Objective: To develop and field test the Multidimensional Acceptance of Loss Scale to measure disability acceptance based on the four value changes identified by Beatrice Wright.

Design: Quantitative descriptive design using exploratory factor analysis to determine the factorial validity of the Multidimensional Acceptance of Loss Scale.

Setting: The Canadian Paraplegic Association.

Subjects: One hundred and sixty-one members of the Alberta, Saskatchewan, Nova Scotia and Manitoba chapters of the Canadian Paraplegic Association were recruited for the current study.

Results: A four-factor structure accounting for 50% of the total variance was found for the Multidimensional Acceptance of Loss Scale. The internal consistency reliability coefficients (Cronbach’s alpha) for the four factors ranged from 0.80 to 0.88. Three clusters of participants with high, moderate and low disability acceptance were identified based on their profiles of Multidimensional Acceptance of Loss Scale subscale scores using cluster analysis. MANOVA results indicated that participants in the three clusters significantly differed on self-esteem, F(2, 154) = 19.78, P<0.001 and quality of life, F(8, 236) = 5.16, P<0.001. Participants with high Multidimensional Acceptance of Loss Scale scores have higher self-esteem and quality of life scores than those with lower scores.

Conclusion: The Multidimensional Acceptance of Loss Scale was found to measure the four value changes in Beatrice Wright’s disability acceptance theory in a sample of Canadians with spinal cord injuries. It demonstrated good internal consistency reliability and construct validity.

Objective: To comprehensively investigate and compare the responsiveness and validity of two instrumental activities of daily living (ADL) measures: a modified version of the Nottingham Extended ADL Scale and the Frenchay Activities Index, after stroke rehabilitation.

Setting: Rehabilitation clinics.

Subjects: Seventy stroke patients received a three-week intervention (mean (SD) age, 55.5 (12.1) years; 46 (65.7%) men; mean (SD) time post stroke, 19.9 (12.5) months).

Measures: Four outcome measures (modified Nottingham Extended ADL Scale, Frenchay Activities Index, Stroke Impact Scale and Motor Activity Log) were administered before and after treatment. We used the standardized response mean (SRM) to examine responsiveness and the Spearman correlation coefficient (ρ) to examine concurrent validity.

Results: Responsiveness was significantly larger for the modified Nottingham Extended ADL Scale (SRM = 0.9) compared with the Frenchay Activities Index (SRM = 0.5). The correlations between the modified Nottingham Extended ADL Scale and Frenchay Activities Index were good to excellent before (ρ = 0.8) and after treatment (ρ = 0.8). The modified Nottingham Extended ADL Scale and Frenchay Activities Index showed fair correlations with the Stroke Impact Scale ADL/Instrumental ADL domain, Stroke Impact Scale total score and Motor Activity Log before treatment (ρ = 0.3—0.4). After treatment, the modified Nottingham Extended ADL Scale and Frenchay Activities Index demonstrated moderate to good correlations with the Stroke Impact Scale ADL/Instrumental ADL domain (ρ = 0.6) and fair correlations with the Stroke Impact Scale total score and Motor Activity Log (ρ = 0.2—0.5).

Conclusions: The modified Nottingham Extended ADL Scale and Frenchay Activities Index are both valid outcome measures but the modified Nottingham Extended ADL Scale is more responsive than the Frenchay Activities Index. While simultaneously considering the properties of responsiveness and validity, the modified Nottingham Extended ADL Scale may be a relatively sound measure of instrumental ADL function in stroke patients receiving rehabilitation.

Objective: To investigate the time course of development of spasticity and contractures at the wrist after stroke and to explore if these are associated with upper limb functional recovery.

Design: Longitudinal observational study using secondary data from the control group of a randomized controlled trial.

Setting: The Acute Stroke Unit at the University Hospital of North Staffordshire.

Subjects: Patients without useful arm function (Action Research Arm Test — ARAT) score of 0 within 6 weeks of a first stroke.

Main measures: Spasticity was measured by quantifying muscle activity during passively imposed stretches at two velocities. Contractures were measured by quantifying passive range of movement and stiffness. Upper limb functional movement was assessed using the ARAT. All assessments were conducted at baseline, and at 6, 12, 24 and 36 weeks after recruitment.

Results: Thirty patients (43% male, median age 70 (range 52—90) years, median time since stroke onset 3 (range 1—5) weeks) were included. Twenty-eight (92%) demonstrated signs of spasticity throughout the study period. Participants who recovered arm function (n = 5) showed signs of spasticity at all assessment points but did not develop contractures. Patients who did not recover useful arm function (n = 25) had signs of spasticity and changes associated with contracture formation at all time points tested.

Conclusion: In this group of patients who had no arm function within the first 6 weeks of stroke, spasticity was seen early, but did not necessarily hinder functional recovery. Contractures were more likely to develop in patients who did not recover arm function.