EVIDENCE FOR CURRENT PHYSIOTHERAPY PRACTICE IN TREATMENT OF STROKE
Evidence to support the different approaches to stroke rehabilitation is sparse. However, over the past 10 years the study of human movement has generated a significant amount of scientific literature which provides a theoretical basis for rehabilitation of individuals with altered movement patterns. This theoretical basis has led to a new approach in rehabilitation which has been termed a movement science approach or “the new paradigm”. (Carr et al, 1994).
The scientific literature has developed in the fields of biomechanics, psychology and neurophysiology, providing new information on motor performance and on the psychological and biological functioning of patients.
As regards motor performance, biomechanics provides a description of the performance of specific everyday actions. Consequently the action of muscles and the strains put upon joints can be determined.
As regards psychological function, the field of motor learning, particularly with regard to the acquisition of skill, provides information about how new actions are learned. Cognitive psychology gives insight into the active nature of learning, motivation, attention, and the relationship between intention and action. In terms of the structure of the environment and the effects on the individual and on motor performance, ecological psychology provides information of value in the planning of a challenging and motivating rehabilitation environment, organised to promote learning.
At the level of biological function, recent neurophysiological research provides new insights into the relationships between neural activity and specific actions and into the mechanisms of recovery following lesions. Both neurophysiology and muscle biology indicate the adaptive changes that take place as a result of variation in amount and type of motor activity (Carr and Shepherd 1989).
Comparison of this new approach with other more traditional approaches is difficult due to the lack of randomised controlled trials. There has been no evidence that a new approach is any more effective than a previous one. This could suggest that the impetus to change has derived more from general experience rather than scientific research. (Carr et al 1994).
However, Langhammer and Stanghelle (2000) carried out a randomised conrolled trial. This compared the Bobath approach (facilitation/inhibition strategies) and the Motor Relearning Programme (task oriented strategies) in stroke rehabilitation. 61 acute stroke patients were randomly assigned to 2 groups. Group 1 (33 patients) received physiotherapy according to the Motor Relearning Programme (MRP) and group 2 (28 patients) received physiotherapy according to the Bobath approach. The patients were tested 3 days after admission, 2 weeks after admission and 3 months post stroke by using four different assessment scales: the Motor Assessment Scale (MAS), the Sodring Motor Evaluation Scale (SMES), the Barthel ADL Index and the Nottingham Health Profile (NHP). The authors also recorded length of stay in hospital, use of assistive devices for mobility and the patient's accommodation after discharge.
The results showed that both groups improved in MAS and SMES but improvement in motor function was significantly greater in the MRP group. The patients receiving MRP were discharged, on average,12 days prior to those receiving Bobath (21 days versus 34 days). Both groups improved in the Barthel ADL Index but the women in the MRP group improved more in ADL than the women in the Bobath group. There were no differences between groups in the life quality test (NHP), use of assistive devices or accommodation after discharge from the hospital. The authors concluded that in the acute rehabilitation of stroke patients, physiotherapy treatment using the MRP is preferable to that using the Bobath approach.
There have been several surveys recently carried out amongst physiotherapists in order to develop an insight into current practice and the perceived theoretical basis behind treatment of stroke patients.
Carr et al (1994) carried out a survey of Australian physiotherapists’ choice of treatment in stroke rehabilitation. This was based on a previous study amongst Swedish physiotherapists (Nilsson & Nordholm, 1992). The aims, as with the Swedish study, were to establish: 1) Choice of treatment in the rehabilitation of individuals following stroke; 2) factors influencing the choice of treatment; 3) The theoretical bases for choice of treatment; 4) Attitudes towards changing interventions.
Results from this survey showed that as regards choice of treatment, the most common treatment category was "functional activities". In terms of factors influencing choice of treatments, respondents ranked "experience through working with patients" as the most important factor and professional literature and basic training as the least important factors. This was similar to the Swedish physiotherapists.
As regards the theoretical basis for treatment, 10% of physiotherapists did not even attempt to describe their theoretical basis and of those who did, 38% of responses were not theoretically based. The majority described a movement science theoretical basis, which is different from the Swedish study in which the majority of respondents listed a combination of approaches.
As regards attitudes towards changing interventions, 64% (Sweden: 75%) were very interested in attending a course on the application of movement sciences as an indication of their attitude towards change, 31% rather interested (Sweden: 16%) and 5% not at all interested (Sweden: 9%). The authors concluded that the difficulty physiotherapists have in describing the theoretical basis for development may hinder the development of physiotherapy as an ongoing science.
A further survey was carried out in a similar fashion by Sackley and Lincoln, (1996), this time amongst physiotherapists in the Trent region of the UK. This study used interview techniques as well as questionnaires.
The results of this study showed that the "Bobath" approach was the most frequently used (80%) and the "functional approach" and the "motor learning approach" were only used by 10% and 4% respectively. Once again, the physiotherapists found it difficult to describe a theoretical basis for their choice of treatment and the reason for choosing a particular approach was again through experience rather than through the use of published results.
The consensus seemed to be that the Bobath approach was the best because "it appeared effective", although nobody could explain how this would be acheived. The subjects seemed unaware of the lack of evidence supporting the Bobath approach, apart from 2 respondents in the "functional" group. The authors agreed with those of the previous studies in concluding that a change in culture is required, with implementation of research results, in order to progress the physiotherapy treatment of stroke patients.
A survey was done by Davidson & Waters, (2000) on physiotherapists working with stroke patients in the U.K. The aims of the study were to 1) Gather demographic information about physiotherapists working with stroke patients. 2) Identify assumptions surrounding physiotherapy intervention. 3) Investigate issues of conflict between physiotherapists and medical/nursing staff. 4) Identify types of approach used.
Results came from 973 physiotherapists with varying clinical experience in several different work locations. 88% of respondents primarily used the Bobath approach although 87% adopted an eclectic approach. Only 4% used Carr & Shepherd’s motor relearning approach despite it being described extensively in literature. Most of these therapists were from Scotland.
When asked about the theoretical basis underlying treatments, respondents gave various answers for the same approach. This could suggest that therapists interpret different concepts in their own way resulting in a lack of consistency in treatment methods.
16% of respondents agreed with the statement “ I am frequently in conflict with nurses and/or doctors because I prevent patients from walking even though they are able to do so.” 22% agreed with the statement “ I am frequently in conflict with nurses and/or doctors over early discharge of stroke patients.” (Davidson & Waters, 2000).
The main finding from this survey is that although therapists claim to be using specific approaches in treatment, many of their assumptions are unsubstantiated. They also seem unclear as to what constitutes individual approaches. By interpreting concepts in their own way, they may be using an approach or approaches which are quite different from the original concept.
Carr, (1996), suggests that approaches are dynamic and moving whilst the concept stays the same. It would appear from these surveys that it is time to redefine the concepts of each approach and establish theoretical bases for them. This could lead to more consistent treatments from physiotherapists based on established theories which have been researched.
REFERENCES
CARR J. AND SHEPHERD R. (1989) A Motor Learning Model for Stroke Rehabilition Physiotherapy July Vol. 75, 7
CARR ET AL (1994) Physiotherapy in Stroke Rehabilitation: Bases for Australian Physiotherapists’ Choice of Treatment Physiotherapy Theory and Practice Vol. 10 201-209
DAVISON I. AND WATERS K. (2000) Physiotherapists working with stroke patients: A national survey Physiotherapy 86 2 69-8
LANGHAMMER B. AND STANGHELLE J. (2000) Bobath or Motor Relearning Programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomised control study Clinical Rehabilitation 14 361-369
SACKLEY C. AND LINCOLN N. (1996) Physiotherapy Treatment for Stroke Patients: A survey of Current Practice Physiotherapy Theory and Practice 12 87-96