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| Beware of the cat if you are mice |
Follow the evidence not the guru
What is science? Simply put science is seeking
of truth or knowledge based on experiments or research. If knowledge is not
based on research and just of personal observation then it becomes a matter of
faith. In physiotherapy science “approaches” or technique starts with personal
observations, theoretical considerations of that particular time and ingenuity.
This is true for all the approaches in neurology starting from Knott & Voss
PNF to Carr & Sheppard’s MRP. When these approaches are first written it was
derived from cutting edge science of that day and even it was considered revolutionary. For example,
when Bobaths wrote their book on adult hemiplegia they departed from Brunstromm’s
Ideas of recovery and treatment principles. (Bobath moved from a 6 stage recovery to 3
stage recovery process in stroke.)
But,
research into various treatment methods and approaches was not carried out
before they were published. One of the early examples of it is weakness as
impairment in upper motor neuron lesions (UMN) was identified as a problem in
the late seventies. In the late 80s and 90s it was being more and more
recognized as an important impairment in UMN lesions. However, most of
curriculum, our training methods did not consider it to consideration. Even as
late as early 2000 course on cerebral palsy was reducing spasticity and
considered weakness as non-issue. Major
reason for it may be because we follow “approaches” propagated by “experts” and
there followers rather than research or evidence.
What is
evidence?
Evidence
is a piece of information that supports a conclusion and in case of medicine
the information should be patient centric and clinically relevant. One of the best ways to do an
experiment to find effectiveness of a treatment is randomized control
trials. In the last decade as auditing
and evidence based practice became the norm and we started to understand the importance
of experiments in physiotherapy science and knowledge acquiring. Randomized control trials (RCTs) on the
efficacy of these approaches increased in the last decade. Even though evidence
is part and parcel of science, soft science like medicine has different grades
of evidence. The quality of the evidence
is vital for our understanding of medical science. The analogous I usually give
to
understand different quality of evidence is the quality of gold. As we know
gold comes with different level of purity and depending on that the quality is
listed. Gold can be 24, 22, 18 or just 16 carat gold. Similarly, evidence can
be different grade depending on the quality of the trials done. When good
quality trials are combined together and made into a systematic review (SR) we
can assume it to be high quality (something like 24 carat gold). When the
trials (RCTs) are done with some bias or flaws and when they are part of the SR
it can be considered as moderate evidence (20-22 carat gold!) and poorly done
studies leads low or very low grade (12-18 carat gold) evidence. It is common to see moderate level evidence
rather than high quality evidence, that too in stroke rehabilitation at this
point of time.
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| Levels of evidence - treatment |
What does
evidence say about gait in stroke rehabilitation?
A Cochrane review in 2014 concluded “Physiotherapists
should choose each individual patient's treatment according to the evidence
available for that specific treatment, and should not limit their practice to a
single 'named' approach” and no one approach is superior to another. I believe this is our next evolutionary step,
to find and apply treatment for each problem rather than following a guru’s
approach. We should be proudly saying I
don’t follow an approach or that technique alone but, say I am follower of
science and evidence.
These are
the following issues we will find if we look into evidence for walking after
stroke:
- Physiotherapy works and it improves gait in persons with stroke - It may look like a simple statement and we may think I already know that but, it is an important finding, because the research (Cochrane reviews and other systematic reviews) says so rather than experts or just clinical intuition alone.
- The next question which arises in our mind next is -What physical rehabilitation measures work? - Systematic reviews on gait rehabilitation have noted a repetitive practice of functional or a task. Primary focus of repetitive practice of task-specific training of everyday motor tasks. Repetitive or task specific practice, simply put means doing the activity which you want to improve again and again. So, to improve walking in persons with stroke repeated practice of walking is the best exercise. Remember, exercise done on a couch does not count as repetitive walking task training.
- How long do my patient needs to practice these activities to get better. One systematic (Cochrane review) review identified, probably 30-60 minutes of practice may have beneficial effects on gait in persons with stroke than lesser intensity. It should be noted 60 minutes of training can consist of training other tasks like standing sit to stand etc.
- What does evidence say about people with
stroke who can walk independently and want to improve their competence in
walking? Evidence suggests (Cochrane review) doing circuit
training, treadmill based gait (Cochrane review) training and repetitive task training (Cochrane review) are the best available methods to do. Circuit training consists of repetitive practice of functional tasks and continual progression of exercises. The participants may complete a series of workstations arranged in a circuit or may complete a series of individualized exercises within a group setting. It has been suggested circuit training can be a good way to improving and maintain walking competence.
A simple circuit training stattions - Treadmill based gait training can again improve parameters
like walking speed in patients who are already able to walk independently,
especially in the first 3 months. It
must be stressed it does not matter whether the training is done with or without
body weight bearing support and it does not produce great value in chronic
patients and people who cannot walk independently.
Why worry and buy a expensive and space eating sytem 
A obstacle training course Community ambulation is the ability of the patients to walk in the community, to participate like walking to the temple, going to the shop, to the bus stop etc, and it is the goal of stroke rehabilitation. Two types of training have been suggested by researchers 1. Simulated walking training like in the community (obstacle training) 2. Walking training outside in the community. Individual studies rather than systematic reviews suggest we may be able to use task specific training to make persons with stroke community ambulatory. However, remember more research is needed in this area.
Community walking training - We have very limited research evidence to prove that we can improve the quality of the movements (i.e. altering the gait pattern). One of the ways it has been suggested is to make your patient walk faster. So, what should we clinicians do? Try out different feedback techniques to correct movement pattern including walking faster. Clinicians should be aware physiotherapy may not be an effective tool to change gait patterns and patients should be educated regarding residual gait pattern abnormities.
- Regarding reducing impairments like contracture and spasticity what does the evidence say? Stretching probably does not reduce contracture or prevents it from developing. Spasticity as a impairment is difficult to manage, however, drugs like Botox does offer reduction in spasticity but not functional improvement. Strengthening exercise may improve muscle power or strength but we are not sure whether resisted exercise helps in improving gait performance. Evidence clearly shows strength training does have harm effect (i.e. it does not increase spasticity)
- What are the issues we don’t know? We are not sure whether physical rehabilitation for chronic patients who are unable to walk can be helpful. We don’t know what is the best prevent contractures, best way to improve walking if they have moderate to severe perceptual problems.
Conclusion:
Even though
evidence based physiotherapy is showing us the way to plan a rehab protocol in
stroke rehabilitation, sadly their findings and implementation of the findings
are not as positive as it ought to be. This can be attributed to many factors
including, traditional teaching and practice models, difficulty in
understanding evidence etc. The next decade in physiotherapy is not going to be
about finding the next cutting edge physiotherapy technique, rather it is going
to be about applying the best available evidence and producing more evidence. It is not going to be mastering a
technique or approach rather follow evidence, finding what best works for
patients with evidence. I am concluding by saying “following the evidence rather
than the guru” is the secret of best practice.
Reference and additional reading:
- Mehrholz J, Pohl M, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD002840. DOI: 10.1002/14651858.CD002840.pub3http://www.cochrane.org/ta/CD002840/pkkvaatttirrku-pirrku-nttntu-celvtai-meempttutt-oottupeaarri-mrrrrum-uttl-ettai-taangki-pyirrci
- English C, Hillier SL. Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007513. DOI: 10.1002/14651858.CD007513.pub2http://www.cochrane.org/CD007513/STROKE_circuit-class-therapy-for-improving-mobility-after-stroke
- Barclay RE, Stevenson TJ, Poluha W, Ripat J, Nett C, Srikesavan CS. Interventions for improving community ambulation in individuals with stroke. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010200. DOI: 10.1002/14651858.CD010200.pub2http://www.cochrane.org/ta/CD010200/pkkvaatttiliruntu-pilllaittvrkll-avrkllinnn-ceaant-cmuukttil-nttmaatt-utvum-cikiccai-tlaiyiittukll
- Pollock A, Baer G, Campbell P, Choo P, 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.pub3http://www.cochrane.org/ta/CD001920/pkkvaatttirrku-pirrku-eerrpttumuttl-ceylpaattucmnilai-mrrrrum-nttai-upaataiklliliruntu-miillvtrrkaannn-uttlcaar-mrruvaalllvu-annukumurraikll
- Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD007455. DOI: 10.1002/14651858.CD007455.pub2http://www.cochrane.org/ta/CD007455/tcai-ottungkllinnncontracture-cikiccai-mrrrrum-tttupptrrku-tcai-illkkll-cikiccaistretching
- Prabhu RKR, Swaminathan N, Harvey LA. Passive movements for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD009331. DOI: 10.1002/14651858.CD009331.pub2http://www.cochrane.org/ta/CD009331/tcai-ottungkll-cikiccai-mrrrrum-tttupptrrku-purrvicai-muuttttu-acaivukll
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