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Posts Tagged physiotherapy
[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.
[Abstract] Combining functional electrical stimulation and mirror therapy for upper limb motor recovery following stroke: a randomised trial
Introduction: There is a growing need to develop effective rehabilitation interventions for people presenting with stroke as healthcare services experience ever-increasing pressures on staff and resources. The primary objective of this research is to examine the effect that mirror therapy combined with functional electrical stimulation has on upper limb motor recovery and functional outcome for a sample of people admitted to an inpatient stroke unit.
Methods: A total of 50 participants were randomised to one of three treatment arms; Functional Electrical Stimulation, Mirror therapy or a combined intervention of Functional Electrical Stimulation with Mirror therapy. Socio-demographic and health information was collected at recruitment together with admission dates, medical diagnoses and baseline measures. Blinded assessments were undertaken at baseline and at discharge post-stroke by a registered physiotherapist and a clinical nurse specialist.
Results: The Action Research Arm Test and the Fugl–Meyer Upper Extremity assessment revealed statistically superior results for Functional Electrical Stimulation compared with Mirror therapy alone (p = 0.03). There were no other significant differences between the three groups.
Conclusion: The theory of combining interventions requires further investigation and warrants further research. Combining current interventions may have the potential to enhance stroke rehabilitation, improve functional outcomes and help reduce the overall burden of stroke.
Researchers at The Ohio State University Wexner Medical Center are among the first in the world studying how a specific type of neurostimulator can improve rehabilitation for stroke patients.
As part of the clinical trial, an electrical device called a vagus nerve stimulator is surgically implanted in the patient’s chest wall. The Vivistim device, which connects to the vagus nerve in the neck, is used to “rewire” circuits in the brain associated with certain motor functions. Stroke can result in the loss of brain tissue and negatively affect various bodily functions from speech to movement, depending on the location of the stroke.
In an earlier pilot study, this approach known as Paired Vagus Nerve Stimulation was shown to benefit approximately 85 percent of the people who received the nerve stimulation, said Dr. Marcie Bockbrader, research physiatrist for the Neurological Institute at The Ohio State University Wexner Medical Center.
“This nerve stimulation is like turning on a switch, making the patient’s brain more receptive to therapy,” Bockbrader said. “The goal is to see if we can improve motor recovery in people who have what is, in effect, a brain pacemaker implanted in their body. The idea is to combine this brain pacing with normal rehab, and see if patients who’ve been through all of the other usual therapies after a stroke can get even better.”
The study is recruiting patients who suffered a stroke and have been left with poor arm function as a result. The study is open to patients who have suffered a stroke at least nine months ago up to 10 years ago.
Each participant will receive three one-hour sessions of intensive physiotherapy each week for six weeks to help improve their arm function.
Half of the group will also receive an implanted vagus nerve stimulator. During rehabilitation therapy sessions, when a patient correctly performs an exercise, the therapist pushes a button to trigger the device to stimulate the vagus nerve. This neurostimulator signals the brain to remember that movement.
“We are trying to see if this neurostimulator could be used to boost the effective therapy, creating a sort of ‘supercharged therapy.’ We want to determine if patients can recover more quickly through the use of this stimulation,” Bockbrader said.
Previous research indicates that vagus nerve stimulation causes the release of the brain’s own chemicals, called neurotransmitters that will help the brain form new neural connections which might improve participant’s ability to use their arm.
Traditional vagus nerve stimulation has been used in the United States and around the world to treat more than 100,000 patients for epilepsy.
[ARTICLE] Media: Home exercise programs made effortless using the PhysioTherapy eXercises patient app – Journal of Physiotherapy
PhysioTherapy eXercises website: www.physiotherapyexercises.com
PhysioTherapy eXercises is a publicly available website, created by Harvey, Messenger, Glinsky, Pattie and a collaboration of physiotherapists. It was designed as a resource for creating and distributing home exercise programs. The website has a database of images, videos and instructions for over 1000 exercises focusing on impairments (strength, balance, range of motion, and cardiovascular fitness), and activities (reaching and manipulation, sit to stand, transfers, and mobility), and is available in 13 different languages. The exercises are evidence-based and include exercises for children through to the elderly, as well as exercises targeting specific populations, such as acute and degenerative neurological conditions, and musculoskeletal conditions, including whiplash and hand injuries. The Physiotherapy Exercises App is one feature of this web-based software and is the focus of this review.
The Physiotherapy Exercises App is free and can be used on both Apple and Android tablets and phones. The app is designed for patients to use, and allows them to access their prescribed home exercise program on their devices, record their progress online, and share this information remotely with their therapist. A recent randomised, controlled trial reported that using the Physiotherapy Exercises App increased adherence to home exercise programs when compared with paper-based methods.1
The therapist designs a home exercise program by selecting relevant exercises from the database and scheduling the frequency and duration of the exercises using the PhysioTherapy eXercises website. The patient then accesses and installs the Physiotherapy Exercises App via a link embedded in an email or smart phone text message that is sent from the website. Once the app is installed, patients have direct access to their home exercise program. The app allows patients to view their program, record completion of each exercise, and provide feedback to the therapist via a ‘notes’ function. The therapist has the ability to remotely monitor the patient’s exercise adherence, review notes recorded by the patient, and adjust the program as required by logging onto the website. Therapists can also receive a notification via an email when a patient’s adherence has decreased below a set threshold, which can be adjusted by the therapist for each patient.
Ease of use
Overall, the design of the Physiotherapy Exercises App is straightforward and the basic features are easy to use. My experience suggests that patients who already use the Internet and/or mobile devices are willing to use the Physiotherapy Exercises App, and use it successfully. Patients with limited technology experience are able to use the app successfully if provided with assistance to download the app and are given a demonstration of how to use it. Once the app has been downloaded, patients have two options: view the exercises that are to be completed on that day via the home screen (Figure 1A); or touch the screen to access the illustration, aims, instructions and dosage for each exercise (Figure 1B). Similarly, recording of the completed exercises can be done by ticking the ‘done all’ box on the home screen or ticking a box on each screen for an individual exercise. Patients can record completing an exercise even if it is not scheduled for a particular day. Notes can be added on each screen that details an individual exercise.
From the perspective of therapist use, the home exercise program is prescribed and monitored by logging directly onto the website. The website has an extensive help section to assist the therapist if required.
Strengths and limitations
The Physiotherapy Exercises App is very well designed for clinical use. One of the key strengths is that patients can only access their home exercise program once it has been prescribed to them by a therapist, which ensures that patients complete exercises appropriate for their rehabilitation. Another valuable feature is that once the Physiotherapy Exercises App has been downloaded, there is no requirement for the patient to login or remember passwords. Other strengths are that the interface is easy to understand, and patients receive detailed information about each exercise, including the aims of the exercise, illustrations, instructions on how to complete the exercise, dosage, precautions, and progressions. Furthermore, therapists have the ability to select what information the patient views on the app and/or modify the instructions and information if required. When the home exercise program is updated online, all changes occur in real time.
Limitations of the Physiotherapy Exercises App are that few patients use all the features of the app, for example the notes function. My experience using the app with people who have Parkinson’s disease is that most people primarily use the app to view and record completion of their home exercise programs. Further encouragement by the therapist is necessary to ensure regular use of the notes function, if desired. At present, patients do not receive an alert via the Physiotherapy Exercises App that their program has been updated; it simply changes on the home screen. Consequently, if the program is updated independently of a consultation, an additional form of communication may be required to inform the patient of changes made.
Overall, the Physiotherapy Exercises App is an excellent and easy to use clinical resource. Increasing the use of devices to provide home exercise programs directly to patients is highly desirable and resource-efficient. It gives patients access to their home exercise program at all times, facilitates self-management, and, importantly, increases communication between the patient and therapist. The advantages of the Physiotherapy Exercises Appare that it is freely available, has an extensive range of exercises covering both musculoskeletal and neurological conditions, and is easy to use for both therapist and patient. Combined with the ability to remotely monitor patients’ adherence to the home exercise program, the Physiotherapy Exercises App has been a valuable addition to my clinical practice and role as a clinical educator.
- Lambert, T. et al. J Physiother. 2017; 63: 161–167