Since you don't know what the fuck you're doing, get the hell out of stroke! Create 100% recovery protocols and your patients will gladly do the millions of reps required since they are looking towards full recovery! Are you that much of blithering idiots that you don't understand that simple explanation?
Send me hate mail on this: oc1dean@gmail.com. I'll print your complete statement with your name and my response in my blog. Or are you afraid to engage with my stroke-addled mind? I need an explanation of your thought processes on stroke research and why you're not solving stroke.
Enhanced physical therapy for arm function after stroke: a one year follow up study
1994, Journal of Neurology, Neurosurgery & Psychiatry
3 Pages
2 Files ▾
Alan Sunderland, Debbie Fletcher, Lesley Bradley, Debbie Tinson,
Richard Langton Hewer, Derick T Wade
Abstract
Ninety seven patients with stroke who
had participated in a randomised trial of
conventional physical therapy v an
enhanced therapy for arm function were
followed up at one year. Despite the
emphasis of the enhanced therapy
approach on continued use of the arm in
everyday life, the advantage seen for
some patients with enhanced therapy at
six months after stroke had diminished
to a non-significant trend by one year.
This was due to some late improvement
in the conventional therapy group
whereas the enhanced therapy group
remained static or fell back slightly. It is
recommended that trials should be conducted comparing very intensive therapy
for the arm with controls without treatment. This would provide a model of the
effects of therapy on intrinsic neural
recovery that would be relevant to all
areas of neurological rehabilitation.
( Neurol Neurosurg Psychiatry 1994;57:856-858)
The Stroke Research
Unit, Frenchay
Hospital, Bristol, UK
A Sunderland
D Fletcher
L Bradley
D Tinson
R Langton Hewer
Rivermead
Rehabilitation Centre,
Oxford, UK
D T Wade
Correspondence to:
Dr A Sunderland,
Department of Psychology,
The University, Leicester
LE1 7RH, UK.
Received 27 November
1992 and in final revised
form 22 October 1993.
Accepted 21 December 1993
In a previous paper' we reported that compared with orthodox physiotherapy an
enhanced physical therapy regime produced
gains in recovery of arm function over the
first six months after stroke. By contrast with
conventional therapy, the enhanced therapy
included more than double the amount of
physiotherapy for the arm and also various
techniques aimed at relearning of motor skills
and encouraging use of the affected arm in
everyday life. The benefits of enhanced
therapy seemed greatest for patients with a
mild initial impairment of arm function and
were statistically significant but insufficient to
lead to clinically significant gains on the
untimed practical tasks of the Frenchay arm
test.2
One hypothesis was that the greater active
involvement of patients with enhanced
therapy in their own therapy programme and
the emphasis on arm use in everyday life
would lead to gains that would be better sustained after discharge from therapy than seen
under conventional therapy. If this were the
case then a clinically significant difference
between conventional therapy and enhanced
therapy groups might emerge at late follow
up. A one year follow up of all patients in the
initial study was therefore attempted.
Patients and methods
PATIENTS
Ninety seven (73%) of the 132 patients who
had been in the treatment trial were
reassessed close to one year after stroke
(mean time since stroke 52 (SD4) weeks;
range 39-64). Death or further major strokes
were the most common reasons for drop out.
There were 48 patients who had received
enhanced therapy (22 women, 26 men; 21
left sided weakness, 27 right; mean age 66
(SD1 1) years), and 49 who had received conventional therapy (27 women, 22 men; 23 left
sided weakness, 26 right; mean age 69 (SD9)
years). As at the earlier assessments, the
groups were similar at one year in their func-
tional independence as assessed by the
Barthel activities of daily living scale
(enhanced therapy group mean 17 (SD3);
conventional therapy group mean 17 (SD3)).
ASSESSMENT METHODS
The tests of arm function were the same as
reported previously.
1-3 These were (a) Range
and strength of active movement (extended
motricity index and motor club assessments)
(b) motor skills (nine-hole peg test and
Frenchay arm test). Also, there was clinical
assessment of resistance and pain on passive
movement of the arm.
Results
EFFECT OF THERAPY ON AMOUNT OF ARM
RECOVERY
The table and figure confirm that up to six
months, patients under the enhanced therapy
regime who had a mild initial impairment
showed better recovery than similar patients
with conventional therapy. This emerged on
those tests that are most sensitive to change
(extended motricity index and nine-hole peg
test). For patients with a severe initial impair-
ment, the figure shows that by chance those
allocated to enhanced therapy had on average
a slightly more profound initial impairment of
arm function, but the recovery curves are
essentially parallel for enhanced therapy and
conventional therapy subgroups.
There was little change between six months and one year. Taking the average for
all 102 patients, only the extended motricity
index showed a statistically significant
increase over this period (mean increase 4;
Wilcoxon signed ranks test, p < 0-01). The
table shows that there was a consistent trend
within the mild subgroup for patients with
enhanced therapy to remain static or decline
slightly whereas patients with conventional
therapy showed a slight improvement. This
trend reached statistical significance on the
motor club assessment.
FINAL OUTCOME
At one year, there were no statistically significant differences between enhanced therapy
and conventional therapy subgroups on any
measure. On the Frenchay arm test the
median scores were zero for both patients
with enhanced therapy and patients with conventional therapy who had a severe initial
impairment, and 5 (full marks) for those with
enhanced therapy and conventional therapy
with a mild initial impairment. On clinical
examination, 26 of the patients with
enhanced therapy had resistance to passive
movement compared with 24 patients with
conventional therapy. Pain was reported for
16 patients with enhanced therapy and 14
patients with conventional therapy.
Discussion
The hypothesis that the patients with
enhanced therapy would show better long
term outcome was not confirmed(Because you didn't have EXACT 100% RECOVERY PROTOCOLS!). For those
patients with an initial mild impairment, the
slight advantage seen for the enhanced
therapy group at six months had diminished
to a non-significant trend by one year. This
was due to the conventional therapy group
making small late gains in arm function and
catching up with the patients with enhanced
therapy, who remained static or fell back
slightly over the same period.
On a more positive note, the recovery
curves for the subgroup of patients who could
be followed up at one year showed a pattern
entirely consistent with the data for the whole
group assessed at six months and reported in
our earlier paper.' The consistency of these
data gives us confidence that our earlier
results were not due to measurement error
but that there was a real effect of enhanced
therapy on early recovery. It seems that
enhanced therapy accelerated recovery to a
plateau that was only approached at a much
later date by patients with conventional
therapy.
This effect, although reliable, was small
and did not on average improve everyday
movement skills as assessed by the Frenchay
arm test. The enhanced regime represented a
small change in rehabilitation practice, which
was highly constrained by the daily routine in
a general hospital,4 and ethical considerations
prevented us from comparing enhanced
therapy with a control group without treatment. We believe that the small effects seen
in this study and the lack of evidence of
therapy related effects in other studies,5-7 provide ethical justification for a much more radical trial in which conservatively managed
controls are compared to a group of patients
with mild initial impairment who receive a
very intensive arm function training pro-
gramme that combines hospital and home
based therapeutic activities. Only by taking
such a radical approach can we discover how
scarce rehabilitation resources can best be
used to the advantage of our patients.
In conclusion, enhanced physical therapy
during the first six months after stroke did
not lead to gains at one year, but it did cause
an early acceleration to a level only
approached much later by patients who
received conventional therapy. This acceleration, although statistically significant, was not
sufficient to have a clinically important effect
on the average patient. A more radical treatment trial is needed to discover if this treatment approach has the potential to produce a
significantly better return of useful motor
skills. The study of recovery of arm function
may provide data on the general rules of
recovery after stroke, and may indicate
whether therapies should continue to focus
on promoting the return of lost brain functions or should instead take as their primary
aim the teaching of ways to adapt to residual
neurological and neuropsychological impairments.
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