Helping stroke survivors get back on their feet

How lucky we are, those of us who just stand up when we want to, without giving it a thought. For many people who’ve had a stroke, this is no longer a thoughtless activity. Nor are many other basic physical functions that we’d hope to take for granted. Problems with movement and balance are very common and six months on more than a third of stroke survivors still can’t walk independently.

Recovering physical independence is a big part of the work physiotherapists undertake with people who have had strokes. There are many different approaches to this and uncertainty about what’s best. Can Cochrane evidence help? The Cochrane Stroke Group has a new review on interventions specifically aimed at improving sit-to-stand ability and an updated review looking at physical rehabilitation for recovering function and mobility more generally after stroke. I asked Clare Major, Lead Therapist (Physiotherapist) of the Early Supported Discharge for Stroke Serivce, based at Oxford’s Acute Stroke Unit, how this evidence is relevant to her as a practitioner in the field. Here’s what the evidence says and what Clare thinks about it.

Does physical rehabilitation help people regain function and mobility after stroke?

The updated review now has results from 96 studies with over 10,000 people, with more than half carried out in China. They were a mixed bag and many were poorly reported.

  • Physical rehabilitation was better than no treatment for functional recovery and the effect lasted beyond the end of the treatment sessions
  • Physical rehabilitation was also more effective than ‘usual care’ for improving motor function, standing balance and walking speed
  • Very limited evidence suggests that an intervention carried out 30 to 60 minutes a day on five to seven days a week was most effective, but more research will be needed to confirm this
  • Intervention carried out sooner after stroke seemed to be more effective than after more of a delay; again this needs further testing
  • No single physical rehabilitation approach was more effective than any other
Self-portrait by Peter Medawar following his stroke

Self-portrait by Peter Medawar following his stroke
Credit: Wellcome Library, London.

It’s unfortunate that the usefulness of this review is limited by shortcomings of the available studies. It was hard for the review team to judge the quality of the evidence because information was so poorly reported. They conclude that “evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.”

Clare says this review supports her practice:

“It is positive that this review finds that physical therapy is better than no therapy. This finding, and that of the recommended frequency and duration of therapy being 30-60 minutes delivered 5-7 days per week, backs up the recommendations for stroke rehabilitation set out in the RCP National Clinical Guidelines for Stroke and the NICE guidelines for long-term rehabilitation after stroke. My feeling is that this does not tell clinicians anything new, but does back up what stroke therapists are already striving to achieve. In practice there has been a gradual move away from following a specific therapeutic approach towards more of a variety of evidence-based treatments. This review supports my mode of practice whereby treatment is tailored towards the patients’ goals and incorporates a mix of different treatment methods depending on the patient’s specific impairments, motivations and social situation.”

What helps people improve their ability to stand up from sitting after stroke?

The review that looked at this is a new one. It’s really important to note that the people studied were mostly those who could already stand up independently, so the results are only relevant for those who can do that.

  • No conclusions could be reached about the effect of sit-to-stand training on the ability to stand up independently
  • There’s moderate quality evidence that sit-to-stand training may improve the speed of rising and the weight taken through the affected leg
  • We don’t know what is the ideal amount of training, nor whether any beneficial effects are long-lasting

Clare says:

Fabric with line and form

Fabric with line and form by Glenis G. in Drawing 1 Sketchbook and Reflections

The evidence presented is for improving sit to stand in the population of people with stroke who were already able to sit-to-stand independently. In practice, this is not the population of stroke patients receiving physiotherapy. The lack of evidence for improving sit to stand ability in patients who are unable to do so independently is frustrating, but from experience I imagine it is hard to research this as there are so many factors which may affect the ability to sit to stand, not all of them physical.

So where does this leave us?

Clare commented “I rely heavily on my past experience to guide my treatment decisions and rehabilitation strategies but I try to keep abreast of the latest research developments and these Cochrane reviews help practitioners to do this. These questions [addressed by the reviews] are important because therapists want to ensure they are providing the best, most evidence based therapies for their patients, at the duration and frequency that is most likely to achieve the desired outcomes.”

She spoke of the “on-going frustration for physiotherapists working in stroke rehabilitation [which] is the lack of high quality evidence to guide therapy” and it’s a shame that these reviews did not have more and better evidence to strengthen their conclusions, but at least they tell us what is known so far. Let’s hope future research will address important gaps and that we, in Cochrane, keep striving to find ways to share our evidence with those who need it and to engage them in producing reviews that are relevant and useful.

These reviews were produced by the Cochrane Stroke Group. Their website tells you how you could get involved in producing reviews.

Our thanks go to Clare Major, Lead Therapist (Physiotherapist) of the Early Supported Discharge for Stroke Service at the Acute Stroke Unit, John Radcliffe Hospital, Oxford.

The featured image at the top is Advanced drawing Anatomy: Knees, movement and the walk cycle. http://mwood-advancedrawing.blogspot.co.uk/2013/10/advanced-drawing-anatomy-knees-movement_21.html

Links:

Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD001920. DOI: 10.1002/14651858.CD001920.pub3.

Cochrane summary and podcast of this review http://summaries.cochrane.org/CD001920/physical-rehabilitation-approaches-for-recovery-of-function-balance-and-walking-after-stroke

Pollock A, Gray C, Culham E, Durward BR, Langhorne P. Interventions for improving sit-to-stand ability following stroke. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD007232. DOI: 10.1002/14651858.CD007232.pub4.

Cochrane summary of this review http://summaries.cochrane.org/CD007232/interventions-for-improving-the-ability-to-rise-to-stand-from-sitting-following-stroke

Intercollegiate Stroke Working Party, Royal College of Physicians. National clinical guideline for stroke. 4th edition. [issued September 2012]. London: Royal College of Physicians; 2012. Available from: http://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition.pdf

National Clinical Guideline Centre, National Institute for Health and Care Excellence (commissioner). Stroke rehabilitation: long term rehabilitation after stroke. London: National Clinical Guideline Centre, Royal College of Physicians; 2013 (NICE CG162). [Issued June 2013]. Available from: http://www.nice.org.uk/guidance/cg162/resources/cg162-stroke-rehabilitation-full-guideline3

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Sarah Chapman

About Sarah Chapman

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Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients. A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

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