Rehab After a Stroke

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

Introduction

Nowadays the majority of those who have had a stroke are prescribed some physical therapy (physiotherapy). This usually consists of a number of half- or one-hour sessions with a therapist, maybe daily, maybe three times a week, for anything up to 3 months. And the general perception is that physical therapy is doing a lot of good. However, the benefits may be much smaller than people think. A recent study reported in the medical journal Lancet tried to measure the benefits of routine physical therapy after a stroke.

How the study was done

The Rehabilitation Services at St Luke's Hospital, Bradford, UK, recruited stroke patients over 50 who had persistent mobility problems at least one year after their stroke. By 'mobility problems' they meant having to use a walking aid other than a stick (e.g. a walker), having a fall in the previous 3 months, being unable to manage stairs or uneven surfaces, or being measurably slow in walking.

A research physical therapist gave all participants a battery of tests at home. The main measure used was an all-inclusive score of mobility, called the Rivermead index; this had a scoring system that ranged from 0 (lowest) to 15 (highest mobility). Walking speed was measured over a distance of 10 meters (that's 33 feet).

The participants were assigned to receive either physical therapy - the 'treatment' group - or 'no treatment' at all, in a random fashion. The actual details of treatment were left to each patient's therapist, but it could be given for up to 13 weeks, and there had to be at least three meetings between patient and therapist. Assessments of progress were made at 3, 6, and 9 months

A total of 170 patients were enrolled, with 85 each allocated to 'treatment' or 'no-treatment' groups. Their average age was 73. Roughly one in five had had a previous stroke. Almost half (40%) had had a fall within the previous 3 months.

At the start of the study, two-thirds of the participants were quite mobile on an even surface, and a quarter of them were mobile on any surface. Their average score on the Rivermead index was 10, out of a maximum 15 points.

What was found

Several participants dropped out, and or died, during the 9-month study period, and only 146 of them completed all the assessments.

The greatest changes were found at the 3-month assessments, and they were not very large. The 'treatment' group scored 11, and the 'no-treatment' group scored 10 at 3 months. In other words, physical therapy was associated with a very small, non-significant improvement compared with no-treatment.

Baseline walking speeds were slightly different in the two groups. After adjusting for this, it was found that the 'treatment' group patients were significantly faster at 3 months by an average difference pf 2.6 meters/minute -- again, a quite small improvement.

Neither the Richmead index nor the walking speed improvements detected at 3 months could be found at 6 or 9 months.

There were no significant effects of 'treatment' on the results of any of the other tests used -- daily activities, social activities, anxiety, depression, or the number of falls; and a measure of the emotional stress in the patients' caregivers also showed no change.

What should we deduce from this?

The results of this study are, quite frankly, disappointing. Of course, the therapy was being tested in patients one year, at least, after their stroke. However, the participants were typical of those sent for physical therapy, and the type of therapy given was 'routine'. The investigators make a revealing statement in their publication. They report that, in interviews with the patients in the 'treatment' group, they found that patients were thankful for the therapy, but felt that it was not designed to help them with their practical difficulties with day-to-day activities.

New thinking about the possible ways stroke patients might restore damaged or destroyed nervous tissue connections suggest the need for very intensive, long-lasting stimulation. Such a degree of stimulation is hardly likely to occur in routine therapy sessions. New approaches are required - balance, strength and endurance training, simple task repetition, group therapy, and family involvement - as well as 'therapy' for several (many?) hours a day. A new concept, forced-use therapy (also called constraint-induced movement therapy -- see link below) is just such a technique that deserves wider trials. It doesn't make sense for HMOs (or other health providers) to continue to pay for therapy that is not clearly very 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

Related Links
Stroke Rehabilitation - a New Approach?
How to Spot Caregiver Burnout
Stroke Info - Constraint Induced Movement

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