The Physiotherapy eSkills Training Online resource improves performance of practical skills: A controlled trial

Background: E-learning is a common and popular mode of educational delivery, but little is known about its effectiveness in teaching practical skills. The aim of this study was to determine whether the Physiotherapy eSkills Training Online resource in addition to usual teaching improved the performance of practical skills in physiotherapy students. Method: This study was a non-randomised controlled trial. The participants were graduate entry physiotherapy students enrolled in consecutive semesters of a neurological physiotherapy unit of study. The experimental group received the Physiotherapy eSkills Training Online resource as well as usual teaching. The Physiotherapy eSkills Training Online resource is an online resource incorporating (i) video-clips of patient-therapist simulations; (ii) supportive text describing the aim, rationale, equipment, key points, common errors and methods of progression; and (iii) a downloadable PDF document incorporating the online text information and a still image of the video-clip for each practical skill. The control group received usual teaching only. The primary outcomes were the overall performance of practical skills as well as their individual components, measured using a practical examination. Results: The implementation of the Physiotherapy eSkills Training Online resource resulted in an increase of 1.6 out of 25 (95% CI -0.1 to 3.3) in the experimental group compared with the control group. In addition, the experimental group scored 0.5 points out of 4 (95% CI 0 to 1.1) higher than the control group for 'effectiveness of the practical skill' and 0.6 points out of 4 (95% CI 0.1 to 1.1) higher for 'rationale for the practical skill'. Conclusion: There was improvement in performance of practical skills in students who had access to the Physiotherapy eSkills Training Online resource in addition to usual teaching. Students considered the resource to be very useful for learning.7 page(s

Feedback in Rehabilitation Following Stroke

Stroke is a major cause of disability worldwide. Following stroke, patients need to re-learn the ability to perform activities such as sitting, standing up, standing, walking, and reaching and grasping objects, since independence in these activities has significant influence on quality of life and the ability to participate in activities of daily living. Information feedback, that is, specific content about successful or unsuccessful components of the attempt in order to enhance the next attempt, received during or after practice, is important for effective re-learning of activities following stroke. The studies included in this thesis aimed to investigate the nature of feedback provided to patients in stroke rehabilitation; and increase evidence of the effect of information feedback from equipment (biofeedback) to improve performance and learning of activities in people following stroke. Study 1 was an observational study of people in stroke rehabilitation that investigated usual therapist feedback during practice of activities. This study found that therapists provided motivational statements more often than information feedback. Presence of the therapist during practice of activities positively influenced the feedback received by patients. However, when the therapist left the patients to practice alone, the therapist’s verbal feedback was not replaced by another source of information feedback. Equipment as a source of information feedback, whether the therapist was present or the patient practicing alone, was used rarely. Study 2 was a systematic review and meta-analysis that investigated the effectiveness of biofeedback in improving activities of the lower limb in people following stroke. Biofeedback had a moderate effect (10 high quality trials, 241 participants; SMD = 0.49, 95% CI 0.22 to 0.75) in the short term compared with usual therapy/placebo. Furthermore, the benefits were still present beyond intervention, although slightly diminished (5 high quality trials, 138 participants; SMD = 0.41, 95% CI 0.06 to 0.75), suggesting learning had occurred. Importantly, this beneficial effect of biofeedback was present even when the amount of practice of the activity was equivalent between the two groups, with the only difference being the substitution of biofeedback for therapist feedback in the experimental group, with an analysis of those trials showing a similar effect (8 trials, 170 participants; SMD 0.51, 95% CI 0.20 to 0.83). This suggested that the mode of feedback is important, and that biofeedback is superior to therapist feedback. Study 3 investigated the feasibility and potential effectiveness of biofeedback from customised equipment during training of standing up in stroke rehabilitation. The intervention was feasible and safe, progressions implemented effectively, compliance excellent, and the participants’ rating of satisfaction was high. The results suggested that the intervention had the potential to improve the ability to stand up in people following stroke, as participants were able to stand up more effectively, i.e. with increased quality and speed. Importantly, these improvements carried over into their activities of daily living, suggesting learning had occurred. Biofeedback appears to be a good source of information feedback, and is more effective in improving activities than usual therapist feedback. This is likely explained by the observation that therapists are more motivational than informative. Biofeedback should be used more often in clinical practice as it is currently used rarely

Effect of information feedback on training standing up following stroke:a pilot feasibilty study

Background and objective: The ability to stand up is reduced following stroke. Traditional biofeedback is effective in improving the performance of lower limb activities. The aim of this study was to investigate the feasibility of and potential for information feedback from a simple inexpensive device to improve the ability to stand up from a chair in people following stroke. Methods: A single-group study with pre–post measures design was used. Twenty people with hemiplegic stroke in inpatient rehabilitation received 10 sessions over 2 weeks of information feedback about foot placement during training of standing up. Progression involved increasing repetitions, increasing difficulty and fading feedback. Feasibility was determined by adherence, time taken, acceptability and safety. Clinical outcomes were the time taken to stand up, quality and foot position measured using the 5-Times-Sit-To-Stand-Test and carryover into daily activities measured by covert observation. Results: The study was feasible with 97% of sessions completed, taking 19 (SD 6) to 25 (SD 10) minutes. Participants understood (4.6/5), found useful (4.6/5), challenging (4.4/5) and would recommend (4.7/5) the training. The time to stand up 5 times decreased by 24 (95% CI -48 to -1) s, and the quality of standing improved by 1.0/10.0 (95% CI 0.2 to 1.8). Carryover of the correct foot placement occurred to real life, with the beginning foot position correct 2.1/3.0 (95% CI 1.6 to 2.6) and end foot position correct 1.8/3.0 (95% CI 1.2 to 2.4) occasions. Conclusions: The training is feasible and has the potential to improve the ability to stand up.7 page(s

Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke:A systematic review

AbstractQuestion: Is biofeedback during the practice of lower limb activities after stroke more effective than usual therapy in improving those activities, and are any benefits maintained beyond the intervention? Design: Systematic review with meta-analysis of randomised trials with a PEDro score > 4. Participants: People who have had a stroke. Intervention: Biofeedback (any type delivered by any signal or sense) delivered concurrently during practice of sitting, standing up, standing or walking compared with the same amount of practice without biofeedback. Outcome measures: Measures of activity congruent with the activity trained. Results: Eighteen trials including 429 participants met the inclusion criteria. The quality of the included trials was moderately high, with a mean PEDro score of 6.2 out of 10. The pooled effect size was calculated as a standardised mean difference (SMD) because different outcome measures were used. Biofeedback improved performance of activities more than usual therapy (SMD 0.50, 95% CI 0.30 to 0.70). Conclusion: Biofeedback is more effective than usual therapy in improving performance of activities. Further research is required to determine the long-term effect on learning. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised widely in clinical practice. [Stanton R, Ada L, Dean CM, Preston E (2016) Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review. Journal of Physiotherapy 63: 11–16

Biofeedback improves activities of the lower limb after stroke: a systematic review.

Question: Is biofeedback during the practice of lower limb activities after stroke effective in improving performance of those activities, and are any benefits maintained after intervention ceases? Design: Systematic review with meta-analysis of randomised trials. Participants: People who have had a stroke. Intervention: Biofeedback during practice of sitting, standing up, standing, or walking. Outcome measures: Continuous measures of activity congruent with the activity trained. Results: 22 trials met the inclusion criteria and 19 contained data suitable for analysis. Effect sizes were calculated as standardised mean differences because different outcome measures were used. Since inclusion of all trials produced substantial statistical heterogeneity, only trials with a PEDro score >4 (11 trials) were included in the final analysis (mean PEDro score 5.7). In the short-term, biofeedback improved lower limb activities compared with usual therapy/placebo 1 to 5 months after the cessation of intervention (SMD = 0.41, 95% CI 0.06 to 0.75). Conclusion: Augmenting feedback through the use of biofeedback is superior to usual therapy/placebo at improving lower limb activities in people following stroke. Furthermore, these benefits are largely maintained in the longer term. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised more widely in clinical practice.11 page(s

Feedback received while practicing everyday activities during rehabilitation after stroke : an observational study

Background and Purpose: The provision of feedback is important for effective skill learning. The purpose of this study was to examine the nature of feedback provided during the practice of everyday activities (such as standing up, walking, and reaching and grasping objects) during stroke rehabilitation, both when the therapist was present and when the patient was practicing alone. Method: Design: A cross-sectional observational study of the feedback received during rehabilitation by people who had had a stroke was conducted. Forty unique patient-therapist dyads were observed during 30minutes of actual practice of everyday activities with data collected through behavioural mapping. The following was recorded: the activity practiced, whether the therapist was present, whether feedback was provided verbally or by equipment, and the content of feedback. Participants: A sample of all therapists providing rehabilitation within one Australian health service and their patients who had had a stroke. Measures: Quantity, frequency, mode (verbal or equipment) and content (information feedback, motivational statements, unrelated or none) of feedback during the practice of everyday activities were determined. Results: For 68% of the time that patients were practicing activities, they received ≥1 occasion of feedback/minute. When the therapist was present, the frequency of motivational statements was more than four times greater, at 1.32 (SD 0.6) occasions/minute, than information feedback. For 25% of the time, the therapist was not present, and no feedback was provided. Conclusion: Given the importance of specific content for learning, therapists could replace some motivational statements with information feedback. When practicing alone, information feedback could be provided by commercially available biofeedback or customized equipment.8 page(s

What is the probability of patients who are nonambulatory after stroke regaining independent walking? A systematic review

Patients after stroke who are nonambulatory require resources, and independent walking becomes a major determinant of the ability to participate in activities of daily living. Our objective was to determine the probability of walking for patients who are nonambulatory in the first month after stroke. We performed a systematic review and meta-analysis of consecutive, prospective studies of nonambulatory patients within the first month after stroke in rehabilitation and acute units. The outcomes were the probability of achieving independent walking at three-, six- and 12 months after stroke. Twenty-six studies were included in the review. Seventeen studies comprising 2856 participants were entered into meta-analyses. For initially nonambulatory stroke patients managed in a rehabilitation unit, the probability of independent walking was 0·60 (95% CI 0·47-0·74, 1373 participants) at three-months, 0·65 (95% CI 0·53-0·77, 444 participants) at six-months and 0·91 (95% CI 0·81-1·00, 24 participants) at 12 months. For patients managed in an acute unit, the probability of independent walking was 0·39 (95% CI 0·27-0·52, 634 participants) at three-months, 0·69 (95% CI 0·46-0·92, 405 participants) at six-months and 0·74 (95% CI 0·59-0·88, 34 participants) at 12 months. 60% of patients managed in a rehabilitation unit who are nonambulatory in the first month after stroke will regain independent walking compared with 39% of those managed in an acute unit. This information can be used clinically to make decisions about allocation of rehabilitation resources, education of patients and carers, and for discharge planning.10 page(s

The <it>Physiotherapy eSkills Training Online</it> resource improves performance of practical skills: a controlled trial

Abstract Background E-learning is a common and popular mode of educational delivery, but little is known about its effectiveness in teaching practical skills. The aim of this study was to determine whether the Physiotherapy eSkills Training Online resource in addition to usual teaching improved the performance of practical skills in physiotherapy students. Method This study was a non-randomised controlled trial. The participants were graduate entry physiotherapy students enrolled in consecutive semesters of a neurological physiotherapy unit of study. The experimental group received the Physiotherapy eSkills Training Online resource as well as usual teaching. The Physiotherapy eSkills Training Online resource is an online resource incorporating (i) video-clips of patient-therapist simulations; (ii) supportive text describing the aim, rationale, equipment, key points, common errors and methods of progression; and (iii) a downloadable PDF document incorporating the online text information and a still image of the video-clip for each practical skill. The control group received usual teaching only. The primary outcomes were the overall performance of practical skills as well as their individual components, measured using a practical examination. Results The implementation of the Physiotherapy eSkills Training Online resource resulted in an increase of 1.6 out of 25 (95% CI −0.1 to 3.3) in the experimental group compared with the control group. In addition, the experimental group scored 0.5 points out of 4 (95% CI 0 to 1.1) higher than the control group for ‘effectiveness of the practical skill’ and 0.6 points out of 4 (95% CI 0.1 to 1.1) higher for ‘rationale for the practical skill’. Conclusion There was improvement in performance of practical skills in students who had access to the Physiotherapy eSkills Training Online resource in addition to usual teaching. Students considered the resource to be very useful for learning.</p