Physical Therapy in Stroke

Summarized by Robert W. Griffith, MD
April 12, 2002 (Reviewed: April 4, 2004)

Introduction

The use of physical therapy (physiotherapy) to restore motor activity in stroke patients has become routine. Unfortunately, firmly established regimens, such as those financed by healthcare providers, are most common; they use such directives as '30 half-hour treatments' or 'three times a week for 10 weeks'. Gradually, results from randomized controlled clinical trials are providing evidence about what works best, and what doesn't work well. One such trial has just been reported in the Lancet; here's a summary of the findings.

Method

The Rehabilitation Services at St Luke's Hospital, Bradford, UK, recruited patients from hospital and community stroke registers; those over 50 with persistent mobility problems at least one year after a stroke were eligible. 'Mobility problems' were defined as: use of a mobility aid other than a stick (e.g. a walker); a fall in the previous 3 months, inability to manage stairs or uneven surfaces; slower gait speed over 10 meters (33 feet) than predicted for age group.

All participants were interviewed at home with a battery of tests administered by a research physiotherapist. The primary outcome measure used was the Rivermead mobility index, with a score ranging from 0 (lowest) to 15 (highest mobility). Gait speed was measured over 10 meters, using the last two of three measurements.

After randomization, patients were assigned to either community physiotherapy treatment, or no treatment. Appropriate blinding techniques were used. A standard treatment period of 13 weeks maximum was set, with a minimum of three contacts between patient and therapist. Assessments were made at 3, 6, and 9 months

Results

A total of 170 patients were recruited, and randomly assigned to receive 'treatment' or 'no-treatment' (85 each). Their mean age was 72.5 years. Roughly 20% had had a previous stroke. At the time of their stroke, 75% were hospitalized. At the start of the study, 66% were independently mobile on an even surface, and 25% were independently mobile on any surface. Nearly 40% had had a fall within the previous 3 months. The mean baseline Rivermead score was 10 for each treatment group.

Only 146 patients had full assessments over 9 months, due to deaths and withdrawals for various reasons.

The Rivermead mobility scores did not differ significantly between the treatment groups at 3 months ('treatment' = 11, 'no-treatment' = 10), but there was a significant difference in the change in scores at 3 months over baseline (p=0.018). However, this difference was small -- only a mean difference of 1 point. In the subgroup of those who had had falls, the change was significant at 3 months (p=0.023), but not in those who hadn't fallen previously.

After adjustment for baseline gait speeds, the groups differed significantly in favor of 'treatment' at 3 months (p=0.027) by 2.6 m/min, but there was no such significant treatment effect at 6 or 9 months.

There were no significant differences in the results of any of the other evaluative tests used -- daily activities, social activities, anxiety, depression, or number of falls, as well as the emotional stress of caregivers.

Conclusions

The results of this study are, quite frankly, disappointing. Routine physical therapy is prescribed in most cases of stroke, and one would hope that greater benefits would have been demonstrated. The patients recruited for the study were typical of those sent for physical therapy, and the type of therapy given was 'routine'. In interviews with the patients in the 'treatment' group, the investigators found that patients were thankful for the therapy, but felt that it was not designed to help them with their practical difficulties with daily activities.

This last point is taken up by an editorial in the same edition of the Lancet¹. The authors point out that a high dose of afferent impulse is required to 'rewire' the brain to achieve re-mapping. Health professionals in routine 'hands-on' therapy cannot provide this amount of stimuli. New strategies are required -- balance, strength and endurance training, simple task repetition, group therapy, family involvement.

Routine thinking may also hinder physical therapists from adapting, or at least evaluating, new concepts, such as forced-use therapy (also called constraint-induced movement therapy -- see link below). It seems illogical for health providers to continue to fund therapy that is not clearly effective, when there may be other more useful but less traditional approaches.

Source

• Physiotherapy for patients with mobility problems more than 1 year after stroke; a randomized controlled trial. J. Green, A. Forster, S. Bogle,  et al., Lancet, 2002, vol. 359, pp. 199--203

Footnotes
1. Assessment of physiotherapy for patients with stroke. Editorial. W. De Weerdt, H. Feys, Lancet , 2002, vol. 159, pp. 182--183

Related Links
Stroke Rehabilitation - Constraint-Induced Movement Therapy
Stroke Info - Constraint Induced Movement