Stroke: The Evidence for Physiotherapy

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly and Adam Vallely Farrell  

Introduction

Physiotherapy is one of the key disciplines involved in Stroke Rehabiliitation as part of an interdiscpilinary team. According to Stokes and Stack (2012) the role of the physiotherapist is to enable individuals with stroke to achieve their optimal physical potential and functional independance [1]. This is achieved through the use of techniques to facilitate the relearning of movements, use of strategies to enhance adaptation, prevention of secondary complications and maintenance of ability and function. Various approaches to physical rehabilitation have been developed and used over the years, according to different ideas about how people recover after a stroke. New strategies to enhance recovery draw from a growing understanding of how types of training, progressive task-related practice of skills, exercise for strengthening and fitness, neurostimulation, and drug and biological manipulations can induce adaptations at multiple levels of the nervous system [2]. Often physiotherapists may follow one specific treatment approach, but Pollock et al (2014) suggest this practice is generally based on personal preference rather than scientific rationale. Considerable debate continues among physiotherapists about the relative benefits of different approaches; therefore it is important to bring together the research evidence and highlight what best practice ought to be in selecting these different approaches [3].

There are many examples of specific training strategies such as strength training or task-specific practice, which are effective at improving movement and function. There are also many clinical guidelines that provide a comprehensive review of all the available evidence to date for multidisciplinary management of individuals post-stroke [1]

Current evidence suggests that Physical Rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke but no one approach has yet been determined to be any more (or less) effective in promoting recovery of function and mobility after stroke. Similarly conclusions in relation to dose of physical therapy is not yet robust as a result of substantial heterogeneity in research. Therefore, current evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin [3]. In order to implement evidence-based practice, physiotherapists must incorporate a wide range of strategies that are supported by the current evidence base into their treatment programmes [4][3].

However, physiotherapists must also continue to rely on their clinical reasoning skills to select appropriate treatment techniques approprites to the needs and goals of their patients and carers as there are still many areas of clinical practice with no evidence or conflicting evidence. This is why accroding to Bernhardt & Legg, 2009, evidence-based practice is defined as the integration of best evidence with clinical expertise and patient values [5]. Evidence-based practice involves three components: evidence available, clinical judgement and service user values. 

Guiding Principles

Lennon and Bassile (2009) put forward eight guiding principles for neurological physiotherapy in order to provide a strong framework of evidence-based practice for development of your treatment plan [6].

Principle 1: The ICF

The ICF is a framework for describing functioning and disability in relation to a health condition. It provides a common language and framework for documenting information on the functional changes associated with physiotherapy interventions. The World Confederation of Physical Therapy (WCPT) adopted a motion supporting the implementation of the ICF in Physiotherapy in 2003 [7]. The ICF Core Sets were developed as a practical tool to facilitate the systematic and comprehensive description of functioning in clinical practice [8][9].

The ICF is a framework on which to approach patient care that shifts the conceptual emphasis away from negative connotations such as disability and places focus on the positive abilities of the individual at the patient level rather than the systems level. The ICF framework is a classification of the health components of functioning and disability and focuses on 3 Perspectives: Body, Individual, and Societal. These 3 perspectives underscore the importance of the interplay and influence of both internal and external factors to each individual’s condition of health[9].

The activities dimension covers the range of activities performed by an individual, while the participation dimension classifies the areas of life in which there are societal opportunities or barriers for each individual with the overall framework providing a mechanism to document the impact of the environment on a person’s functioning. Neurological physiotherapy may directly target both impairment and activity aiming to improvequality of life and increased participation in desired life roles [9][1].

Principle 2: Team Work

A variety of health care professionals are involved in the provision of care and exchange of information with the patient and family members and therefore teamwork is key to coordinate the rehabilitation process and the roles of those involved. It is important to understand the holistic approach to rehabilitation following a neurological impairment and the role of the physiotherapist within the multidisciplinary/interdisciplinary environment [1][6]. It would appear that team working is an essential factor in improving patient outcomes post Stroke as was highlighted in the Stroke Unit Trialists Collaboration [10] which identified that patients who received organized stroke unit care provided in hospital by clinical specialists working in a coordinated team were more likely to survive their stroke, return home and become independent in looking after themselves.

Principle 3: Patient-Centred Care

Increasingly evidence shows improvements in self-care, quality of life, satisfaction with care, increased engagement and reduced anxiety when care is patient-centred. Patients and their carers should be involved in the process of creating a treatment plan and provided with information on which to make decisions about their goals and select treatment solutions and therefore the emphasis should be placed on the patient as the problem solver and the decision maker [6]. Goal setting provides a mechanism for patient-centred care by enabling autonomy, and appropriate pacing of information and responsibility.

Principle 4: Neural Plasticity

The term Neuroplasticity is derived from the root words Neuron and Plastic. A neuron refers to the nerve cells in our brain. Each individual neural cell is made up of an axon, dendrites, and is linked to one another by a small space called the synapses. The word plastic means to mould, sculpt, or modify. Neuroplasticity refers to the potential that the brain has to reorganize by creating new neural pathways to adapt, as it needs.

Advances in neuroimaging have shown us that plasticity (enduring changes in structure and function) can occur following damage to the nervous system, and also as a result of experience and therapy allowing for some degree of spontaneous recovery following brain damage such as occurs in Stroke. According to Stokes and Stack (2012) the ability for neuroplastic change implies that the main aim of therapy post stroke should be recovery of movement and function rather than the promotion of independence using the unaffected side, e.g. compensation. [1]

Principle 5: A Systems Model of Motor Control

In the article “Is Neuroplasticity Promoted by Task Complexity” the authors suggest that in order to maximise the potential for neuroplasticity and motor learning physiotherapists should select complex motor tasks over simple motor tasks when training patients. Following injury to the neurological system, or onset of a neurological disease, the body’s neural pathways become altered, affecting the nerves that control movement and sensation. Such changes to the nervous system give rise to the many symptoms associated with a neurological disorder. Movements & responses that were once automatic may become abnormal & difficult to produce in the way a person is used to. 

The control of human movement has been described in many different ways with many different models of Motor Control put forward throughout the 19th & 20th Centuries. Motor Control Theories include production of reflexive, automatic, adaptive, and voluntary movements and the performance of efficient, coordinated, goal-directed movement patterns which involve multiple body systems (input, output, and central processing) and multiple levels within the nervous system. Within the field of Neurology many textbooks and researcher recommend adoption of a systems model of Motor Control incorporating neurophysiology, biomechanics and motor learning principles which also considers learning solutions based on the interaction between the patient, the task and the environment. As a therapist it is these key areas that we need to be aware of when planning our interventions. As therapists we can change the environment, or the task in such a way as to enable our patients to achieve their goals [11]

Principle 6: Functional Movement Re-education

Principle 7: Skill Acquisition

Skill Acquisition is the science that underpins movement learning and execution and is more commonly termed motor learning and control (Williams & Ford, 2009). Motor learning or skill acquisition can be divided into three phases (Marley et al., 2000), Cognitive Stage, Associative Stage and Autonomous Stage. Each stage embodies unique characteristics relative to an athlete’s level of performance of a skill or activity. All of which, are affected by a range of environmental constraints that can include factors such as: level of instruction, quality and frequency of feedback, opportunity to make decisions, type and frequency of practice, exposure to other sports, organismic factors and socio-economic/cultural limitations (Ericsson & Lehman, 1996; Fairbrother, 2010; Magill, 2009; Newell, 1986 & Schmidt & Wrisberg, 2004).

Principle 8: Self Management (Self-Efficacy)

Self-management, incorporating active involvement of in decisions about treatment and shared responsibility has become more part of rehabilitation for individuals with long term neurological conditions. Understanding what it is and why it is becoming such a key element of the rehabilitation process are important to ensuring your treatment has patient involvement and is patient focused. Read the following resources on Self Management.[12][13]

References

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  1. 1.0 1.1 1.2 1.3 1.4 Stokes M and Stack E. Physical Management for Neurological Rehabilitation - Third Edition. Elsevier Health Sciences; 2012.
  2. Dobkin BH, Dorsch A. New evidence for therapies in stroke rehabilitation. Current atherosclerosis reports. 2013 Jun 1;15(6):331.
  3. 3.0 3.1 3.2 Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. The Cochrane Library. 2014 Jan 1.
  4. Pollock A, Baer G, Pomeroy VM, Langhorne P. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke. The Cochrane Library. 2007 Jan 1.
  5. Bernhardt, J., Legg, L., 2009. Chapter 1.Evidence-based practice. In: Lennon, S., Stokes, M. (Eds.), Pocketbook of Neurological Physiotherapy. Elsevier Science, London,fckLRpp. 3–15.
  6. 6.0 6.1 6.2 Lennon, S., Bassile, C., 2009. Guiding Principles for neurological physio- therapy. In: Lennon, S., Stokes, M. (Eds.), Pocketbook of Neurological Physiotherapy. Elsevier Ltd, London, pp. 97–111.
  7. Escorpizo R, Stucki G, Cieza A, Davis K, Stumbo T, Riddle DL. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther. 2010;90:1053-63.
  8. Kesselring J, Coenen M, Cieza A, Thompson A, Kostanjsek N, Stucki G. Developing the ICF Core Sets for multiple sclerosis to specify functioning. Mult Scler. 2008;14:252-4.
  9. 9.0 9.1 9.2 Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil. 2008;44(3):329-42.
  10. Stroke Unit Trialists Collaboration (SUTC), 2006. Organised inpatient (stroke unit) care for stroke(review). The Cochrane Library (3).
  11. Bate P, Motor Control. In: Sheila Lennon and Maria Stokes. Pocketbook of Neurological Physiotherapy. Churchill Livingstone, 2008. p31 - 40.
  12. Mudge, S. et al, Who is in Control? Clinicians’ View on their Role in Self-management Approaches: A Qualitative Metasynthesis , BMJ Open, 2015
  13. Jones, F. Chapter 19: Self-management , in Stokes, M. &s Stack, E., Physical Management for Neurological Conditions, Churchill Livingstone, 2013.