Effect of innovative vs. usual care physical therapy in subacute rehabilitation after stroke. A multicenter randomized controlled trial

Background: Research on stroke rehabilitation often addresses common difficulties such as gait, balance or physical activity separately, a fragmentation contrasting the complexity in clinical practice. Interventions aiming for recovery are needed. The purpose of this study was to investigate effects of a comprehensive low-cost physical therapy intervention, ICoreDIST, vs. usual care on postural control, balance, physical activity, gait and health related quality of life during the first 12 weeks post-stroke. Methods: This prospective, assessor-masked randomized controlled trial included 60 participants from two stroke units in Norway. Participants, who were randomized to I-CoreDIST (n = 29) or usual care physical therapy (n = 31), received 5 sessions/week when in-patients or 3 sessions/week as out-patients. Primary outcomes were the Trunk Impairment Scale-modified Norwegian version (TISmodNV) and activity monitoring (ActiGraphsWgt3X-BT). Secondary outcomes were the Postural Assessment Scale for Stroke, MiniBesTEST, 10- meter walk test, 2-minute walk test, force-platform measurements and EQ5D3L. Stroke specific quality of life scale was administered at 12 weeks. Linear regression and non-parametric tests were used for statistical analysis. Results: Five participants were excluded and seven lost to follow-up, leaving 48 participants in the intention-to-treat analysis. There were no significant between-group effects for primary outcomes: TIS-modNV (p = 0,857); daily average minutes of sedative (p = 0.662), light (p = 0.544) or moderate activity (p = 0.239) and steps (p = 0.288), or secondary outcomes at 12 weeks except for significant improvements on EQ5D-3L in the usual care group. Withingroup changes were significant for all outcomes in both groups except for activity levels that were low, EQ5D-3L favoring the usual care group, and forceplatform data favoring the intervention group. Conclusions: Physical therapy treatment with I-CoreDIST improved postural control, balance, physical activity and gait during the first 12 weeks after a stroke but is not superior to usual care

Embodiment, tailoring, and trust are important for co-construction of meaning in physiotherapy after stroke: A qualitative study.

Background and Purpose: Physiotherapy, with an emphasis on high intensity, individually tailored, and person-centered treatment, is an effective route for recovery after a stroke. No single approach, however, has been deemed paramount, and there is limited knowledge about the patient experience of assessment, goal-setting, and treatment in physiotherapy. In this study, we seek to report patient experiences of I-CoreDIST-a new physiotherapy intervention that targets recovery-and those of usual care. The purpose is to investigate how individuals with stroke experience the bodily and interactive course of physiotherapy during their recovery process. Methods: A qualitative study, nested within a randomized controlled trial, consisting of in-depth interviews with 19 stroke survivors who received either I-CoreDIST or usual care. Data were analyzed using systematic text condensation, and this analysis was informed by enactive theory. Results: Interaction with the physiotherapist, which was guided by perceived bodily changes, fluctuated between being, on the one hand, formal/explicit and, on the other, tacit/implicit. The experiences of participants in the intervention group and the usual care group differed predominantly with regards to the content of therapy sessions and the means of measuring progress; divergences in levels of satisfaction with the treatment were less pronounced. The perception of positive bodily changes, as well as the tailoring of difficulty and intensity, were common and essential features in generating meaning and motivation. An embodied approach seemed to facilitate sense-making in therapy situations. In the interaction between the participants and their physiotherapists, trust and engagement were important but also multifaceted, involving both interpersonal skills and professional expertise. Conclusion: The embodied nature of physiotherapy practice is a source for sense-making and meaning-construction for patients after a stroke. Trust in the physiotherapist, along with emotional support, is considered essential. Experiencing progress and individualizing approaches are decisive motivators.The study was funded by the Northern Norway Regional Health Authority

The precarity of patient participation - a qualitative interview study of experiences from the acute stroke and rehabilitation journey

Introduction: Active patient participation is an important factor in optimizing post-stroke recovery, yet it is often low, regardless of stroke severity. The reasons behind this trend are unclear. Purpose: To explore how people who have suffered a stroke, perceive the transition from independence to dependence and whether their role in post-stroke rehabilitation influences active participation Methods: In-depth interviews with 17 people who have had a stroke. Data were analyzed using systematic text condensation informed by the concept of autonomy from enactive theory. Results: Two categories emerged. The first captures how the stroke and the resultant hospital admission produces a shift from being an autonomous subject to “an object on an assembly line.” Protocol-based investigations, inactivity, and a lack of patient involvement predominantly determine the hospital context. The second category illuminates how people who have survived a stroke passively adapt to the hospital system, a behavior that stands in contrast to the participatory enablement facilitated by community. Patients feel more prepared for the transition home after inpatient rehabilitation rather than following direct discharge from hospital. Conclusion: Bodily changes, the traditional patient role, and the hospital context collectively exacerbate a reduction of individual autonomy. Thus, an interactive partnership between people who survived a stroke and multidisciplinary professionals may strengthen autonomy and promote participation after a stroke

Utprøving av intervensjon for optimalisering av funksjon, fysisk aktivitet og arbeidsdeltakelse ved multippel sklerose

publishedVersio

The effect of exercise and physical activity-interventions on step count and intensity level in individuals with multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials

BackgroundReduced physical activity is a worldwide challenge in individuals with multiple sclerosis (MS). The aim of this systematic review and meta-analysis was to identify devise-measured effects of physical activity, exercise and physiotherapy-interventions on step count and intensity level of physical activity in individuals with MS.MethodsA systematic search of the databases of PubMed (including Medline), Scopus, CINHAL and Web of Science was carried out to retrieve studies published in the English language from the inception to the first of May 2023. All trials concerning the effectiveness of different types of exercise on step count and intensity level in people with MS were included. The quality of the included studies and their risk of bias were critically appraised using The modified consolidated standards of reporting trials and the Cochrane Risk of Bias tool, respectively. The pooled standardized mean difference (SMD) and 95% CI of the step-count outcome and moderate to vigorous intensity level before versus after treatment were estimated in both Intervention and Control groups using the random effect model. The Harbord test were used to account for heterogeneity between studies and assess publication bias, respectively. Further sensitivity analysis helped with the verification of the reliability and stability of our review results.ResultsA total of 8 randomized clinical trials (involving 919 individuals with MS) were included. The participants (including 715 (77.8%) female and 204 (22.2%) male) had been randomly assigned to the Intervention (n = 493) or Control group (n = 426). The pooled mean (95% CI) age and BMI of participants were 49.4 years (95% CI: 47.4, 51.4 years) and 27.7 kg/m2 (95% CI: 26.4, 29 kg/m2), respectively. In terms of the comparison within the Intervention and the Control groups before and after the intervention, the results of the meta-analysis indicate that the pooled standardized mean difference (SMD) for step-count in the Intervention group was 0.56 (95% CI: -0.42, 1.54), while in the Control group it was 0.12 (95% CI: -0.05, 0.28). Furthermore, there was no significant difference in the pooled SMD of step-count in the physical activity Intervention group compared to the Controls after the intervention (pooled standard mean difference = 0.19, 95% CI: -0.36,0.74). Subgroup analysis on moderate to vigorous intensity level of physical activity revealed no significant effect of the physical activity intervention in the Intervention group compared to the Control group after the intervention, or within groups before and after the intervention. Results of meta regression showed that age, BMI, duration of disease and Expanded Disability Status Scale (EDSS) score were not the potential sources of heterogeneity (all p > 0.05). Data on the potential harms of the interventions were limited.ConclusionThe results of this meta-analysis showed no significant differences in step count and moderate to vigorous physical activity level among individuals with MS, both within and between groups receiving physical activity interventions. More studies that objectively measure physical activity are needed.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD4202234362

Påvirker individualisert fysioterapibehandling, kombinert med gangtrening på tredemølle med vektavlastning, gange hos pasienter med MS?

Hensikt: Hensikten med studien var å undersøke om individualisert fysioterapibehandling, kombinert med gangtrening på tredemølle med vektavlastning kan påvirke gange hos pasienter med MS. Metode: To pasienter med sekundær progressiv MS deltok i studien. Single Subject Experimental Design, med A-B-A-A faser ble benyttet. Pasientene ble testet 15 ganger; før, under og etter studiens intervensjon med Timed Up & Go (TUG), 10 meter gangtest, 2 minutter gangtest, Rivermead Visual Gait Assessment (RVGA), VAS-skala (selvopplevd gangproblem) og Rivermead Mobility Index (RMI). Pasientene fikk behandling 4 ganger i uken, i tre uker. Intervensjonen besto av 30 minutter individualisert fysioterapibehandling og 30 minutter gangtrening på tredemølle med vektavlastning. Resultater: Pasient A utførte TUG signifikant hurtigere i intervensjonsfasen og i oppfølgingsfase 1, og tenderte til hurtigere utførelse i oppfølgingsfase 2. Han gikk signifikant hurtigere på 10 meter gangtest i oppfølgingsfase 1 og tenderte å gå hurtigere i intervensjonsfasen. Pasient A gikk med større grad av abnormal gange kvalitetsmessig (RVGA) i alle faser etter baseline. Pasient B utførte TUG signifikant raskere i oppfølgingsfase 2 og gikk signifikant lengre på 2 minutter gangtest i oppfølgingsfase 1. Konklusjon: Resultatene indikerer at intervensjonen kan ha påvirket pasient A til å gå hurtigere, men kan også ha påvirket han til å gå med større grad av abnormal gange kvalitetsmessig. Intervensjonen kan ha påvirket pasient B til å gå lengre gangdistanse på kort sikt. For å evaluere effekt av denne typen fysioterapibehandling til pasienter med MS og gangproblemer, behøves imidlertid større studier og randomiserte kontrollerte forsøk. Nøkkelord: Multippel sklerose, gangproblemer, individualisert fysioterapibehandling, gangtrening, tredemølle, vektavlastning

Feasibility of a new intervention addressing group-based balance and high-intensity training, physical activity, and employment in individuals with multiple sclerosis: a pilot randomized controlled trial

Background and purpose: Impaired sensorimotor function, reduced physical activity and unemployment are common challenges in persons with multiple sclerosis (pwMS), even when disability is low. CoreDISTparticipation is a new, multidisciplinary intervention delivered across healthcare levels systematically addressing these elements. This study primarily aimed to evaluate the feasibility of CoreDISTparticipation in terms of process, resources, management, and scientific outcomes. The secondary aim was to evaluate initial efficacy in terms of possible short-term effects compared with the usual care on barriers to employment, balance, walking, health-related quality of life (HRQoL), and physical activity. Methods: This assessor-blinded prospective pilot randomized controlled trial included 29 pwMS [Expanded Disability Status Scale (EDSS): 0–3.5] randomly allocated to the intervention group (CoreDISTparticipation) (n = 15) or usual care (n = 14). CoreDISTparticipation consists of three phases: (1) hospital outpatient clinic: MS nurse work-focused session and physiotherapist exploring balance; (2) municipality: a digital meeting with pwMS, employer, MS nurse, and physiotherapist addressing employment and physical activity, 4 weeks indoor CoreDIST balance training (60 min × 2/week); and (3) 4 weeks outdoor CoreDIST balance training and high-intensity running/walking (60 min × 2/week). Assessments were undertaken at baseline and at weeks 6 and 11. Primary feasibility metric outcomes were the reporting of process, resources, management, and scientific outcomes. Efficacy measures included evaluation of the Multiple Sclerosis Work Difficulties Questionnaire-23 Norwegian Version (MSWDQ-23NV) and 6 Minute Walk-test as well as the Trunk Impairment Scalemodified Norwegian Version, Mini-Balance Evaluation Systems Test (MiniBESTest), Multiple Sclerosis Walking Scale-12, Multiple Sclerosis Impact Scale-29 Norwegian Version (MSIS-29NV), ActiGraph wGT3x-BT monitors, and AccuGait Optimized force platform. The statistical analyses included repeated-measures mixed models performed in IBM SPSS Version 29. Results: The primary feasibility metric outcomes demonstrated the need for minor adjustments in regard to the content of the intervention and increasing the number of staff. In regard to the efficacy measures, one person attended no postintervention assessments and was excluded, leaving 28 participants (mean EDSS: 1.8, SD: 1). The mean percentage employment was 46.3 (SD: 35.6) and 65.4 (SD: 39.3) in the CoreDISTparticipation and usual care group, respectively. No between-group differences were found. MSWDQ-23NV demonstrated a within-group difference of 5.7 points from baseline to Week 11 (P = 0.004; confidence interval: 2.2–9.3). MiniBESTest and MSIS-29NV demonstrated within-group differences. The study is registered in ClinicalTrials.gov (Identifier: NCT05057338). Discussion: The CoreDISTparticipation intervention is feasible to support pwMS when the identified feasibility metric outcomes in regard to process, resource, management, and scientific outcome metrics are adjusted to improve feasibility. Regarding efficacy measures, no between-group differences were detected; however, within-group differences in barriers to employment, balance, and HRQoL were detected for the CoreDISTparticipation group. A larger comparative trial is needed to explore between-group differences and should accurately and precisely define usual care and address the identified limitations of this study

Group-based, individualized exercises can provide perceived bodily changes and strengthen aspects of self in individuals with MS: a qualitative interview study

Background: Group-based physiotherapy is effective for individuals with MS; nevertheless individualization within groups is questioned and little is known regarding individuals´ experiences with individualization in small groups. Objective: We aimed to explore the short- and long-term experiences of individuals with MS participating in a 6-week, group-based, individualized physiotherapy-intervention. Methods: Within a randomized controlled trial (RCT), 25 in-depth interviews with a strategic sample of 13 people (9 women; age 25–79 years old; European Disability Status Scale (EDSS) 1–6.5) were conducted at weeks 7 and 30 using systematic text condensation, with dynamic systems theory and phenomenology as analytical frameworks. Results: The main categories were: 1) movement control, orientation and insights: Bodily improvements were associated with targeted exercises, specific adjustments by the physiotherapist, emotional engagement and re-access to activities; and 2) the individual within the group: Equal distributions of one-to-one interactions and attention were important for experiencing success. Less attention and improvements turned attention toward own disability. Physical changes felt particularly emotional short term, implying that individuals’ feelings of ownership and control of body and movement, new views of themselves and changed affordances in daily life were involved. Conclusion: Equally distributed attention and engagement, targeted exercises and hands-on adjustments resulting in visible and perceived bodily changes were experienced as key factors of individualization in small groups

Group-based, individualized exercises can provide perceived bodily changes and strengthen aspects of self in individuals with MS: a qualitative interview study

Background: Group-based physiotherapy is effective for individuals with MS; nevertheless individualization within groups is questioned and little is known regarding individuals´ experiences with individualization in small groups. Objective: We aimed to explore the short- and long-term experiences of individuals with MS participating in a 6-week, group-based, individualized physiotherapy-intervention. Methods: Within a randomized controlled trial (RCT), 25 in-depth interviews with a strategic sample of 13 people (9 women; age 25–79 years old; European Disability Status Scale (EDSS) 1–6.5) were conducted at weeks 7 and 30 using systematic text condensation, with dynamic systems theory and phenomenology as analytical frameworks. Results: The main categories were: 1) movement control, orientation and insights: Bodily improvements were associated with targeted exercises, specific adjustments by the physiotherapist, emotional engagement and re-access to activities; and 2) the individual within the group: Equal distributions of one-to-one interactions and attention were important for experiencing success. Less attention and improvements turned attention toward own disability. Physical changes felt particularly emotional short term, implying that individuals’ feelings of ownership and control of body and movement, new views of themselves and changed affordances in daily life were involved. Conclusion: Equally distributed attention and engagement, targeted exercises and hands-on adjustments resulting in visible and perceived bodily changes were experienced as key factors of individualization in small groups