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Posts Tagged physiotherapy
[ARTICLE] Feedback Design in Targeted Exercise Digital Biofeedback Systems for Home Rehabilitation: A Scoping Review – Full Text PDF
Digital biofeedback systems (DBSs) are used in physical rehabilitation to improve outcomes by engaging and educating patients and have the potential to support patients while doing targeted exercises during home rehabilitation. The components of feedback (mode, content, frequency and timing) can influence motor learning and engagement in various ways. The feedback design used in DBSs for targeted exercise home rehabilitation, as well as the evidence underpinning the feedback and how it is evaluated, is not clearly known. To explore these concepts, we conducted a scoping review where an electronic search of PUBMED, PEDro and ACM digital libraries was conducted from January 2000 to July 2019. The main inclusion criteria included DBSs for targeted exercises, in a home rehabilitation setting, which have been tested on a clinical population. Nineteen papers were reviewed, detailing thirteen different DBSs. Feedback was mainly visual, concurrent and descriptive, frequently providing knowledge of results. Three systems provided clear rationale for the use of feedback. Four studies conducted specific evaluations of the feedback, and seven studies evaluated feedback in a less detailed or indirect manner. Future studies should describe in detail the feedback design in DBSs and consider a robust evaluation of the feedback element of the intervention to determine its efficacy.
The Vagus Nerve Stimulation (VNS) may promote reorganization of motor networks via engaging a variety of molecular and neuronal mechanisms through ascending neuromodulatory systems. A recently published review from Frontiers in Neuroscience (N.D. Engineer et al. Targeted Vagus nerve stimulation for rehabilitation after stroke, Front Neurosci. 2019, 29;13:280) has laid out how recent experimental and clinical studies are providing increasing evidence for a beneficial effect of vagus nerve stimulation for the motor recovery after stroke of both, ischemic and hemorrhagic origin. Two multi-site, randomized controlled pilot trials have suggested that when paired with neurorehabilitation, VNS stimulation may generate temporally precise neuromodulatory feedback within the synaptic eligibility trace and may hence, drive synaptic plasticity.
- A single-blinded, randomized feasibility study evaluating VNS paired with motor rehabilitation was performed by Dawson et al. (2016) in 20 participants > 6 months after ischemic stroke who had moderate to severe upper limb weakness. Subjects were randomized to VNS paired with rehabilitation (n = 9; implanted) or rehabilitation alone (n = 11; not implanted). VNS was triggered by a physiotherapist pushing a button during task-specific movements. The main outcome measures were a change in upper extremity Fugl-Meyer Assessment (FMAUE) score and response rate – FMA-UE change _6 points was considered clinically meaningful. After 6 weeks of in-clinic rehabilitation, participants in the paired VNS group showed a 9.6-point improvement from baseline while the control group improved by 3 points in the per-protocol analysis (between group difference = 6.5 points, CI: 0.4 to 12.6, p = 0.038). The response rates were 66 and 36.4% in VNS and control groups, respectively. No serious adverse device effects were reported.
- The second study was a multicenter, fully blinded and randomized study (Kimberley et al., 2018). All participants were implanted with the VNS device, which allowed the control group to crossover to receive paired VNS therapy after completion of blinded follow-up. This permitted a within subject comparison of gains. To evaluate the lasting effects of VNS stimulation combined with home-based physiotherapy was included as part of the study. Seventeen participants who had moderate to severe upper extremity impairment after stroke were enrolled at four sites. Both groups had 1 month of at-home exercises with no VNS followed by 2 months of home-based therapy. During home therapy, participants in both groups activated the VNS device at the start of each 30-min session via a magnetswipe over the implanted pulse generator to deliver either Active or Paired VNS (0.8 mA) or Control VNS (0 mA), respectively. After 2 months of home-based therapy, thepaired VNS group continued the VNS therapy while the Control Group switched over to receive paired VNS. After 6 weeks of in-clinic therapy, the FMA-UE score increased by 7.6 points for the VNS group and 5.3 points for controls. Three months after the end of in-clinic therapy (post-90), the FMA-UE increased by 9.5 in the paired VNS group and 3.8 points in controls. At post-90, response rate (FMA-UE change _6 points) was 88% in the VNS group and 33% in controls (p = 0.03).
Noteworthy in both studies seemed the greater improvement of the upper limb function when physiotherapy was applied simultaneously with vagal nerve stimulation. VNS likely supported the recovery of upper limb functions via activation of multiple neuromodulatory networks that regulate synaptic plasticity. This may include the noradrenergic, cholinergic, and serotonergic systems (Nichols et al., 2011; Hulsey et al., 2017). These neuromodulators, in turn, act synergistically to alter spike-timing dependent plasticity (STDP) properties in active networks. The studies above align well with the time scale of the synaptic eligibility trace. VNS may drive temporally precise neuromodulatory release to reinforce ongoing neural activity related to the therapeutic event. An open question is whether similar improvement can be achieved using non-invasive vagal nerve stimulation. To this moment, the identifying and consistently delivering stimulation within a particular range of parameters appears to be of greater challenge with non-invasive VNS than with the implanted VNS device.
Physiotherapy combined with vagal nerve stimulation seems to be a new and promising approach to enhance the functional recovery after stroke.
- Vagus Nerve Stimulation (VNS) may promote reorganization of motor networks
- Experimental and clinical studies pointed towards a beneficial effect for the motor recovery after stroke
- VNS may drive temporally precise neuromodulatory release to reinforce ongoing neural activity
Targeted Vagus Nerve Stimulation for Rehabilitation After Stroke. https://www.ncbi.nlm.nih.gov/pubmed/30983963
[ARTICLE] Preliminary Analysis of Perception, Knowledge and Attitude of Home Health Patients Using Tele Rehabilitation in Riyadh, Saudi Arabia – Full Text
Telerehabilitation is defined as delivery of rehabilitation services over telecommunication networks and the internet, which comprise of clinical assessment (the patient’s functional abilities in his or her environment) and clinical therapy.This new area of medical advancement, using state of the art technology is developing at a great speed and is definitely going to be the next milestone in health care revolution.The objective of this study was to explore the awareness, knowledge and perception of the patients for using telerehabilitation as a medium to provide physiotherapy services as a part of home healthcare services. A pretest-post test design was used where the home healthcare patients (n = 90) aged between 50 -75 years were asked to express views by given a validated modified TUQ questionnaire followed by an indepth interviewing to develop a key understanding regarding the themes. Interviews were transcribed and a qualitative thematic analysis was conducted. The awareness level regarding the telerehabilitation changed significantly from 57% to 96% post session(p<0.05). Similarly, the knowledge of the participants regarding online consultation, followup and online therapy changed significantly from 50%, 47% and 57% to 96%, 76% and 96% respectively post session of rehabilitation(p<0.05). The perception level regarding the key benefits including its usage in emergency(83%), convenience of no travel(84%), ease of getting treated at home(97%) and availability of specialist consultation (84%) were the prime ideas for excellent rating among 95% participants (p<0.05) post session. Findings are helpful to health practitioners in designing their intervention programs across the kingdom. However the actual impact could be only derived from future studies which has to conducted based on different clinical conditions.
Telerehabilitation is defined as the provision and delivery of rehabilitation health services at a distance using information and communication technologies and tools (Tan 2005; Russell 2007). Throughout the world, the health care practices is going through major transformation as it is driven through sea change because of the increased use of technology. The kingdom of Saudi Arabia too is witnessing a massive change with significant restructuring of healthcare systems with some major high-end technology driven development solutions. The increased demand is created on account of rapidly increasing saudi population including the growing elderly community, changing disease patterns, global climatic changes and financial inequity (Mahmood 2018). According to a United nations report the elderly population of Saudi Arabia those aged 60 and above is projected to increase from 3% in 2010 to 9.5% and 18.4% in 2035 and 2050, respectively (UN Report, 2018).
Similarly, comparing this phenomenon to an average life expectancy of the population in Saudi Arabia, the latest WHO data published in 2018, suggests that Saudi male and female have an average of 73.5 and female 76.5 life years with an average life expectancy of 74.8 years as against an average world life expectancy of 84 years.The increased demand in kingdom also raised because of immense economic pressure with steep fall in global oil prices in 2015-16 affecting the GDP significantly thereby been one of the key stimulus for the government to take timely corrective actions and diversify the economy from heavily oil dependent to develop other verticals for revenue generation (MoH Report, 2018).
Brian child of Crown Prince HH Mohammad Bin Salman, Vision 2030 was adopted in April 2016 and has identified its priorities across all economic sectors and serves as a roadmap for the economic development of the KSA with development of health services been one of the most important key themes. Therefore, as a part of realization of this vision the government strongly supports the partnership of private and public sectors and been seen as a strong indication of the Government’s commitment for making healthcare accessible to its citizens irrespective of the disparities available in the Saudi society (Vision 2030 Report, 2016). Access to healthcare generally relates to people’s ability to use health services when and where they are needed. Determinants of healthcare access are the types and quality of services, including the costs, time, distance (ease of travel) as well as regular interface between service users and healthcare providers. Saudi Arabia is the largest and fastest growing health care market in the region and is estimated to reach $40 billion by 2020 (NTP 2020 Report, 2016).
Moreover, the steep increase in the number of hospitals across all major cities of KSA are run by both government and private organizations which use corporate business strategies and technology driven specializations, which aim to create demand as well as attract high number patients as the facilities in majority of these hospitals are world class.Among the various strategies listed in the NTP Report 2020, one of the key components of making healthcare accessible across the kingdom is the enhanced use of telemedicine (NTP 2020 Report, 2016). In the last one decade the health services across the kingdom have taken gigantic leap jumps with private healthcare taking lead and using innovations in delivering healthcare. One of such innovations is using Home Healthcare for delivering physiotherapy and other rehabilitation based services for the patients at home (Pulse Report 2018).
Rehabilitation is a very important component in medical care and helps in propelling patient to preinjury level. It is a well known fact that in all long term cases which requires follow-ups such as in surgical cases and other debilitating disorders including Stroke, Cancer, Multiple Sclerosios, rehabilitation is time consuming and financially constraining. To add to this, patients travelling long distances for treatment, it is not only physically challenging but emotionally draining too and especially in case of geriatric patients.Therefore home tele rehabilitation programs, are winding up progressively as an elective method of service delivery. In the western countries, quite a number of research studies has been proved that the Telerehabilitation for the delivery of health services is quite effective, however the scope of using such services in the kingdom is still novice and requires a detailed study, (Hailey et al., 2010, Johansson and Wild 2011, Chang et al 2019 ).
There are scant studies to prove its efficacy in the developing countries as its successful will depends on a number of factors (Clemens et al 2018) . However, among all the variables, the two most important are the technological component and second been its implementation in real terms (Jackson and McClean 2012, Clemens et al 2018). Accordingly, these both are of extreme critical importance from the patient satisfaction point of view. The perceptions of the stakeholders, i.e. the patient and the members of the Rehabilitation team are of utmost importance for its use and wide spread application.The home healthcare services in Saudi Arabia is still in infancy stages with few delivery partners across the kingdom. The usage of telerehabilitation is even more nascent, as the perception of patients in using such a technology for delivering healthcare would be quite critical and important to understand the phenomenon which would be quite useful in framing the guidelines for its applications at a mass level, (Alaboudi et al 2016).
Therefore, this study is an attempt to study the awareness, knowledge and perceptions of the home healthcare patients in using physiotherapy services delivered via cloud based telerehabilitation. This study, to our knowledge is the first of its kind in the kingdom especially from the perspective of home healthcare patients. It aims to explore the key ideas which might work in favour or against the successful implementation of telerehabilitation used for the home healthcare delivery.
Materials and Methods
The pretest-post test study design was conducted on home healthcare patients so as to obtain an in-depth understanding of the patients’ perception about telerehabilitation services which they will receive as a part of home health services. While a few studies conducted earlier emphasized about telemedicine to be a key part in delivery of health services, however none of the studies emphasized on perception of patients to implement telerehabilitation as part of home healthcare (Clemens et al 2018, Khalil et al 2018).
Due necessary approval were taken from the ethical clearance committee of the respective organization, which is a reputed home healthcare organization based in Riyadh. In order to recruit participants for the study, sample population were selected from a pool of home healthcare patients who were undergoing treatment under one of the most prominent home healthcare organizations in the kingdom, which incidentally was the only first licensed stand-alone home healthcare services company in Riyadh province.
The study was conducted from Jan 15 to May 30, 2019. In this context, non-probability sampling method was used. Out of 113 home healthcare patients who underwent treatment for different ailments, 90 were randomly selected who also gave their consent to participate in the study out of which 57 were males and 33 were females. Those patients who suffered from orthopedic problems such as Knee pain, low back ache, disc prolapse etc. or underwent orthopedic surgeries such as knee replacement or meniscectomy etc. participated in the study. The study mainly included common geriatric patients for the study who were willing to participate but excluded the pediatric and the critical care, neurological and cardiac patients as they underwent major surgeries such as for stroke or CABG and also were unable to respond directly to answer the questions. The patients who were able respond in English or Arabic were recruited for the study.
Based on literature review and discussion with key stakeholders, a questionnaire and an the interview guide was prepared, modified from Telehealth Usability Questionnaire (TUQ) based on key themes of perceived usefulness, ease of use and learnability, Interaction quality, Reliability and Satisfaction and future use (Langbecker et al 2017) . The questionnaire was converted to Arabic version adapted from the original English version and pilot tested for the home healthcare patients using both forward and backward translation methods and achieved very acceptable score of confirmatory factor analysis of 0.78 using SPSS. It was also pilot tested for the members of the rehabilitation team. The questionnaires as given in Appendix 1 were responded by the patients and the members of the rehabilitation team followed by a semi structured individual interview from the patient as well as from the team members involved in providing home health services. The interviews were audio recorded and transcribed verbatim using Text Analysis Markup System (TAMS) Analyzer as suggested by Yin (Yin 2013).
The Tele-rehabilitation Technological solutions were a part of home health services which were delivered by the company. As a part of cloud based HIPAA compliant network, the telemedicine unit consists of a portal to track health metrics and rehabilitation treatment plan and progress by the PT specialists as well as the Case Managers. The system included case briefing, consultation by specialists as well as providing physiotherapy sessions both by Home health therapists or via health workers such as PTAs within the vicinity of home environment at patient’s ease as schematically represented in Fig. no.1.
The participants were given a pre and post session modified TUQ and asked to reflect on their entire rehabilitation experience using the Telerehabilitation platform so as to get relevant information about telemedicine services including key events such as finding out they would receive services at home by videoconference, having the internet and videoconferencing equipment installed at home and receiving services by videoconference including dealing with technical issues. Following the same detailed interview was taken using the TAMS so as to identify key ideas which can affect usage of telerehabilitation. . Statistical tests was conducted using SPSS for Pre-post differences evaluation. using paired t-tests to assess factors associated with awareness, knowledge and perception. Significance was set a priori at p < 0.05. […]
[WEB PAGE] Pioneering rehabilitation app helps physios track patients’ progress and prescribe exercise videos
Independent physiotherapy provider Ascenti has launched PhysioNow, a new exercise and rehabilitation app which aims to revolutionise the way musculoskeletal injury is treated by providing patients with physiotherapy services at the touch of a button.
PhysioNow supports users throughout their journey to recovery by providing 24/7 access to expert advice through digital triage, virtual consultations and tailored exercise programmes from approved Ascenti clinicians. Users can book appointments directly through the app and try out exercises in their own home, with access to guided videos that can be downloaded and viewed at any time.
A fully integrated digital care solution, the app will benefit patients by allowing them to track their own progress and compliance with their rehabilitation programme, improve their knowledge and empowerment through education and self-management advice, and increase their confidence knowing they are following the correct exercise prescription.
PhysioNow is fully integrated with Ascenti’s bespoke patient workflow system. This means that physiotherapists can prescribe video exercises, track patient progress and adjust according to real-time patient feedback, all within the same system that supports them in all other aspects of their daily role (from writing treatment notes to accessing clinical dairies).
For patients, this means a digitally enhanced and hassle-free journey, whether their treatment is face-to-face or virtual.
Currently, a third of all musculoskeletal referrals Ascenti receives come from patients suffering with back pain. PhysioNow will enable enhanced clinical outcomes and more cost-effective care, including for common conditions such as back pain.
A beta test version of the app launched earlier this year and has been used by 1,400 patients, with 93 percent of users endorsing the app and saying that they would recommend it to friends and family.
The PhysioNow app is available to all Ascenti patients and will be accessible when they book their first physio appointment.
Additionally, the app will be available to download from the App Store for Apple iOS users and the Play Store for android devices. There will also be a web-based service that people can use at physionow.ascenti.co.uk
Stephanie Dobrikova, CEO at Ascenti, commented: “The launch of PhysioNow makes Ascenti the market leader when it comes to the provision of digitally-enabled physiotherapy and musculoskeletal (MSK) services.
“In today’s healthcare industry we are seeing more and more technological advances that are transforming patient care – improving the experience of clinicians and service users alike.
“Our Digital Health Strategy has placed us at the forefront of these advancements and our mission is to keep bringing the very best digitally enabled services to our patients and partners.”
Ascenti is a provider of physiotherapy and associated services in the UK and is a trusted partner to more than 20 NHS Clinical Commissioning Groups and 400 private businesses across the UK.
The company has over 300 highly trained clinicians delivering upwards of 52,000 treatment sessions every month.
[Abstract + References] Virtual Reality Game Development Using Accelerometers for Post-stroke Rehabilitation – Conference paper
Stroke can generate several types of sequelae, including motor difficulties in both upper and lower limbs. One way to eliminate or reduce these difficulties is through physical therapy, but this type of treatment can often become tiresome and monotonous, decreasing the patient’s interest. Thus, aiming to assist in the rehabilitation of patients, this work seeks to use immersive virtual reality games with the purpose of interacting with physiotherapy exercises. In this type of game the individual must use special equipment (glasses) to feel in an environment where they can interact in different ways with the scenery. Among the possible equipment used for immersive virtual reality was chosen to use a smartphone in conjunction with a virtual reality glasses. In this way an environment was developed that allows the individual to move through the scenario by the control of the upper virtual members by accelerometry sensors, which will be positioned properly to identify the actual movement of the limbs. Thus, an equipment was developed capable of reading the movements and sending this information to a smartphone that executes the developed game.
[Letter to the Editor] Societá Italiana de Fisioterapia and the Physiotherapy Evidence Database (PEDro) – Full Text
This paper provides an overview of a free resource that can be used by physiotherapists to assist their efforts to undertake evidence-based practice. The resource is the Physiotherapy Evidence Database (PEDro; www.pedro.org.au) – a searchable online database that in February 2019 indexes the details of over 42,000 pieces of published evidence about the effects of physiotherapy interventions. PEDro is searched millions of times each year by users worldwide. Societá Italiana de Fisioterapia (SIF; www.sif-fisioterapia.it) has entered into a collaboration with the developers of PEDro. In addition to describing the evidence available on PEDro and who uses it, this paper also summarises the features of PEDro that can facilitate evidence-based physiotherapy. This paper concludes by outlining the collaboration between SIF and PEDro.
The approach to the clinical care of patients known as “evidence-based practice” is becoming more widely accepted within the physiotherapy profession. The approach was defined by its developers as the “integration of the best research evidence with clinical expertise and patient values” . Clinical physiotherapists who want their practice to be evidence-based must therefore identify the best evidence that is available to help inform their decisions about patient management.
It is difficult for physiotherapists to keep abreast of all the research that might be relevant to the types of patients they treat in clinical practice. One contributor to this difficulty is that, with ongoing publications, the number of trials of physiotherapy interventions is growing exponentially [2, 3]. If we consider physiotherapists who graduated in 2011, their university training could only have been based on about half of the evidence that currently exists about the efficacy of physiotherapy interventions. Another issue is that it can be laborious to find the relevant evidence on databases. For example, if a physiotherapist wanted to find evidence about the effects of physiotherapy treatments for knee osteoarthritis, a search of ‘knee osteoarthritis’ on the PubMed database in February 2019 returned over 31,500 articles, many of which have nothing to do with physiotherapy interventions. Searching can be targeted towards more relevant articles but this requires a knowledge of sophisticated search strategies, which involve category searches, Medical Subject Headings (MeSH) terms, Boolean operators, truncation and quotations [4, 5]. This inefficiency is an important issue because most clinical physiotherapists have limited time to find and read evidence. It would be simpler and more efficient if physiotherapists seeking evidence to guide their clinical practice could use a database that indexed only research publications about the effects of physiotherapy interventions.
To address the situation described above, a group of physiotherapists established the Physiotherapy Evidence Database. More commonly referred to as ‘PEDro’, the database is freely available for anyone to use at www.pedro.org.au. This section of the paper will describe the content and features of PEDro, relating these to how they can assist physiotherapists who want to keep abreast of the growing body of evidence about physiotherapy interventions. This section will conclude with a review of how often and how widely PEDro is used
Content of PEDro
Evidence indexed on PEDro
PEDro indexes the bibliographic details and abstracts of three types of documents. One type of document is randomised clinical trials of physiotherapy interventions (or interventions that could become part of physiotherapy care). Another type of document is systematic reviews that include at least one randomised trial of a physiotherapy intervention.1 The third type of document is clinical practice guidelines that are based on a systematic literature search and that contain at least one recommendation relevant to physiotherapy practice. Although there are other forms of evidence (for example, inception cohort studies provide evidence about prognosis), the most unbiased evidence about the effects of interventions comes from the forms of evidence indexed on PEDro: randomised trials, systematic reviews and clinical practice guidelines.
[Abstract] Effectiveness of static stretching positioning on post-stroke upper-limb spasticity and mobility: Systematic review with meta-analysis
To systematically review the effects of static stretching with positioning orthoses or simple positioning combined or not with other therapies on upper-limb spasticity and mobility in adults after stroke.
This meta-analysis was conducted according to PRISMA guidelines and registered at PROSPERO. MEDLINE (Pubmed), Embase, Cochrane CENTRAL, Scopus and PEDro databases were searched from inception to January 2018 for articles. Two independent researchers extracted data, assessed the methodological quality and rated the quality of evidence of studies.
Three studies (57 participants) were included in the spasticity meta-analysis and 7 (210 participants) in the mobility meta-analysis. Static stretching with positioning orthoses reduced wrist-flexor spasticity as compared with no therapy (mean difference [MD]=-1.89, 95% confidence interval [CI] -2.44 to -1.34; I2 79%, P<0.001). No data were available concerning the spasticity of other muscles. Static stretching with simple positioning, combined or not with other therapies, was not better than conventional physiotherapy in preventing loss of mobility of shoulder external rotation (MD=3.50, 95% CI -3.45 to 10.45; I2 54.7%, P=0.32), shoulder flexion (MD=-1.20, 95% CI -8.95 to 6.55; I2 0%, P=0.76) or wrist extension (MD=-0.32, 95% CI -6.98 to 5.75; I238.5%, P=0.92). No data were available concerning the mobility of other joints.
This meta-analysis revealed very low-quality evidence that static stretching with positioning orthoses reduces wrist flexion spasticity after stroke as compared with no therapy. Furthermore, we found low-quality evidence that static stretching by simple positioning is not better than conventional physiotherapy for preventing loss of mobility in the shoulder and wrist. Considering the limited number of studies devoted to this issue in post-stroke survivors, further randomized clinical trials are still needed.
The Cochrane Database of Systematic Reviews is widely considered the “gold standard” for health care professionals who want to know what current, high-quality research says about the efficacy of various interventions. But when it comes to physical therapy, a “researcher or clinician would not necessarily be able to turn to [Cochrane reviews] for a definitive answer” on a treatment strategy, write authors of an article in the International Journal of Rehabilitation Research (abstract only available for free).
Reviewers for the Cochrane Collaboration—an international network of subject-matter groups that produces evidence-based resources—are known for their systematic analysis of evidence obtained from randomized clinical trials and provide recommendations for specific interventions. Like any systematic review, Cochrane reviews (CRs) are based on the existing research, and randomized controlled trials vary in quality.
For the Rehabilitation Research study, a multidisciplinary group of researchers in Japan turned to physical therapy to find out what CRs had to say about various interventions. They examined 283 CRs to evaluate just how conclusive the evidence is with regard to physical therapy, as well as what factors influence the degree of conclusiveness.
Authors classified a CR as “conclusive” if it identified a particular intervention as “superior to another” or found that interventions are “equivalent.” Inconclusive reviews concluded that “no decision can be made.”
While the authors acknowledge that CRs “often show a lack of strong evidence for the efficacy of a particular treatment or strategy,” they found that an overwhelming majority of reviews related to physical therapy—94.3%—were inconclusive and recommended further study, a rate higher than in many other areas of study. Reviews that evaluated a larger number of trials or included greater total numbers of patients were more likely to list conclusive results; still, even among CRs with conclusive results, 68.8% recommended further study.
According to the authors, many factors were associated with recommendations for further research, including low-quality study design, small sample sizes, too few available studies, and not enough data on participant subgroups or on adverse effects.
“The low proportion of conclusive studies may be attributable to the poor quality of evidence” in physical therapy, the authors write, noting, however, that, unlike other areas of study, blinded randomized controlled trials are “often hard to achieve” in physical therapy research.
Authors emphasized that although inconclusive reviews cannot assist in clinical decision making, “high-quality inconclusive reviews…are of great value” to identify gaps in the literature and areas for further study.
And while there’s much work to be done to increase the number of physical therapy-related CRs with conclusive recommendations, authors think the effort is worthwhile—and timely.
“Trials in physiotherapy are worth conducting, as the field is positioned as a new frontier and is receiving much attention,” they write. “Future research in physiotherapy and further development of the [Cochrane Collaboration] are eagerly awaited.”
Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association’s PTNow website.
[ARTICLE] In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study – Full Text
Following orthopaedic injury or stroke, there is clear evidence that people who do more practice in rehabilitation achieve better outcomes.1, 2, 3, 4, 5 In stroke survivors, a pooled analysis of eight trials3 established that if the therapy dose provided is increased by more than two times, the effect size on activity outcomes is 0.59 (95% CI 0.23 to 0.94). Scrivener et al established that the number of lower limb repetitions achieved in the first week of rehabilitation after a stroke is a good clinical predictor of walking speed at discharge from rehabilitation.4 This dose-response relationship has also been shown in people with orthopaedic conditions. Inpatients having rehabilitation following a hip fracture achieved better functional outcomes if they were more active in therapy sessions.6 Inpatients with lower limb orthopaedic conditions achieved better functional outcomes and had a shorter length of stay if they were more active throughout the entire day.2
Despite the evidence that increased amounts of practice result in better outcomes, patientsin rehabilitation do not generally engage in large amounts of physical practice. The time spent in physiotherapy for stroke survivors in inpatient rehabilitation ranges from 24 to 87 minutes per day.7, 8, 9, 10, 11, 12, 13, 14, 15, 16 Similarly, the time spent in physiotherapy for patients with orthopaedic conditions is only 45 minutes per day.13 Additionally, the time spent in active practice during therapy sessions is low, with many studies reporting that less than half of a therapy session is spent in active practice.11, 17, 18, 19, 20 The main reason for these short times spent in therapy and in active practice is that the most common mode of delivery of therapy in the gym area is one-to-one therapy (ie, the patient practises under direct supervision of one or more therapists, therapy students or therapy assistants). This results in a very limited number of patients being in the therapy area at one time, and high therapist to patient ratios. A recent study on inpatient stroke rehabilitation reported that the mean number of staff per patient was two, and patients were participating in less than 30 minutes of physiotherapy a day.21 One potential solution to this problem is to provide opportunities for ‘semi-supervised practice’, meaning that patients practise in the therapy area without the direct supervision of a therapist. This provides the opportunity for patients to spend much longer periods of the day in the gym area with the potential for achieving more time in active practice.
The following strategies can be used to facilitate the provision of semi-supervised practice for patients in rehabilitation. First, the environment of the therapy area can be structured to provide permanent practice areas.22 For example, all the required equipment for different exercises can be placed at workstations, allowing efficient set up for practice. Second, the environment at these workstations can be modified to provide safety when patients are practising without a therapist (eg, the use of adjacent walls, benches and plinths). Third, therapists or therapy assistants can supervise many patients at the same time in class or group settings.7 Additionally, members of the patient’s family can provide assistance with practice. Interestingly, when families are involved in therapy, this not only improves outcomes for stroke survivors but decreases the caregiver strain experienced by the family members.23
Currently, in the risk-averse setting of a hospital, semi-supervised practice is generally not provided24 and in some settings is actually not permitted. To date, it appears that the provision of semi-supervised practice has not been evaluated to establish what percentage of practice occurs as semi-supervised practice when that option is provided, whether patients continue to practise when they are not under direct supervision of a therapist, and whether semi-supervised practice can be provided without compromising patient safety. This information could help to change current clinical management to include more semi-supervised practice, thereby enabling patients in rehabilitation to achieve greater amounts of practice and spend more of their time active.
Therefore, the research questions for this observational study were as follows. When a hospital gymnasium used for inpatient rehabilitation is set up to facilitate semi-supervised practice:
- What percentage of practice is performed as semi-supervised practice?
- What percentage of patients in the gym are actively engaged in practice (as opposed to resting) at any time?
- Is the semi-supervised practice that occurs safe?
Physiotherapy could be getting a high-tech update with the development of a virtual coach.
The idea behind the coach is to have a program where clients can receive feedback from a physiotherapist while working on prescribed exercises at home.
“It minimizes error – because I can teach them the exercise and then they have to go home and do it on their own,” said Bruce Craven, owner of Craven SPORT Services. “If they can do their technique correctly, with fewer errors, then it improves learning. Then when they come back and see me again, we can progress.”
The project – currently in its pilot stage – was developed in partnership between Craven SPORT Services and Saskatchewan Polytechnic. It uses video game-like technology to create a user-based kinematic system that registers movements of the body through a camera.
“We can actually evaluate the person’s movement without having to marker them,” Craven said. “It uses the person’s body and markers where that body is in space. Then as they do the exercise, it can calculate whether or not they’re doing the exercise properly.”
Craven works with a wide range of clients, from Olympic athletes to people who want to lessen pain while gardening. He said the goal is to eventually have the program available for everyone for use on tablets, laptops, and even TV monitors.
According to Terry Peckham, a Sask. Polytech research chair, one of the benefits of the coach comes for patients who live in other provinces, or don’t live in major centres – because they would no longer have to travel long distances to receive feedback from their physiotherapist.
“Some of those expert resources are very difficult to come across,” he said. “So the ability to be able to remotely coach or coach over long distances would be huge. It allows our athletes access to training facilities they don’t currently have where they happen to be.”
Sask. Polytech provided a team of both researchers and students to develop the program from an idea, to a working prototype. Peckham said the ability to work on the program was a huge benefit for the students, because they’re able to apply what they’ve learned in the classroom to real world situations.
“We end up with a much better student at the end of it because they’ve actually had a chance to put it in practice,” he said.