What treatment packages do UK physiotherapists use to treat postural control and mobility problems after stroke?

OBJECTIVE: The aim of this study was to identify the treatment packages (combinations of interventions) used to treat postural control and mobility problems for patients with stroke. METHOD: A convenience sample of 74 physiotherapists from 34 National Health Service hospitals recorded the interventions used to treat postural control and mobility problems for 251 patients with stroke in 1156 treatment sessions using the Stroke Physiotherapy Intervention Recording Tool (Tyson and Selley, Disabil Rehabil 2004;26:1184 - 1188). Descriptive statistics assessed the frequency with which the interventions were used and geometric coding identified treatment packages. RESULTS: The most frequently used interventions involved facilitation, practice of activities and their components and mobilisations. The least frequently used interventions involved the provision of equipment, teaching carers or professionals and exercise. Two treatment packages were identified; one involving the facilitation (of activities and their components) and the other involving whole activities (facilitation and practice). CONCLUSIONS: Interventions are often combined in two treatment packages to treat postural control and mobility problems after stroke. One involved facilitation (of whole and component activities) and the other involved practice and facilitation of whole activities. Future research in which conventional or standard UK stroke physiotherapy is delivered should focus on these interventions and exclude atypically used interventions.

Real-life step and activity measurement: reliability and validity.

OBJECTIVES: Investigation of the reliability and validity of activity monitoring using a range of methods, namely manual counting, self report and two commercially available activity monitors. STUDY DESIGN: Reliability, accuracy and validity study. METHODS: Multiple convenience samples of healthy subjects were recruited to the study. Reliability of manual step count was determined using an intraclass correlation coefficient (ICC) (n = 10). Relationships between data from the Step Watch monitor (SAM) and (a) manual step counts (n = 18); (b) a second (different) activity monitor (ActivPAL); and (c) self reported activity levels (n = 22) were assessed using correlations. A Pearson's correlation and paired t-test was used to assess relations between routinely used monitors. RESULTS: Intra-rater reliability for manual step counts was excellent (ICC 0.99), but inter-rater reliability was poor (ICC 0.26). Indoor accuracy of the SAM was 96.06% and outdoor accuracy was 99.58%. Moderate correlations (rho = 0.423 to 0.595, p < 0.05) were identified between the SAM monitor activity levels and self report diaries. The SAM and the ActivPAL were found to be internally reliable within themselves (ICC 0.96 and 0.95 respectively), significantly correlated (r = 0.93, p < 0.001) but also significantly different (t = 2.179, p < 0.05) when used simultaneously over the same circuit. CONCLUSIONS: Activity monitors provide information that is related to actual activity and provide accurate and reliable data when tested on functional walking circuits. Activity monitors should not be used interchangeably due to the potential for systematic differences between the measurements obtained when applied simultaneously over the same repeated circuit.

What is Bobath? A survey of UK stroke physiotherapists' perceptions of the content of the Bobath concept to treat postural control and mobility problems after stroke.

OBJECTIVE: The aim of this study was to identify which interventions used to treat postural control and mobility are considered part of the Bobath concept (BC). DESIGN. Hospital-based UK stroke physiotherapists identified interventions which they perceived to be part of the BC from a pre-published list of interventions used to treat postural control and mobility problems. Interventions that > 75% of participants felt were part of the BC were classified as 'definitely Bobath'. Interventions that < 25% felt were part of the BC were classified as 'definitely not Bobath'. Other interventions were classified as 'unsure'; those indentified by 50-74% of participants as part of the BC were classified as 'probably Bobath' and those indentified 26-49% were classified as 'probably not Bobath'. RESULTS: Seventy-four physiotherapists from 33 hospitals participated. Facilitation, mobilizations and practicing components of activities were most strongly associated with the BC. Exercise and the use of equipment were identified as 'not' or 'probably not Bobath'. There was uncertainty about practicing activities, teaching patients and carers and arranging independent practice. CONCLUSIONS: UK stroke physiotherapists perceive that the BC involves interventions that focus on facilitating movement, mobilization, practicing components of activities and some whole activities. Their views about what is not part of the BC and the areas where they are uncertain contrast with British and international teachers of the BC. Consequently, it was not possible to define a 'typical package' of treatment for postural control and mobility that represents the BC. Future research into the BC should focus on the effectiveness of specific, well-defined interventions.

Mobility and falls in people with Huntington's disease.

OBJECTIVE: The aim of this study was to estimate the frequency of falls in people with Huntington's disease (HD) and make a preliminary assessment of tools appropriate for assessing the risk of falling. DESIGN: Observational study. SETTING: Hospital clinic. SUBJECTS: 24 people with HD. MAIN MEASURES: Balance was assessed using the Berg Balance Scale (BBS) and Timed "Up & Go" (TUG) test. Walking speed over 10 m was recorded. Long-term monitoring of walking activity was undertaken. Unified Huntington Disease Rating Scale (UHDRS) motor, Functional Assessment Scale (FAS), Independence Scale (IS) and Total Functional Capacity (TFC) scores were obtained as well as data about falls and stumbles. Differences between "recurrent fallers" (>or=2 falls/year) and "non-fallers" (or=2 falls in the previous 12 months. Recurrent fallers walked less (p<0.01) and slower than non-fallers. Their balance (BBS) (p<0.01) was worse and TUG scores were higher (p<0.01). People with HD had increased risk of falls if TUG scores were >or=14 s or BBS scores

Functional balance and mobility tests in healthy participants: reliability, error and influencing factors.

BACKGROUND AND PURPOSE: Knowledge of the measurement error and reliability of measurement tools is required to judge whether true changes in performance have occurred. How a patient's performance relates to that of a healthy individual, and which factors would influence performance, also need to be considered to assess whether a patient's performance is 'normal'. The aim of the present study was to assess within-session and test-retest reliability, and measurement error, of a hierarchical series of functional tests of balance and walking in healthy participants. Obtaining indicative data in a group of healthy participants was an additional aim. METHOD: Forty healthy participants aged 20-60 years were recruited from staff and students of Cardiff University. The participants completed eight functional balance and mobility tests on two occasions on the same day. Intra-class correlation co-efficients (ICCs), assessed within-session, and test-retest reliability and measurement error were calculated from the mean squares error term of a repeated measures analysis of variance (ANOVA). The relationship to the overall mean score was calculated and linear regression investigated the factors influencing performance. RESULTS: Within-session and test-retest reliability for each of the tests was moderate to high (ICCs = 0.88-0.98 and 0.77-0.94, respectively). The overall measurement error was 3% to 11% of the mean scores. Age was the most frequent factor influencing performance; level of activity and body mass index (BMI) did not influence performance on any of the tests. CONCLUSIONS: Functional balance and mobility tests are reliable but are subject to random error up to 11% of the mean. The present study provides initial reference data for physiotherapists in clinical practice. It is important to begin to develop a database of a standard range of scores to give a context with which to judge more accurately the importance and relevance of clinical measurements from patients.

Can directed activity improve mobility in Huntington's disease?

Huntington's disease is an inherited disorder of the CNS that results in progressive deterioration of mobility and cognition and also affects behaviour. There are no disease-modifying interventions available to date, although there has been considerable progress in research directed at understanding the pathological basis of the disease with a view to identifying potential treatments. It is however important not to overlook currently available treatment strategies, including rehabilitation approaches. There has been little work to date to explore the potential of such approaches and here we highlight the need for more systematic studies in this area as well as the need for good objective assessment tools and the potential role that rehabilitation and training may have in the application of novel treatment options.

Community walking activity in neurological disorders with leg weakness.

BACKGROUND: The aims of this study were to determine walking mobility in the community in individuals with lower limb weakness and to establish the extent to which some clinic based measures predict such activity. METHODS: Five groups (n = 12-18) of independently ambulant patients with lower limb weakness due to neurological conditions and a matched healthy control group were recruited. Measures of isometric knee extension/flexion muscle strength, time to stand up (sit-to-stand, STS), gait speed, and daily step counts (recorded over 7 days) were obtained. The Rivermead Mobility Index (RMI) provided a measure of functional ability. Between group differences and associations were explored. Backward stepwise regression analysis was used to identify variables influencing daily step count in individuals with neurological impairment. RESULTS: Patients were significantly weaker (mean (SD) quadriceps strength 69+/-34% v 102+/-37% predicted), slower to stand up (2.9+/-1.3 v 2.0+/-0.6 s), and had slower self selected gait speed (0.74+/-0.3 v 1.2+/-0.2 m/s) than controls. Mean daily step count was also lower (3090+/-1902 v 6374+/-1819) than in controls. In neurology patients step count was correlated with RMI score (r(s) = 0.49, p<0.01) and STS (r = -0.19, p<0.05). However, self selected gait speed was the only significant predictor in the regression analysis (p<0.01) of daily mean step count. CONCLUSIONS: Measures of muscle strength, timed STS, and RMI do not appear to closely reflect community walking activity in these patient groups. Self selected gait speed was partially predictive. Measurement of community walking activity may add a new dimension to evaluating the impact of interventions in neurological disorders.

Falls and stumbles in myotonic dystrophy.

OBJECTIVE: To investigate falls and risk factors in patients with myotonic dystrophy type 1 (DM1) compared with healthy volunteers. METHODS: 13 sequential patients with DM1 from different kindreds were compared with 12 healthy volunteers. All subjects were evaluated using the Rivermead Mobility Index, Performance Oriented Mobility Assessment, and modified Activities Specific Balance Confidence scale. Measures of lower limb muscle strength, gait speed, and 7-day ambulatory activity monitoring were recorded. Subjects returned a weekly card detailing stumbles and falls. RESULTS: 11 of 13 patients (mean age 46.5 years, seven female) had 127 stumbles and 34 falls over the 13 weeks, compared with 10 of 12 healthy subjects (34.4 years, seven female) who had 26 stumbles and three falls. Patients were less active than healthy subjects but had more falls and stumbles per 5000 right steps taken (mean (SD) events, 0.21 (0.29) v 0.02 (0.02), p = 0.007). Patients who fell (n = 6) had on average a lower Rivermead Mobility score, slower self selected gait speed, and higher depression scores than those who did not. CONCLUSIONS: DM1 patients stumble or fall about 10 times more often than healthy volunteers. Routine inquiry about falls and stumbles is justified. A study of multidisciplinary intervention to reduce the risk of falls seems warranted.

Quantified measurement of activity provides insight into motor function and recovery in neurological disease.

BACKGROUND: A direct quantitative measurement of locomotor activity in an individual's own environment over an extended period may help in evaluating the impact of impairments in neurological disorders. OBJECTIVE: To investigate the reliability and validity of activity monitoring in neurological patients and healthy subjects. METHODS: Initial reliability studies were completed on 10 healthy subjects and 10 mobility restricted neurological patients. Validity was investigated using 7 days of ambulatory monitoring with the Step Watch( step activity monitor, laboratory based measures of gait and the Rivermead Mobility Index (RMI) in 10 patients with multiple sclerosis, 10 with Parkinson's disease, and 10 with a primary muscle disorder. Additionally, 30 healthy subjects participated in the study. Two clinical illustrations of ambulatory monitoring are provided. RESULTS: The mean (range) right step count of 7 days of monitoring in both healthy and neurological patients proved a reliable measure of activity (intra-class correlations 0.89 and 0.86 respectively). The 7 day mean (range) right step count was 5951 (2886-9955) in healthy subjects, 3818 (1611-5391) in patients with Parkinson's disease, 3003 (716-5302) in those with muscular disorders, and 2985 (689-5340) in those with multiple sclerosis. A moderate correlation was noted between 7 day mean step count and gait speed (r = 0.45, p = 0.01) in the grouped neurological patients but not the RMI (r(s) = 0.3, p = 0.11). CONCLUSION: Ambulatory monitoring provides a reliable and valid measure of activity levels. Neurological patients, living independently, demonstrate lower activity levels than healthy matched controls. Ambulatory monitoring as an outcome measure has potential for improving the evaluation of ambulation and providing insight into participation.