Goal-oriented instructions increase the intensity of practice in stroke rehabilitation compared with non-specific instructions: a within-participant, repeated measures experimental study

This would be much easier if we had definitive stroke rehab protocols that led to recovery. Survivors would do anything if they knew if recovery would be the outcome. Right now one knows anything in stroke rehab. It is all guesswork.  Fix the guesswork and stroke survivors will respond accordingly. 

Goal-oriented instructions increase the intensity of practice in stroke rehabilitation compared with non-specific instructions: a within-participant, repeated measures experimental study

TessaHillig^aHaotianMa^aSimoneDorsch^ab

https://doi.org/10.1016/j.jphys.2019.02.007Get rights and content

Under a Creative Commons license

Abstract

Questions

In stroke rehabilitation, do goal-oriented instructions increase the intensity of practice during therapy compared to a non-specific instruction? Is one type of goal-oriented instruction more effective at increasing the intensity of practice achieved by stroke survivors during therapy?

Design

A within-participant, repeated measures experimental study.

Participants

Twenty-four adults undertaking stroke rehabilitation at a metropolitan hospital as an inpatient or outpatient.

Intervention

Participants were observed performing exercises across 3 days. On each day, they performed an exercise with a non-specific instruction (‘do some [exercise]’) as a baseline measure and the same exercise with one of three goal-oriented instructions, delivered in a randomised order. The three goal-oriented instructions were: ‘do [exercise] 25 times’ (instruction A), ‘do [exercise] 25 times as fast as you can’ (instruction B), and ‘do [exercise] 25 times, as fast as you can, aiming for a personal best’ (instruction C). The last instruction included verbal encouragement during the exercise.

Outcome measures

The time taken to complete 25 repetitions under the baseline condition and each instruction was recorded and converted into repetitions per minute.

Results

All of the goal-oriented instructions resulted in a significant increase in the rate of repetitions of the exercise being performed compared to the baseline measure: percentage increase from baseline (95% CI) was 62% (31 to 93) with instruction A, 116% (67 to 165) with instruction B, and 128% (84 to 171) with instruction C. Instruction C had a significantly greater effect than instruction A: mean difference in percentage increase 65% (95% CI 13 to 118).

Conclusion

Goal-oriented instructions can result in significant increases in the rate of repetitions of exercise in stroke rehabilitation. The use of goal-oriented instructions is a simple, no-cost strategy that can be used to increase the intensity of practice in stroke rehabilitation.

Trial registration

ACTRN12619000146190.

Key words

Stroke

Practice

Communication

Rehabilitation

Physical therapy

Introduction

Following a stroke, there is clear evidence that people who do larger amounts of task-specific practice achieve better activity outcomes. The first systematic review to suggest this dose-response relationship calculated that an additional 16 hours of therapy early after stroke could result in small to moderate improvements in activity.¹ A recent systematic review calculated that at least a 240% increase in usual therapy time is needed to produce significant improvements in activity outcomes.² In addition to increased time, it appears that a high intensity of practice (ie, a high number of repetitions) is required to improve activity outcomes.3, 4 Carey et al found that intensive finger tracking training (involving almost 7000 repetitions over 20 sessions) resulted in improved tracking accuracy and grasp and release function, and these improvements were accompanied by neuroplastic changes seen on functional magnetic resonance imaging.³ Scrivener et al established that completing a higher dose of lower limb exercise repetitions (> 703 repetitions in the first week after stroke) resulted in faster recovery of unassisted walking and that the number of lower limb exercise repetitions completed in the first week could predict stroke survivors’ walking speed at discharge from rehabilitation.⁴

Despite current literature and clinical guidelines recommending large doses of therapy after stroke, this is not being achieved in clinical practice.2, 5, 6 A systematic review of activity during physiotherapy sessions found that therapy sessions are 50 minutes long and that stroke survivors are active for an average of only 60% of a session.⁷ During these short therapy sessions, a stroke patient may perform as few as 32 repetitions of upper limb exercise,⁶ 202 steps of walking practice, or 11 stand-ups.⁸ These amounts of practice are unlikely to cause neuroplastic changes that are sufficient to improve clinical outcomes after stroke.

Strategies are needed to help achieve larger therapy doses within the rehabilitation setting. A scoping review of studies in which extra practice was done in stroke rehabilitation found that generally this was done with full supervision by extra staff.⁹ This is not a sustainable solution in usual clinical settings, where lack of time is the most commonly cited reason for not being able to increase therapy dosages.¹⁰ The authors of that scoping review suggest that the use of goal-oriented instructions could increase dosages of practice by increasing the intensity at which stroke survivors work within a session. However, the use of goal-oriented instructions to increase practice intensity does not appear to have been examined in stroke rehabilitation. There are studies that have examined the effect of modifying instructions in order to modify the speed of stroke survivors’ task performance.11, 12, 13 These studies have demonstrated increases in the speed of task performance in response to different instructions. However, they were not aiming to examine changes in intensity of practice and therefore only examined the change in speed of one repetition of a task. There are currently no studies that have investigated the effect of goal-oriented instructions on increasing the intensity of practice done over a sustained period. If using goal-oriented instructions has a significant impact on the intensity of practice achieved (ie, intensity in terms of rate of repetitions achieved) during a therapy session, this could increase therapy doses without additional staff, equipment, cost or time.

Therefore, the research questions for this within-participant, repeated measures experimental study were:

1.

In stroke rehabilitation, do goal-oriented instructions increase the intensity of practice achieved by stroke survivors during therapy?

2.

Is one type of goal-oriented instruction more effective at increasing the intensity of practice achieved by stroke survivors during therapy?