Clinical Rehabilitation

To investigate the effects of motor imagery training on the balance and gait abilities of post-stroke patients.

Randomized controlled trial.

Outpatient rehabilitation centre.

Twenty-eight individuals with chronic stroke.

The experimental group (n = 15) performed motor imagery training involving imagining normal gait movement for 15 minutes embedded in gait training for 30 minutes (45 minutes/day, 3 times/week); the control group (n = 13) performed gait training only (30 minutes/day, 3 times/week).

Balance and gait abilities were measured by the Functional Reach Test, Timed Up-and-Go Test, 10-m Walk Test and Fugl-Meyer assessment before and after interventions.

All measurements improved significantly compared with baseline values in the experimental group. In the control group, there were significant improvements in all parameters except the Fugl-Meyer assessment. All parameters of the experimental group increased significantly compared to those of the control group as follows: Functional Reach Test (control vs. experimental: 28.1 ± 3.1 vs. 37.51 ± 3.0), Timed Up-and-Go Test (20.7 ± 4.0 vs. 13.2 ± 2.2), 10-m Walk Test (17.4 ± 4.6 vs. 16.0 ± 2.7) and Fugl-Meyer assessment (12.0 ± 2.9 vs. 17.6 ± 1.3).

Gait training with motor imagery training improves the balance and gait abilities of chronic stroke patients significantly better than gait training alone.

To determine whether the efficacy of botulinum toxin type A in chronic plantar fasciitis was maintained for more than six months after treatment.

Observational follow-up study.

Twenty-four patients who received botulinum toxin type A injection in a previous randomized study of chronic plantar fasciitis (active treatment group) and who presented a benefit one month after treatment.

A visual analogue scale for pain and the Foot Health Status Questionnaire were used to re-evaluate results 12 months after the botulinum toxin injection. No further injections of botulinum toxin had been administered during the follow-up period. Patients were also asked to give a subjective assessment of treatment outcome.

At 12 months, compared with the six-month evaluation, there was a further improvement in foot pain measured using the visual analogue scale, though this did not reach significance (1.78 at 6 months versus 1.22 at 12 months; P = 0.142). However, there were significant improvements in two domains of Foot Health Status Questionnaire: foot pain (91.11 at 6 months versus 80.00 at 12 months; P = 0.001) and foot function (96.19 at 6 months versus 89.38 at 12 months; P = 0.047). There was a small, non-significant deterioration in the shoe and foot health domains. Satisfaction with the outcome was good or very good in the large majority of patients.

In patients with chronic plantar fasciitis, the positive effect detected six months after treatment with botulinum toxin type A was maintained at 12 months and there was a further improvement in pain and foot function.

Compare the effects of treadmill training and training with overground walking (both without partial weight support) on motor skills in children with cerebral palsy.

Randomized controlled clinical trial.

Physical therapy clinics.

Thirty-six children with cerebral palsy (levels I–III of the Gross Motor Functional Classification System) randomly divided into two intervention groups.

Experimental group (17 children) submitted to treadmill training without partial weight support. Overground walking group (18 children) submitted to gait training on a fixed surface (ground). Training was performed for seven consecutive weeks (two sessions per week), with four subsequent weeks of follow-up.

Both groups demonstrated improvements on the 6-minute walk test (experimental group from 227.4 SD 49.4 to 377.2 SD 93.0; overground walking group from 222.6 SD 42.6 to 268.0 SD 45.0), timed up-and-go test (experimental group from 14.3 SD 2.9 to 7.8 SD 2.2; overground walking group from 12.8 SD 2.2 to 10.5 SD 2.5), Pediatric Evaluation Disability Inventory (experimental group from 128.0 SD 19.9 to 139.0 SD 18.4; overground walking group from 120.8 SD 19.0 to 125.8 SD 12.2), Gross Motor Function Measure-88 (experimental group from 81.6 SD 8.7 to 93.0 SD 5.7; overground walking group from 77.3 SD 7.0 to 80.8 SD 7.2), Berg Balance Scale (experimental group from 34.9 SD 8.5 to 46.7 SD 7.6; overground walking group from 31.9 SD 7.0 to 35.7 SD 6.8) after treatment. The experimental group demonstrated greater improvements than the overground walking group both after treatment and during follow up (p < 0.05).

Treadmill training proved more effective than training with overground walking regarding functional mobility, functional performance, gross motor function and functional balance in children with cerebral palsy.

To evaluate the effectiveness of additional balance training on mobility and function outcome in patients with knee osteoarthritis after total knee replacement.

A prospective intervention study and randomized controlled trial.

A university-based teaching hospital.

Patients who received total knee replacement surgery were recruited sequentially from the orthopedic department. They were randomly assigned to either the experimental group or control group.

The control group received conventional function training for eight weeks. The experimental group not only received the same conventional training as the control group, but also received additional balance exercises in each admission.

Before and after training we took the following measurements: distance of functional forward reach; duration of single leg stance; timed sit-to-stand test; timed up-and-down stair test; timed 10-m walk; timed up-and-go test; and the Western Ontario and McMaster Universities Osteoarthritis Index score.

58 patients in the experimental group with a mean (SD) age of 71.4 (6.6) years and 55 in the control group with mean (SD) age of 72.9 (7.3) years, completed the study. After eight-weeks intervention with additional balance exercises, the experimental group demonstrated significant changes in 10-m walk (P < 0.001, 95% confidence interval (CI): 3.6 to 4.4 seconds) and in timed up-and-go (P < 0.001, 95% confidence interval: 2.6 to 3.4 seconds) tests. Significant changes of all other measures and Western Ontario and McMaster Universities Osteoarthritis Index score were also observed in the experimental group (all P < 0.001).

Additional balance training exerted a significant beneficial effect on the function recovery and mobility outcome in patients with knee osteoarthritis after total knee replacement.

To investigate the impact of high-frequency chest wall oscillation in chronic obstructive pulmonary disease patients with infective exacerbation.

Clinical randomized controlled trial.

Patients received high-frequency chest wall oscillation therapy at the Department of Pulmonology.

Stage III-IV chronic obstructive pulmonary disease patients hospitalized with acute infective exacerbation who had received high-frequency chest wall oscillation therapy were studied.

Patients were randomized into two groups, which were classified as I and II. All patients have been treated with bronchodilators, antibiotics, if necessary oxygen and patient education, as part of acute chronic obstructive pulmonary disease exacerbation protocol. Group II patients received additional high-frequency chest wall oscillation therapy.

Body mass index (B), forced expiratory volume in the first second (O), modified Medical Research Council dyspnea scale (D) and 6-minute walking test (E) (BODE) index, forced expiratory volume in the first second, dyspnea, exercise capacity, oxygenation parameters and hospitalization of duration were recorded at baseline and at three-days and five-days follow-up.

From April 2009 to July 2011, a total of 99 patients were assessed for eligibility, 50 patients were enrolled and randomized into two groups. A total of 50 (100%) patients (25 in Group I and 25 in Group II) were followed up for five days. Application of high-frequency chest wall oscillation therapy resulted in no significant advantage in all outcomes (p > 0.05). Mean (SD) baseline BODE index value in Group I was 7.72 (1.76), in Group II was 7.72(1.89) (p = 0.55). On the fifth-day assessment, mean (SD) BODE index value in Group I was 7.24 (1.83), in group II was 6.44 (2.46) (p = 0.18).

The application of high-frequency chest wall oscillation therapy offers no additional advantages on infective exacerbations in chronic obstructive pulmonary disease.

The purpose of this study was to determine if there is a practice effect present in the timed 25-foot walk in ambulatory individuals with multiple sclerosis.

Thirty six people (30 women and 6 men) diagnosed with relapsing remitting multiple sclerosis participated in two testing sessions, one week apart. Each participant performed two sequential trials of the timed 25-foot walk test per session and the walk performance was measured with a laser timing system.

We observed improvements in walking speed between the two trials of session one (trial one: 6.42 (0.09) vs. trail two: 5.97 (0.08) seconds, p < 0.001). Within session two, performance remained stable (trial three: 5.71 (0.07) vs. trial four: 5.63 (0.07) seconds, p > 0.05). We also observed a significant improvement in walking speed when averages of the two trials were compared across sessions (session 1: 6.19 (0.09) vs. session 2: 5.67 (0.07) seconds, p < 0.01).

Based on our results, familiarization of the timed 25-foot walk test improves stability of walk performance scores in ambulatory individuals with relapsing remitting multiple sclerosis.

To further validate the simplified modified Rankin Scale questionnaire (smRSq), we compare it here to a well-established predictor of functional outcome after stroke, the initial stroke severity.

Retrospective correlation analysis.

Forty patients identified from a registry of stroke patients treated with intravenous tissue plasminogen activator.

Community and 17 hospital Emergency Departments within a web-based telestroke network throughout the state of Georgia, USA.

Five certified raters assessed the initial stroke severities with the National Institutes of Health Stroke Scale (NIHSS) via the telestroke system. Over a 20 month period, one certified rater, unaware of the NIHSS scores, attempted to contact each patient in the registry to assess their functional outcomes with the smRSq via telephone. We analyzed patients who had the smRSq assessment at least three months after stroke.

Forty of 120 registered patients were contacted and qualified for this study. The baseline clinical characteristics of the 40 analyzed and the 80 disqualified patients were similar. The correlation between the initial NIHSS and the smRSq was good (r = 0.69, R² = 0.47, P < 0.001).

The good correlation of the smRSq with the initial stroke severity further confirms the smRSq validity in assessing functional outcome after stroke.

To evaluate the psychometric properties of the Arm Activity Measure (ArmA), a patient-reported measure of active and passive function in the paretic upper limb.

Psychometric evaluation study.

Two specialist rehabilitation and spasticity management services.

Patients (n = 92) with upper limb paresis were recruited from two specialist neurorehabilitation centres. Mean age 44.5 (SD 16.7). Diagnostic distribution: stroke 48 (52%); other brain injury 28 (31%); or other neurological condition 16 (17%). Evaluation of convergent and divergent validity; unidimensionality, scaling, reliability (internal consistency and test–retest); responsiveness to change and feasibility of the ArmA were undertaken.

Expected convergent and divergent relationships were seen with the Leeds Adult Spasticity Impact Scale and the Disabilities of Arm Shoulder and Hand (DASH) (rho 0.5–0.63). Principal components analysis confirmed that active and passive function formed two separate constructs in each sub-scale. Mokken analysis corroborated the findings of the principal components analysis and demonstrated scaling using the monotone homogeneity model (Item H>0.5 for all items). Cronbach’s alpha was 0.85 and 0.96, respectively, for the passive and active function subscales. Item level test–retest agreement ranged from 92-97.5% (quadratic-weighted Kappa 0.71-0.94). In the subgroup treated for spasticity with botulinum toxin (n = 58), the ArmA passive function scale identified a significant difference between responder and non-responder groups (Mann Whitney U = 0.85, p < 0.01). Respondents reported the ArmA to be relevant (77%), easy to use (90%) and timely to complete (83% under 10 minutes).

The ArmA is a valid and reliable tool feasible for use in the evaluation of upper limb function in the context of treatment for spasticity.

Recovery from stroke requires the provision of specialist rehabilitative care, yet there is a lack of research evidence on optimal methods of delivery and inequitable service provision across countries. Following consensus on Early Supported Discharge, our aim was to define core components of evidence-based community stroke services.

We used a modified Delphi approach with a purposive sample of 26 UK-based expert panellists (10 academics, 15 stroke service leads or commissioners, one stroke survivor). Statements based on research literature and policy documents were generated by an independent, mixed academic and service improvement team of nine. In three rounds of consultation panellists indicated their level of agreement with statements. Free text comments were analysed thematically.

Consensus of opinion (>70% agreement) was obtained on 76 of 80 statements. Panellists agreed that stroke specialist care tailored to clinical need should be provided following discharge from hospital. Flexible care pathways should be commissioned and provided through strategic and collaborative leadership across health and social care. Teams need to deliver stroke specialist rehabilitation, handing over responsibility to non-specialist services when patient rehabilitation goals have been met. Lack of consensus on whether to provide services exclusively for stroke patients and the need of support for carers highlights areas for further research.

Consensus on the provision of evidence-based community stroke rehabilitation has been reached. Commissioning services with a clearly defined remit, which can deliver tailored care to individual stroke patients, is a challenge that needs further exploration.

To investigate patients’ and carers’ experiences of Early Supported Discharge services and inform future Early Supported Discharge service development and provision.

Semi-structured interviews were completed with 27 stroke patients and 15 carers in the Nottinghamshire region who met evidence-based Early Supported Discharge service eligibility criteria. Participants were either receiving Early Supported Discharge or conventional services.

Community stroke services in Nottinghamshire, UK.

A thematic analysis process was applied to identify similarities and differences across datasets. Themes specific to participants receiving Early Supported Discharge services were: the home-based form of rehabilitation; speed of response; intensity and duration of therapy; respite time for the carer; rehabilitation exercises and provision of technical equipment; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Participants receiving Early Supported Discharge or conventional community services experienced difficulties related to: limited support in dealing with carer strain; lack of education and training of carers; inadequate provision and delivery of stroke-related information; disjointed transition between Early Supported Discharge and ongoing rehabilitation services.

Accelerated hospital discharge and home-based rehabilitation was perceived positively by service users. The study findings highlight the need for Early Supported Discharge teams to address information and support needs of patients and carers and to monitor their impact on carers in addition to patients, using robust outcome measures.

To use data and patient involvement to identify categories within the International Classification of Functioning, Disability and Health (ICF) component activities and participation relevant for patients with affective, somatoform, anxiety and adjustment disorders.

The first step was to identify systematically, outcome instruments used in randomized controlled trials, to relate item content to the ICF. Then four patient focus group discussions (n = 21 participants) were conducted, and finally an expert panel (n = 11 participants) was used to identify the most relevant categories in therapy settings.

Focus groups: inpatient psychotherapy patients. Expert panel: clinicians, stakeholders, patient representative.

In the literature search, 313 measures were identified, which included 1562 meaningful concepts (separate content units). These were allocated to ICF categories that were validated and complemented in focus groups and by an expert panel. The resulting core set includes 27 categories related to the nine chapters of the ICF component activities and participation.

A core set of items, set within the World Health Organization ICF and relevant to the treatment of people with affective, somatoform, anxiety and adjustment disorders, has been developed based on existing evidence.