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Can Young Severely Disabled Patients Regain the Ability to Walk Independently More than Three Months after a Stroke?
Abstracts
The Effect of Positive Verbal Encouragement on the Measurement of Quadriceps Strength and the Ability to Sustain a Straight Leg Raise: A pilot study A K Jones, A Clough Leeds Metropolitan University Purpose: The purpose of this study was twofold; first to test the common assumption that verbal encouragement motivates patients to perform to their maximum ability (Bickers, 1993); and secondly whether the effect of verbal encouragement varied with an endurance or strength task. Method: As the purpose of this study was twofold, three hypotheses were formed: 1. Positive verbal encouragement positively alters the measurement of maximal quadriceps contraction. 2. Positive verbal encouragement positively alters a subject's ability to maintain a straight leg raise. 3. Positive verbal encouragement significantly increases the percentage improvement of performance of one task over the other. Thirty young healthy female volunteers, with no previous experience of either task, were randomly divided into two groups. Group A performed the strength task (maximum voluntary contraction of the quadriceps) and group B performed the endurance task (sustained straight leg raise). All
Can Young Severely Disabled Patients Regain the Ability to Walk Independently More than Three Months after a Stroke? D Jackson, H Thornton, L Turner-Stokes Regional Rehabilitation Unit, Northwick Park Hospital, Harrow The ability to walk independently may be crucial in determining return to functional independence following stroke. It has been suggested (Blower et al, 1995; Jorgensen et al, 1995) that patients not walking by three or four months afterwards are unlikely to walk again, implying that no benefit will be gained from therapy targeted towards this goal. However, much of this evidence comes from analysis of elderly populations. We investigated the acquisition of walking in young severely disabled stroke patients unable to walk three months after onset. The study took place in a regional unit admitting patients for intensive specialist in-patient rehabilitation. Data were gathered by retrospective examination of case notes for 152 consecutively admitted stroke patients (98 male, 54 female) aged 15 to 69 years (median 54, IQR 47 to 60) admitted over three years.
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subjects first per formed their given task without verbal encouragement. A predetermined rest period was then given before they repeated the task with verbal encouragement, administered by a tester. A single-blind design was used, the tester was therefore aware of the hypothesis and group allocation. Results: The mean score in Newtons for task 1 was 158 without verbal encouragement and 207.5 with verbal encouragement. The mean score in seconds for task 2 without verbal encouragement was 57.2 and without verbal encouragement 76.4 seconds. Related t-tests showed a significant improvement to the 0·0005 level, in performance for both groups with verbal encouragement (group A: t = 5.09, df = 14, group B: t = 5.65, df = 14). However, no significant improvement in performance of one task over the other was found using the Mann-Whitney U test (U = 84.5, p = 0.24). A trend was noted that subjects improved their per formance to a greater extent with an endurance task and positive verbal encouragement (group B). Conclusions: The results suggest that verbal encouragement is a useful tool to improve subjects’ performance on either task under controlled conditions. These conclusions were also supported by the literature reviewed. However, there may have been a carry-over effect accounting in part for the improvement between trials 1 and 2. Further investigations into this subject in the clinical setting are needed to confirm the effectiveness of verbal encouragement as a clinical tool. Reference Bickers, M J (1993). ‘Does verbal encouragement work? The effect of verbal encouragement on a muscular endurance task’, Clinical Rehabilitation, 7, 196-200.
Besides physical deficits, 86% had cognitive and 58% language impairments. Seventy-five patients regained the ability to walk independently from three to 11 months after onset (median 6, IQR 4 - 7.3). Comparison by Mann-Whitney tests showed that time taken to walk was not related to sex, side of stroke, dyspraxia or urinary incontinence on admission. However, patients took six to eight weeks longer to walk if, on admission, they had: ■ Cognitive impairments (z = --2.29; p = 0.02). ■ Neglect (z = - 2.33; p = 0.02). ■ Absence of dynamic sitting balance (z = --3.41; p < 0.001. ■ Absence of standing balance (z = --2.89; p = 0.004). Spearman’s correlation coefficients revealed no association between time taken to walk and age, but independent positive associations were found between this time and: Physiotherapy January 2000/vol 86/no 1
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■ Time from onset to referral for rehabilitation (rho = 0.55; p = < 0.001). ■ Time from acceptance to admission: waiting list time (rho = 0.3; p = 0.008). With intensive specialist input, significant numbers of severely disabled young stroke patients can regain independent walking many months after onset. The timing, intensity and content of rehabilitation for these patients warrants further investigation. Waiting list delay may prolong rehabilitation and potentially compromise cost effectiveness.
Range of Motion in the Lumbar Spine and the Effects of Age and Gender G Van Herp, P J Rowe Department of Physiotherapy, Queen Margaret University College, Edinburgh P M Salter Napier University, Faculty of Health Sciences, Edinburgh The spine is a complex three-dimensional structure. Low back pain (LBP) is thought to limit motion of the spine. Hence the assessment of the range of lumbar spinal movement is a common feature of clinical assessment in back pain patients (Hindle et al, 1990). Furthermore, many physiotherapy techniques and patient management programmes are designed to help patients with LBP and restore function of the spine (Maitland, 1986). To date, an objective, three-dimensional measure of lumbar spinal range of motion, which can be employed in the clinical environment to analyse functional movements, has been lacking. This paper presents the preliminary data from a study using a new method for measuring spinal motion based on an electromagnetic tracking device (3Space Isotrak®). This device was used to create a normative database for three-dimensional rotational measurements of the lumbar spine. One hundred subjects (50 female, 50 male) with no history of recent LBP were recruited. The 3 Space Isotrak was calibrated and
References Blower, P W, Carter, L C and Sulch, D A (1995). ‘Relationship between wheelchair propulsion and independent walking in hemiplegic stroke’, Stroke, 26, 606-608. Jørgensen, M D, Nakayama, H, Raaschou, H O and Olsen, T S (1995). ‘Recovery of walking function in stroke patients: The Copenhagen stroke study’, Archives of Physical Medicine and Rehabilitation, 76, 27-32. The authors wish to thank Hillingdon Health Authority (Regional Audit Funding Programme for Rehabilitation) for providing financial support.
then carefully attached between the sacrum and the T12/L1 intervertebral junction. The device was held in place using double sided tape, adjustable pitch wedges and four specially commissioned straps. The subjects then per formed six movements to the limit of range. Greater flexibility was found in females than males for the six ranges of motion across all ages. The t-test for independent samples (two-tailed significance and 95% confidence interval) showed these differences to be significant for extension (p = 0.001; 2.9, 10.6) and axial rotations (p = 0.010; 0.6, 4.9) for all age groups. Significant differences were found between the young (20-29 years) and older (60+) groups for all movements. The data indicate that 55° of flexion, 23° of extension, 22° of side bending to each side and 14° of axial rotation in each direction can be expected in the normal adult spine. In addition females are more flexible than males by an average of 1.5° and the young more flexible than the older subjects by an average of 6° when an average is taken across all six movements. Clinicians could make use of these normal values in examination and remember to assess patient’s range of movement in light of their age and sex. References Hindle, R J, Pearcy, M J, Cross, A T and Miller, D H T (1990). ‘Three-dimensional kinematics of the human back’, Clinical Biomechanics, 5, 218-228. Maitland, G D (1986). Vertebral Manipulation, Butterworth, London, 5th edn.
Spinal angles in degrees achieved for six movements
Age (years) Flexion Extension Left side bending Right side bending Left axial rotation Right axial rotation
20-29 58.9 37.0 25.1 26.3 18.6 18.6
Physiotherapy January 2000/vol 86/no 1
Females (n = 50) 30-39 40-49 58.2 31.2 25.6 26.2 18.0 15.6
57.5 29.0 20.7 23.4 15.7 13.4
50-59
60+
20-29
53.6 20.5 21.9 23.2 14.7 14.2
50.8 15.1 19.4 19.2 14.7 13.0
56.4 22.5 25.8 26.2 14.4 14.6
Males (n = 50) 30-39 40-49 54.2 22.1 25.6 25.0 11.9 9.1
54.2 20.0 19.3 21.2 11.6 12.7
50-59
60+
52.8 17.2 19.0 22.4 11.3 11.3
52.3 16.9 14.6 15.5 10.9 12.8
The Effect of Positive Verbal Encouragement on the Measurement of Quadriceps Strength and the Ability to Sustain a Straight Leg Raise: A pilot study A K Jones, A Clough Leeds Metropolitan University Purpose: The purpose of this study was twofold; first to test the common assumption that verbal encouragement motivates patients to perform to their maximum ability (Bickers, 1993); and secondly whether the effect of verbal encouragement varied with an endurance or strength task. Method: As the purpose of this study was twofold, three hypotheses were formed: 1. Positive verbal encouragement positively alters the measurement of maximal quadriceps contraction. 2. Positive verbal encouragement positively alters a subject's ability to maintain a straight leg raise. 3. Positive verbal encouragement significantly increases the percentage improvement of performance of one task over the other. Thirty young healthy female volunteers, with no previous experience of either task, were randomly divided into two groups. Group A performed the strength task (maximum voluntary contraction of the quadriceps) and group B performed the endurance task (sustained straight leg raise). All
Can Young Severely Disabled Patients Regain the Ability to Walk Independently More than Three Months after a Stroke? D Jackson, H Thornton, L Turner-Stokes Regional Rehabilitation Unit, Northwick Park Hospital, Harrow The ability to walk independently may be crucial in determining return to functional independence following stroke. It has been suggested (Blower et al, 1995; Jorgensen et al, 1995) that patients not walking by three or four months afterwards are unlikely to walk again, implying that no benefit will be gained from therapy targeted towards this goal. However, much of this evidence comes from analysis of elderly populations. We investigated the acquisition of walking in young severely disabled stroke patients unable to walk three months after onset. The study took place in a regional unit admitting patients for intensive specialist in-patient rehabilitation. Data were gathered by retrospective examination of case notes for 152 consecutively admitted stroke patients (98 male, 54 female) aged 15 to 69 years (median 54, IQR 47 to 60) admitted over three years.
41
subjects first per formed their given task without verbal encouragement. A predetermined rest period was then given before they repeated the task with verbal encouragement, administered by a tester. A single-blind design was used, the tester was therefore aware of the hypothesis and group allocation. Results: The mean score in Newtons for task 1 was 158 without verbal encouragement and 207.5 with verbal encouragement. The mean score in seconds for task 2 without verbal encouragement was 57.2 and without verbal encouragement 76.4 seconds. Related t-tests showed a significant improvement to the 0·0005 level, in performance for both groups with verbal encouragement (group A: t = 5.09, df = 14, group B: t = 5.65, df = 14). However, no significant improvement in performance of one task over the other was found using the Mann-Whitney U test (U = 84.5, p = 0.24). A trend was noted that subjects improved their per formance to a greater extent with an endurance task and positive verbal encouragement (group B). Conclusions: The results suggest that verbal encouragement is a useful tool to improve subjects’ performance on either task under controlled conditions. These conclusions were also supported by the literature reviewed. However, there may have been a carry-over effect accounting in part for the improvement between trials 1 and 2. Further investigations into this subject in the clinical setting are needed to confirm the effectiveness of verbal encouragement as a clinical tool. Reference Bickers, M J (1993). ‘Does verbal encouragement work? The effect of verbal encouragement on a muscular endurance task’, Clinical Rehabilitation, 7, 196-200.
Besides physical deficits, 86% had cognitive and 58% language impairments. Seventy-five patients regained the ability to walk independently from three to 11 months after onset (median 6, IQR 4 - 7.3). Comparison by Mann-Whitney tests showed that time taken to walk was not related to sex, side of stroke, dyspraxia or urinary incontinence on admission. However, patients took six to eight weeks longer to walk if, on admission, they had: ■ Cognitive impairments (z = --2.29; p = 0.02). ■ Neglect (z = - 2.33; p = 0.02). ■ Absence of dynamic sitting balance (z = --3.41; p < 0.001. ■ Absence of standing balance (z = --2.89; p = 0.004). Spearman’s correlation coefficients revealed no association between time taken to walk and age, but independent positive associations were found between this time and: Physiotherapy January 2000/vol 86/no 1
42
■ Time from onset to referral for rehabilitation (rho = 0.55; p = < 0.001). ■ Time from acceptance to admission: waiting list time (rho = 0.3; p = 0.008). With intensive specialist input, significant numbers of severely disabled young stroke patients can regain independent walking many months after onset. The timing, intensity and content of rehabilitation for these patients warrants further investigation. Waiting list delay may prolong rehabilitation and potentially compromise cost effectiveness.
Range of Motion in the Lumbar Spine and the Effects of Age and Gender G Van Herp, P J Rowe Department of Physiotherapy, Queen Margaret University College, Edinburgh P M Salter Napier University, Faculty of Health Sciences, Edinburgh The spine is a complex three-dimensional structure. Low back pain (LBP) is thought to limit motion of the spine. Hence the assessment of the range of lumbar spinal movement is a common feature of clinical assessment in back pain patients (Hindle et al, 1990). Furthermore, many physiotherapy techniques and patient management programmes are designed to help patients with LBP and restore function of the spine (Maitland, 1986). To date, an objective, three-dimensional measure of lumbar spinal range of motion, which can be employed in the clinical environment to analyse functional movements, has been lacking. This paper presents the preliminary data from a study using a new method for measuring spinal motion based on an electromagnetic tracking device (3Space Isotrak®). This device was used to create a normative database for three-dimensional rotational measurements of the lumbar spine. One hundred subjects (50 female, 50 male) with no history of recent LBP were recruited. The 3 Space Isotrak was calibrated and
References Blower, P W, Carter, L C and Sulch, D A (1995). ‘Relationship between wheelchair propulsion and independent walking in hemiplegic stroke’, Stroke, 26, 606-608. Jørgensen, M D, Nakayama, H, Raaschou, H O and Olsen, T S (1995). ‘Recovery of walking function in stroke patients: The Copenhagen stroke study’, Archives of Physical Medicine and Rehabilitation, 76, 27-32. The authors wish to thank Hillingdon Health Authority (Regional Audit Funding Programme for Rehabilitation) for providing financial support.
then carefully attached between the sacrum and the T12/L1 intervertebral junction. The device was held in place using double sided tape, adjustable pitch wedges and four specially commissioned straps. The subjects then per formed six movements to the limit of range. Greater flexibility was found in females than males for the six ranges of motion across all ages. The t-test for independent samples (two-tailed significance and 95% confidence interval) showed these differences to be significant for extension (p = 0.001; 2.9, 10.6) and axial rotations (p = 0.010; 0.6, 4.9) for all age groups. Significant differences were found between the young (20-29 years) and older (60+) groups for all movements. The data indicate that 55° of flexion, 23° of extension, 22° of side bending to each side and 14° of axial rotation in each direction can be expected in the normal adult spine. In addition females are more flexible than males by an average of 1.5° and the young more flexible than the older subjects by an average of 6° when an average is taken across all six movements. Clinicians could make use of these normal values in examination and remember to assess patient’s range of movement in light of their age and sex. References Hindle, R J, Pearcy, M J, Cross, A T and Miller, D H T (1990). ‘Three-dimensional kinematics of the human back’, Clinical Biomechanics, 5, 218-228. Maitland, G D (1986). Vertebral Manipulation, Butterworth, London, 5th edn.
Spinal angles in degrees achieved for six movements
Age (years) Flexion Extension Left side bending Right side bending Left axial rotation Right axial rotation
20-29 58.9 37.0 25.1 26.3 18.6 18.6
Physiotherapy January 2000/vol 86/no 1
Females (n = 50) 30-39 40-49 58.2 31.2 25.6 26.2 18.0 15.6
57.5 29.0 20.7 23.4 15.7 13.4
50-59
60+
20-29
53.6 20.5 21.9 23.2 14.7 14.2
50.8 15.1 19.4 19.2 14.7 13.0
56.4 22.5 25.8 26.2 14.4 14.6
Males (n = 50) 30-39 40-49 54.2 22.1 25.6 25.0 11.9 9.1
54.2 20.0 19.3 21.2 11.6 12.7
50-59
60+
52.8 17.2 19.0 22.4 11.3 11.3
52.3 16.9 14.6 15.5 10.9 12.8