Towards evidence-based physiotherapy for patients with stroke

Abstract

The first aim of the thesis was to collect and review systematically, and to appraise critically the available evidence stemming from physiotherapy and physiotherapy-related studies in patients with stroke. It can be concluded that the application of physiotherapy improves performance to execute regular daily activities by patients with stroke. As the systematic reviews in this thesis demonstrate, walking ability in patients with stroke can best be improved by interventions to train specific functional gait and gait related tasks, e.g., gait training added by external auditory rhythms during gait, or on a treadmill, with and without body weight support. Functional use of the paretic arm and hand can best be improved by for instance constraint-induced movement therapy, and activities of daily living (ADL), for instance sit-to-stand transfers by frequent training of taking a seat and standing up. Based on the review results physiotherapists involved in stroke management were recommended to train their patients intensively and in a task- and context specific manner. The favourable effect on ADL is shown, if patients received augmented therapy for at least 16 hours within the first 6 months post stroke. On the basis of these findings, recommendations were made, that permitted guidance of the clinical decision-making process of physiotherapists involved in the care of patients with stroke, presented as the Clinical practice Guideline on Physiotherapy management of patients with Stroke (CPGPS), the first physiotherapy specific stroke guideline worldwide. The CPGPS states 72 recommendations which concern three important aspects of physiotherapy: 1) prediction of functional recovery of ADL, including walking ability and hand/arm use, 2) selection of cost-effective physiotherapy interventions, and 3) selection of relevant outcome measures, of which seven are to be seen as a minimal optional base, to determine impairments and activity limitations. The second aim was to integrate the recommendations of the guideline into daily physiotherapists’ practice. Subsequently, one part of the clinical practice guideline related with using the core set of outcome measures was implemented. The use of outcome measures by professionals can be seen as a useful indicator of guideline adherence. A survey was carried out on Dutch physiotherapists involved in stroke management (N=400; effective response: 43%). On the base of this survey can be concluded that responders demonstrate a positive attitude for the use of outcome measures but still claim to use only three out of the seven recommended instruments. Based on an analysis of barriers and facilitators of implementation, an educational program was performed, the Physiotherapists Educational Program Clinimetrics in Stroke (PEPCiS). In a randomized controlled feasibility study differences were detected between a group of physiotherapists trained by either a tutor with high-experience with outcome measures in stroke versus a group trained by a tutor with low-experience. After PEPCiS, both groups reported the use of outcome measures more often in their patient records, from 3 to 6 for those trained by the expert-tutor and from 3 to 4 for the non-expert trained group. However the between-group differences were not statistically significant (p=0.07).