Posts Tagged neurologic rehabilitation

[A CLINICAL PRACTICE GUIDELINE] A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation

Background: Use of outcome measures (OMs) in adult neurologic physical therapy is essential for monitoring changes in a patient’s status over time, quantifying observations and patient-reported function, enhancing communication, and increasing the efficiency of patient care. OMs also provide a mechanism to compare patient and organizational outcomes, examine intervention effectiveness, and generate new knowledge. This clinical practice guideline (CPG) examined the literature related to OMs of balance, gait, transfers, and patient-stated goals to identify a core set of OMs for use across adults with neurologic conditions and practice settings.

Methods: To determine the scope of this CPG, surveys were conducted to assess the needs and priorities of consumers and physical therapists. OMs were identified through recommendations of the Academy of Neurologic Physical Therapy’s Evidence Database to Guide Effectiveness task forces. A systematic review of the literature on the OMs was conducted and additional OMs were identified; the literature search was repeated on these measures. Articles meeting the inclusion criteria were critically appraised by 2 reviewers using a modified version of the COnsensus-based Standards for the selection of health Measurement INstruments. (COSMIN) checklist. Methodological quality and the strength of statistical results were determined. To be recommended for the core set, the OMs needed to demonstrate excellent psychometric properties in high-quality studies across neurologic conditions.

Results/Discussion: Based on survey results, the CPG focuses on OMs that have acceptable clinical utility and can be used to assess change over time in a patient’s balance, gait, transfers, and patient-stated goals. Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence. Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance. Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers. Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care.

Disclaimer: The recommendations included in this CPG are intended as a guide for clinicians, patients, educators, and researchers to improve rehabilitation care and its impact on adults with neurologic conditions. The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT). The Guideline Development Group (GDG) used a rigorous review process and was able to freely express its findings and recommendations without influence from the APTA or the ANPT. The authors declare no competing interest.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A214.

TABLE OF CONTENTS

  • INTRODUCTION AND METHODS
  • Levels of Evidence and Grades of Recommendations ………………………………………………..178
  • Summary of Action Statements ………………………………………………..179
  • Introduction ………………………………………………..181
  • Methods ………………………………………………..182
  • OUTCOME MEASURE RECOMMENDATIONS
  • The Core Set of Outcome Measures for Neurologic Physical Therapy ………………………………………………..191
  • Action Statement 1: Static and Dynamic Sitting and Standing Balance Assessment ………………………………………………..191
  • Action Statement 2: Walking Balance Assessment ………………………………………………..195
  • Action Statement 3: Balance Confidence Assessment ………………………………………………..197
  • Action Statement 4: Walking Speed Assessment ………………………………………………..199
  • Action Statement 5: Walking Distance Assessment ………………………………………………..203
  • Action Statement 6: Transfer Assessment ………………………………………………..207
  • Action Statement 7: Documentation of Patient Goals ………………………………………………..208
  • Action Statement 8: Use of the Core Set of Outcome Measures ………………………………………………..209
  • Action Statement 9: Discuss Outcome Measure Results and Use
  • Collaborative/Shared Decision-Making With Patients ………………………………………………..211
  • Guideline Implementation Recommendations ………………………………………………..212
  • Summary of Research Recommendations ………………………………………………..215
  • ACKNOWLEDGMENTS AND REFERENCES
  • Acknowledgments ………………………………………………..217
  • References ………………………………………………..217
  • TABLES
  • Table 1: Levels of Evidence ………………………………………………..178
  • Table 2: Grades of Recommendations ………………………………………………..178
  • Table 3: Outline of the CPG Process ………………………………………………..183
  • Table 4: Inclusion and Exclusion Criteria for Article Review ………………………………………………..187
  • Table 5: COSMIN Ratings for Strength of Statistics ………………………………………………..189
  • Table 6: Process Used to Make Recommendations ………………………………………………..190
  • Table 7: Evidence Table, Berg Balance Scale ………………………………………………..192
  • Table 8: Evidence Table, Functional Gait Assessment ………………………………………………..196
  • Table 9: Evidence Table, Activities-specific Balance Confidence ………………………………………………..198
  • Table 10: Evidence Table, 10 meter Walk Test ………………………………………………..201
  • Table 11: Evidence Table, 6-Minute Walk Test ………………………………………………..205
  • Table 12: Evidence Table, 5 Times Sit-to-Stand ………………………………………………..208

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[ARTICLE] Effects of observation of hand movements reflected in a mirror on cortical activation in patients with stroke – Full Text PDF

Abstract.

[Purpose] The purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

[Subjects and Methods] The subjects of this study were 14 patients with stroke (6 females and 8 males). The subjects were assessed by measuring the alpha and beta waves of the EEG (QEEG-32 system CANS 3000). The mirror therapy intervention was delivered over the course of four weeks (a total of 20 sessions).

[Results] Relative alpha power showed statistically significant differences in the F3, F4, O1, and O2 channels in the situation comparison and higher for hand observation than for mirror observation. Relative beta power showed statistically significant differences in the F3, F4, C3, and C4 channels.

[Conclusion] This study analyzed activity of the brain in each area when patients with stroke observed movements reflected in a mirror, and future research on diverse tasks and stimuli to heighten activity of the brain should be carried out.

INTRODUCTION

Dysfunction from upper extremity hemiparesis impairs performance of many activities of daily living (ADL)1) . Individuals affected by stroke will learn or relearn competencies necessary to perform ADL. Traditionally, the practice of skills provided in neurologic rehabilitation has focused on reducing motor impairment and minimizing physical disability2, 3) . Since 2000, various studies of upper extremity function recovery using interventions such as constraint-induced movement therapy, functional electric stimulation, robotic-assisted rehabilitation, and bilateral arm training have been carried out4) . Such interventions were effective in increasing upper extremity functions in patients with stroke and are continually utilized in the clinical field5–7) .

However, most of the treatment protocols for the paretic upper extremity are labor intensive and require one on one manual interaction with therapists for several weeks, which makes the provision of intensive treatment for all patients difficult8) . Hence, alternative strategies and therapies are needed to reduce the long-term disability and functional impairment from upper extremity hemiparesis9) .

Mirror therapy may be a suitable alternative because it is simple; inexpensive; and, most importantly, patient-directed treatment that may improve upper extremity function8, 10) . Emerging methods in mirror therapy aim to restore motor control through a change in brain function, i.e. motor relearning11, 12) . Voluntary movements of the paretic upper extremity and hand by referring to a mirror activate the bilateral cortex and cause reorganization for other areas around the damaged brain to replace its function, thereby affecting recovery in motor function13) .

Although such methods are promising, they have failed to restore functional motor control for many patients who have experienced stroke. It is important to explore new methods that may facilitate the recovery of brain function and the restoration of more normal motor control14) . Many studies have addressed the neurophysiological effects of mirror therapy. The EEG study gave diverse stimulations to the thumb with or without a mirror to examine which area of the cortex was activated. They observed common activation areas in the primary motor cortex (M1), cingulate, and prefrontal cortex15) . And the study with healthy adults used mirror therapy with functional MRI (fMRI) and showed no difference between the dominant and non-dominant hand. Excitability of M1 ipsilateral to a unilateral hand movement was facilitated by viewing a mirror reflection of the moving hand16) . This finding provides neurophysiological evidence supporting the application of mirror therapy in stroke rehabilitation. Even though, previous studies concerned healthy subjects and had no interventions, a diversity of studies have shown upper extremity functional improvement through mirror therapy8) .

Thus, the purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

Full Text PDF

 

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