As Mr ND emerges from coma and becomes more orientated in the general surgical ward and, later, in the rehabilitation unit, the physiotherapist will need to make a decision about the quantity of motor training to provide. To investigate this issue about the amount of training and functional outcomes, I have posed the question: ‘After THI, does more intensive physiotherapy intervention lead to better functional outcomes when compared with less intensive physiotherapy intervention?’
A search of the PEDro database using the term ‘intensity’ in the abstract field and ‘neurology’ in the subdiscipline field produced 13 records. While none of the records related to THI, there were two systematic reviews directly addressing the question for the stroke population (Kwakkel et al., 1997 A; Langhorne et al., 1996 A), two relevant randomized controlled trials for the stroke population that were published after the systematic reviews (Kwakkel et al., 1999 A; Lincoln et al., 1999 A) and nine other randomized controlled trials. Searching Medline, CINAHL and DARE did not yield any additional trials or reviews. I decided to appraise the most recent systematic review (Kwakkel et al., 1997 A) as well as the two relevant and more recent randomized controlled trials. The latter was undertaken to confirm that the results were consistent with the review and to assist with establishing the clinical significance of the results.
The Kwakkel et al. (1997 A) review passed both of the methodological filters for systematic reviews and summarized the results of nine random
ized controlled studies. On average, intensive physiotherapy (48.4 minutes per day) was about twice the quantity of regular physiotherapy
(18.5 minutes per day). Intensive therapy was associated with better outcomes for activities of daily living (mean effect of 0.28 standard units, with a 95% confidence interval of 0.16 to 0.40), higher neuromuscular scores (mean effect of 0.37 standard units, with a 95% confidence interval of 0.13 to 0.61) and a trend towards higher functional levels (mean effect of 0.10 standard units, with a 95% confidence interval of –0.11 to 0.31). Each of the effect sizes was calculated by Kwakkel et al. (1997 A). Because the results were expressed as standard units, it was not possible to determine the effect size using clinically meaningful units.
Both of the randomized controlled trials were of relatively high quality (Kwakkel et al., 1999 A; Lincoln et al., 1999 A) (see Table 3). Kwakkel et al.
(1999 A) compared standard physiotherapy (30 minutes per day) plus airsplint immobilization of the arm and leg with standard physiotherapy plus 30 minutes per day extra arm training, and standard physiotherapy plus 30 minutes per day extra leg training after stroke. Interventions used in the extra training could be broadly classified as task specific. During the 20 weeks of intervention, the extra leg training group could walk significantly faster and had significantly better functional ambulation, dexterity and functional abilities compared with the control group. For example, at 20 weeks subjects in the extra leg training group could walk an average of 0.36 metres per second faster than the control group, with a 95% confi-dence interval of 0.02 to 0.70 metres per second (effect size calculated by the author of this chapter). Over the same period, the extra arm training group had significantly better dexterity than the control group. Six weeks after training the reported effects were reduced. These results are consistent with the previously published systematic review by Kwakkel et al. (1997 A).
In contrast with the Kwakkel et al. (1999 A) trial, the Lincoln et al.
(1999 A) study produced non-significant results. Lincoln et al. (1999 A) investigated the intensity of Bobath therapy on arm function after stroke.
The control group received 30 to 45 minutes per day of Bobath therapy for five weeks. The experimental groups received the control therapy plus two hours per week extra Bobath therapy from either a qualified physiotherapist or a physiotherapy assistant. There were no significant between-group differ
ences for dexterity or functional abilities at any of the follow-up assessments.
There do not appear to be any systematic reviews and randomized controlled trials that evaluate the effect of therapy intensity after THI. Until this research is undertaken, estimates for the effect size of intensive therapy may be drawn from the stroke literature. It is difficult to adjust the effect sizes reported by Kwakkel et al. (1997 A, 1999 A) to the THI population.
People with THI are younger and generally free from concomitant disease processes, which suggests that larger effect sizes should be expected clinic
ally. In contrast, however, people with THI have global neuropsychological
Table 3: Critical appraisal of randomized controlled trials examining the effects of physiotherapy intensity Trial Random Concealed allocation allocation Assessor Blinding Adequate follow up Therapists Subjects Kwakkel et al. (1999 A) yes yes yes no no yes Lincoln et al. (1999 A) yes yes yes no no no
impairments and neurobehavioural sequelae associated with frontal lobe damage, which would reduce the expected effect size.
One challenge faced by the physiotherapist is how to implement more intensive therapy in the presence of Mr ND’s neuropsychological impair
ments (including memory problems and decreased attention). Based on clinical experience, strategies which may increase the total amount of practice include practising tasks important to Mr ND, using strong cues to draw his attention to the task (such as using a limb-load monitor to provide feedback about the amount of weight being borne through the right leg), changing the task or exercise frequently and having frequent but shorter physiotherapy sessions in order to maximize the total amount of practice.
These strategies require empirical validation.
Ada (1999 C) has highlighted that implementing intensive one-on-one physiotherapy may be difficult in the current economic climate. Physio
therapists may need to explore other models of service delivery in order to provide more intense therapy without increasing staffing levels. Some solutions could include group exercise (a circuit class), structuring practice the patient can complete independently or with the assistance of their family and friends, and setting up work stations. Again, these solutions still require empirical validation.
Implications
The five-step process of evidence-based practice described by Sackett et al.
(2000) was used to review the current evidence for physiotherapy interven
tion for people with THI. Four questions (two about complications and two about motor training) were posed. Only one randomized controlled trial conducted with THI subjects was identified during the four searches. For each question, systematic reviews and randomized controlled trials from other patient populations (mainly stroke) were used to estimate the effects of different treatments for Mr ND, an 18-year-old man with a severe THI.
The answers to the questions reflect the external evidence available in early 2000. Evidence-based practice is a dynamic process, so it will be very inter
esting to repeat these questions in five years’ time to see how the treatment recommendations have changed.
The search results from the questions posed about Mr ND’s physio
therapy treatment highlight some areas of need for clinical research. Future research could be directed toward establishing the optimum type and amount of stretching and therapy specifically for the THI population. This research would expand the external evidence available to physiotherapists to facilitate evidence-based clinical decision-making.
References
Ada L (1999) Commentary on intense lower limb training enhances lower limb func
tion and intense upper limb training enhances upper limb function following stroke. Australian Journal of Physiotherapy 45(4): 319.
Ada L, Canning C (1990) Anticipating and avoiding muscle shortening. In Ada L, Canning C (Eds) Key Issues in Neurological Physiotherapy. Oxford: Heinemann Medical, pp 219–36.
Bobath B (1990) Adult Hemiplegia: Evaluation and Treatment, 3rd edn. London:
Heinemann Medical.
Bohannon RW, Larkin PA (1985) Passive ankle dorsiflexion increases in patients after a regimen of tilt table-wedge board standing: a clinical report. Physical Therapy 65(11): 1676–8.
Booth A, Madge B (1998) Finding the evidence. In Bury T, Mead J (Eds) Evidence-based Healthcare: A Practical Guide for Therapists. Oxford: Butterworth-Heinemann, pp 107–35.
Carr JH, Shepherd RB (1998) Neurological Rehabilitation: Optimizing Motor Performance. Oxford: Butterworth-Heinemann.
Conine TA, Hershler C, Daechsel D, Peel C, Pearson A (1994) Pressure sore prophy
laxis in elderly patients using polyurethane foam or Jay wheelchair cushions.
International Journal of Rehabilitation Research 17(2): 123–37.
Cullum N, Deeks J, Sheldon TA, Song F, Fletcher AW (1999) Beds, mattresses and cushions for pressure sore prevention and treatment (Cochrane Review). The Cochrane Library, Issue 4: Oxford: Update Software.
Dean CM, Shepherd RB (1997) Task-related training improves performance of seated reaching tasks after stroke. A randomized controlled trial. Stroke 28(4): 722–8.
Fisher M (Ed) (1989) Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Baltimore: Williams & Wilkins, ch. 1.
Guyatt GH, Sackett DL, Cook DJ (1993) Users’ guides to the medical literature, II:
How to use an article about therapy or prevention, A. Are the results of the study valid? JAMA 270(21): 2598–601.
Herbert RD, Moseley AM, Sherrington C (1998–99) PEDro: a database of randomised controlled trials in physiotherapy. Health Information Management 28(4):
186–8.
Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ (1993) Clinical utility and cost-effective-ness of an air suspension bed in the prevention of pressure ulcers. JAMA 269(9):
1139–43.
Kwakkel G, Wagenaar RC, Koelman TW, Lankhorst GJ, Koetsier JC (1997) Effects of intensity of rehabilitation after stroke: a research synthesis. Stroke 28(8): 1550–6.
Kwakkel G, Wagenaar RC, Twisk JW, Lankhorst GJ, Koetsier JC (1999) Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial.
Lancet 354(9174): 191–6.
Langhorne P, Wagenaar R, Partridge C (1996) Physiotherapy after stroke: more is better? Physiotherapy Research International 1(2): 75–88.
Light KE, Nuzik S, Personius W, Barstrom A (1984) Low-load prolonged stretch vs.
high-load brief stretch in treating knee contractures. Physical Therapy 64(3):
330–3.
Lim R, Sirett R, Conine TA, Daechsel D (1988) Clinical trial of foam cushions in the prevention of decubitis ulcers in elderly patients. Journal of Rehabilitation Research and Development 25(2): 19–26.
Lincoln NB, Parry RH, Vass CD (1999) Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke.
Stroke 30(3): 573–9.
Moseley AM (1997) The effect of casting combined with stretching on passive ankle dorsiflexion in adults with traumatic head injuries. Physical Therapy 77(3):
240–7.
Oxman AD, Cook DJ, Guyatt GH (1994) Users’ guides to the medical literature, VI:
How to use an overview. JAMA 272(17): 1367–71.
Richardson WS, Wilson MC, Nishikawa J, Hayward RS (1995) The well-built clinical question: a key to evidence-based decisions. ACP Journal Club 123(3): A12–A13.
Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB (2000) Evidence-Based Medicine: How to Practise and Teach EBM, 2nd edn. Edinburgh: Churchill Livingstone.
Steffen TM, Mollinger LA (1995) Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. Physical Therapy 75(10):
886–95.
Yarkony GM, Sahgal V (1987) Contractures: a major complication of craniocerebral trauma. Clinical Orthopaedics and Related Research 219: 93–6.
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