2009 annual evidence update on stroke rehabilitation - mobility

Tyson, S

Abstract

There is strong evidence that exercise and intensive tasks specific functional training can improve mobility after stroke (Van Peppen et al 2004, Van de Port et al 2007). Detail of interventions which can be operationalised to achieve these goals and the need for a paradigm shift within UK Stroke physiotherapy is now emerging.

Treadmill training can improve mobility in people who can already walk when the speed and incline of the treadmill is adjusted to reach intensity targets for cardio-respiratory training effect (Eich et al 2004; Hesse 2008) and underlying neuroplastic changes in brain activity have been identified thereby confirming the mechanism of action. (Luft et al 2008, Forrester et al 2008). It is also known that electromechanical gait training can enable more patients to regain the ability to walk after a stroke; for every four immobile patients with stroke treated using electro-mechanical gait training during their rehabilitation, one extra person will regain the ability to walk, compared to conventional therapy (Merholz et al 2007) and interventions involving repetitive task-orientated practice (such as exercise, treadmill training and electro-mechanical training) have been shown to be cost-effective (French et al 2007).

There is however some debate about which type of intervention might be most effective; ‘low technology’ interventions such as exercise and over-ground gait training may be as effective as ‘high technology’ interventions such as treadmill training and electro-mechanical training for people with chronic stroke (States et al 2009, Dickstein 2008), however there are few studies that specifically compare interventions and comparative studies of cost-effectiveness and patient satisfaction are particularly lacking.

There is also growing evidence of the effectiveness of exercise for mobility after stroke. Recent systematic reviews have confirmed the effectiveness of task-orientated circuit training (Wevers et al 2009) and strength training (Ada 2006). The evidence to support exercise and intensive task-specific functional training to improve mobility after stroke is convincing; the challenge now is to establish the best way to implement these interventions into clinical practice. Further research to establish the optimal ‘dose’ of therapy (intensity, frequency, duration), type of exercise or task practice, time point during the stroke journey and characteristics of the patients who are, and are not, able to benefit of these interventions are now imperative. Further novel interventions are needed for those for whom exercise and task-specific practice is not effective.

As the evidence of the clinical and cost-effectiveness of exercise and intensive task-specific functional training grows, evidence that the ‘traditional’ treatment approaches used in the UK are not effective is becoming clearer. Most UK stroke physiotherapists base their treatment choices on the Bobath Concept (Tyson et al 2009a, Tyson et al 2009b) but an authoritative review found little or no evidence to support traditional treatment approaches, such as Bobath (Van Peppen et al 2009). In 2009 a review specifically of the Bobath Concept found strong evidence in favour of other approaches compared to Bobath for mobility after stroke (Kollen et al 2009). However the ‘other approaches’ were varied (problem oriented willed movement, rhythmic auditory stimulation and treadmill training) so it was not possible to specify which alternative interventions were superior.

The strength of evidence that exercise and task-specific functional training are effective while Bobath is not indicates that a paradigm shift is needed within UK Stroke physiotherapy if evidence based practice is to be implemented; as has occurred in other countries in Europe. Physiotherapists need to urgently explore ways in which exercise and intensive task-specific functional training can be utilised within their practice in preference to Bobath based interventions. It is increasingly difficult to justify the continued use of the Bobath Concept and its associated treatment techniques.

Citation

Tyson, S. (2009). 2009 annual evidence update on stroke rehabilitation - mobility

• Journal Article Type: Article
• Publication Date: Jan 1, 2009
• Deposit Date: Jan 11, 2010
• Journal: NHS Evidence
• Peer Reviewed: Peer Reviewed
• Publisher URL: http://www.library.nhs.uk/stroke/ViewResource.aspx?resID=331167