We all know (or at least I hope we do!) that exercise and functional task practice are the most effective interventions to promote physical recovery and thus should be the mainstay of physiotherapy practice. We also know that the intensity of the exercise and functional task practice (let’s call it FTP for short!) is crucial – the more the better and the sooner the better. But most stroke patients spend most of their time inactive and alone and receive insufficient therapy to maximise recovery. So we need to find ways to increase the amount of practice/ exercise/ therapy.
Here are some resources that I have collected together which give the details of how to deliver good quality, effective exercise and intensive tasks specific practice. Many thanks to the folk who have passed them on to me: Professors Janice Eng, Jan Merholz, Louise Ada, and Lisa Harvey, plus Bex Townley of Laterlife Training and Annie Merhag for the CIMT links. Most are free and will tell you exactly what to do and how to do it. You just need to work out which are the appropriate bits for your patient – that’s where the clinical skill comes in!
Please let me, and everyone else know how you get on via the blog – what are your experiences of using them? Your top tips and handy hints? Also please add any additional resources that you have found useful and would be willing to share with others
GRASP (upper limb) and FAME (lower limb/ mobility) are evidence based exercise and functional practice programmes developed by Janice Eng and team at University of BC in Vancouver with strong evidence that they improve impairments and activity/ disability levels. They can be used in hospital, out-patient or community settings. The manuals and relevant papers can be downloaded here.
Later Life Training – http://www.laterlifetraining.co.uk have produced effective exercise programmes focussing on mobility and falls prevention. There are best practice guidelines for exercise for stroke here http://www.exerciseafterstroke.org.uk/ with all the details about how to set up and deliver an exercise group. They also run courses about how to run exercise programmes for people with stroke and to become a certified instructor. There are also courses for postural stability; the Otago Falls programme and chair based exercise. Laterlife are a non-profit making organisation and all profits are ploughed back into the developing the programmes.
Physiotherapy Exercises www.physiotherapyexercises.com is a free website of exercises for people with disabilities and injuries. There are 100’s!! And there are specific collections for people with stroke, TBI, SCI, MS and other conditions and one can also select exercises according to exercise type and difficulty, equipment used, patients’ age, and /or body part so it’s straight forward to select and then download/ print out the simple line drawing and instructions for whatever suits individual patients. They were developed by physiotherapists working in Sydney and NSW, led by Lisa Harvey.
Constraint Induced Movement Therapy. I have recently come across a good book – How to do Constraint Induced Movement Therapy: A practical guide, written by one of my former MSc students, Annie Mehag (not that I’m name dropping or anything) and Jill Kings about how they deliver CIMT in the UK. It is full of evidence, experience and good sense. It only costs £24. They also run courses on how to do CIMT, not that I know anything about those or can vouch for them, one way or the other. The book can be ordered from http://www.harrisontraining.co.uk/
Treadmill Training improves mobility, walking speed and fitness for ambulant stroke survivors. But which type of treadmill to use? The difficulty is that many treadmills don’t go slow enough to accommodate the most disabled and nervous patients, you really need one that starts of 0.1m/s and most only start at 0.5 m/s, which is too fast for many neurological patients. The only one I have come across in the UK which goes slow enough is supplied by Biodex, they also produce a gantry/ bodyweight support (www.biodex.com) but there may be others.
Treadmill training is most effective if patients practise walking as fast as they can. How to deliver this? Here is the treatment protocol that Prof Jan Merholz (author of many Cochrane reviews!) uses in his practice, Klinik Bavaria (http://www.rehabilitationsforschung-kreischa.de )
Speed dependent treadmill training protocol
- Warm-up on the treadmill (5-minutes)
- Step 1 (maximum over ground walking speed, work this out before the session starts). Over 1 – 2 minutes increase the belt speed, in communication with the patient, to the highest speed at which the patient can walk safely and without stumbling. (hold Step 1 for 10 seconds) followed by a recovery period
- Step 2 Increase speed by 10% during the next attempt = (step 1 + 10%)
- Step 3 Increase speed by 10% during the next attempt = (Step 2 + 10%)
- Step 4 Increase speed by 10% during the next attempt = (Step 3 + 10%)
- Step 5 Increase speed by 10% during the next attempt = (Step 4 + 10%)
- Cool down for the rest of the session
- Repeat three times a week for at least 4 weeks (e.g. Monday, Wednesday, Friday)
- At the next session start at the speed used in Step 5 and increase as above, as tolerated by the patient
Pohl M, Mehrholz J, Ritschel C, Ruckriem S. Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: a randomized controlled trial. Stroke 2002; 33: 553-558. http://stroke.ahajournals.org/content/33/2/553.short
Gait training for non-ambulant stroke survivors. So that’s gait rehab for those who can walk sorted, but what about those who can’t walk? Well, the most effective option seems to be robotic gait training AKA ‘electromechanical gait training’ (let’s call it elec-mech gait training for short). In fact the Cochrane review suggests that using an elec-mech training could increase the number of stroke survivors who regain independent mobility by ~20% How good is that??!!! Can you imagine what a difference that would make if you could get 20% more people walking out of your hospital / clinic??
Mehrholz J, Elsner B, Werner C, Kugler J, Pohl M. Electromechanical-assisted training for walking after stroke: updated evidence. Cochrane Database Syst Rev. 2013 Jul 25;7:CD006185. doi: 10.1002/14651858.CD006185.pub3. http://www.ncbi.nlm.nih.gov/pubmed/23888479 .
But very people have access to an elec-mech gait trainer as they are very large and eye-wateringly expensive. Just to plug my work, keep your eyes peeled for the Morow mobility robot which I am developing (with clever colleagues, obvs) which is clinical-sized and trains sit-to-stand and walking, inexpensively. We putting the finishing touches to the final prototype at present and should start clinical testing in the Autumn.
In the meantime …… Body weight supported treadmill training (BWSTT) is an option. The evidence about its effectiveness is mixed. There is good trial evidence that it enables more people to get on their feet than usual care and over-ground gait training. Some recent systematic reviews have found it effective (Ada et al below) while others haven’t (Merholz et al below). The discrepancy is probably because of differences in the research question and the methodologies used. IMHO, I would interpret the meta-analysis/ systematic review data as saying that BWSTT works to get some people to get back on their feet but not everyone, and probably fewer people than elec-mech training. Pragmatically, in the absence of elect-mech trainers I would suggest you use BWSTT as the evidence is stronger than anything else apart from elec-mech training.
Ada L, Dean CM, Vargas J, Ennis S (2010) Mechanically assisted walking with body weight support results in more independent walking than assisted over-ground walking in non-ambulatory patients early after stroke: a systematic review. Journal of Physiotherapy 56: 153–161] http://www.ncbi.nlm.nih.gov/pubmed/20482476
Merholz J, Pohl J, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev. 2014 Jan 23;1:CD002840. doi: 10.1002/14651858.CD002840.pub3. http://www.ncbi.nlm.nih.gov/pubmed/24458944
Prof Louise Ada has kindly provided the treatment protocol used in the MOBILISE trial of BWSTT for non-ambulant stroke survivors, which showed a positive effect – more stroke patients became independently mobile with BWSTT than training with over-ground walking. She has also sent a chapter than she and Jan Merholz wrote for German text book (thankfully translated!) which has lots of practical information about using treadmill training – attached below.
Louise Ada, Cath Dean Meg Morris et al Randomized Trial of Treadmill Walking With Body Weight Support to Establish Walking in Subacute Stroke. The MOBILISE Trial Stroke 2010; 41:1237-1242 doi: 10.1161/STROKEAHA.109.569483 http://stroke.ahajournals.org/content/41/6/1237.short
Dean CM, Ada L, Bampton J, Morris M, Katrak PH & Potts S. (2010). Treadmill walking with body weight support in subacute non-ambulatory stroke improves walking capacity more than overground walking: a randomised trial. Journal of Physiotherapy, 56(2), 97-103. http://www.sciencedirect.com/science/article/pii/S1836955310700394