An investigation into independent practice as an addition to physiotherapy intervention for patients with recently acquired stroke.

Pollock, Alexandra Susan (1998). An investigation into independent practice as an addition to physiotherapy intervention for patients with recently acquired stroke. PhD thesis The Open University.

DOI: https://doi.org/10.21954/ou.ro.00010211

Abstract

This study of physiotherapy intervention for patients with recently acquired stroke had two defined aims. The first aim was to explore the recovery of symmetry of weight distribution during the postures of sitting and standing and during the movements of rising to stand, sitting down and reaching. This aim involved the comparison of data from stroke patients with data from healthy subjects. The second aim was to determine the effect of a regime of independent practice, based on the evidence for the optimal learning of motor skills. This aim was met using a randomised controlled trial.

Twenty-eight patients with stroke were recruited into the randomised controlled trial. Using a blocked randomisation procedure, subjects were assigned to a practice group (n=9) or to a control group (n=19). Using a clinical measurement system, comprising a standard chair and a platform within which were a series of force measuring sections, weekly objective measurements of the symmetry of weight distribution during the specified postures and movements were recorded. Measurements were collected weekly for a maximum of 7 weeks. Both groups received normal physiotherapy intervention, based on the Bobath Concept. In addition to this, the practice group subjects carried out a practice regime aimed at improving sitting balance. The practice regime was carried out daily for 4 weeks. Subjects who were discharged from the hospital prior to the completion of 7 weeks of data collection did not attend for any further measurement sessions. The lack of recorded data from subjects discharged from the hospital placed limitations on the analysis of the study results and on the conclusions that could be drawn from the study.

In order to explore the recovery of symmetry of weight distribution in the patients with stroke, patient data were compared with "normative" values collected from 20 young and 20 elderly healthy subjects. The normative values revealed that healthy subjects tended to have highly symmetrical weight distribution, with less than 14% difference in weight distribution between the sides, during sitting, standing, rising to stand and sitting down. During lateral reaching healthy subjects generally distributed between 83% and 97% of body weight to one side.

At the time of the baseline measurement 13(11 control group; 2 practice group) of the 28 patients had "normal" weight distribution in sitting; 2 (1 control; 1 practice) in standing; 1 (1 control; 0 practice) in the seat-off phase of rising to stand; 0 in the seat-off phase of sitting down. 10 (8 control; 2 practice) of the patients achieved a "normal" magnitude of weight transference when reaching to the unaffected side, and 13 (10 control; 3 practice) during reaching to the affected side. Following reaching to the unaffected side 12 (9 control; 3 practice) of the patients returned to having "normal" weight distribution in sitting, and following reaching to the affected side 12 (7 control; 5 practice) had "normal" weight distribution in sitting.

At the time of the final measurement, 11 (58%) of the 19 control group subjects had “normal” weight distribution in sitting; 7 (36%) in standing; 6 (31%) in rising to stand; 2 (11%) in sitting down; and 12 (64%) achieved “normal” weight transference during reaching to the unaffected side and 13 (68%) during reaching to the affected side. 13 (69%) of the control group subjects achieved "normal" weight distribution during sitting following reaching to the unaffected side, and 10 (53%) during sitting following reaching to the affected side. For the practice group these values were 3 (33%) for sitting; 4 (44%) for standing; 1 (11%) for rising to stand; 1 (11%) for sitting down; 4 (44%) for reaching to die unaffected side and 6 (67%) for reaching to die affected side; and 4 (44%) for sitting after reaching to the unaffected side and 5 (56%) for sitting after reaching to the affected side.

Statistical analysis was carried out, using the Chi-squared test, to compare the proportion of control and practice group subjects classified as "unable" to perform a task, or as achieving "normal" or "abnormal" outcomes during each test week. There was no significant difference (p>0.05) between the groups for the tasks of sitting, standing, rising to stand or sitting down, or for the peak weight transference achieved during reaching, on any of the test weeks. There was a significant difference between the groups for the symmetry of weight distribution achieved during sitting following reaching to the unaffected side at week 3 (p=0.016) and during sitting following reaching to the affected side at week 4 (p^.027). Descriptive statistics were used to explore the changes in the outcome measures over the test weeks. This revealed that, although the number of subjects able to perform standing, rising to stand and sitting down increased over the test weeks, there was no observable change in the proportion of subjects able to perform any of the tasks with "normal" symmetry of weight distribution or weight transference over the study period.

The lack of difference in the outcome of the practice and control group and the absence of recovery observed in the measured outcomes over the study period are discussed. Based on the study results, methods for improving the regime of independent practice are presented, and potential implications of the lack of change in the ability of the stroke patients to achieve the functional tasks with “normal” symmetry of weight distribution are proposed.

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