Stroke rehabilitation: an article review
Posted on January 24, 2014 by Sarah Rodgers
Why did I choose this topic?
During my 8-week clinical rotation in an inpatient rehabilitation setting, I had the opportunity to treat many patients who had functional limitations following a stroke. I was introduced to Bobath’s Neuro-Developmental Treatment, or commonly known as NDT, as a means of therapy to improve function and ultimately, quality of life, in patients with neurological conditions. I chose to dive into current evidence observing the benefits of NDT on this patient population. A very simplified explanation of this technique would be almost like a slow dance – a patient moves through specific motions while a therapist leads by providing hands-on cueing to the corresponding muscles to re-teach them to contract. While treating these patients who were unable to do some of things I take for granted, I was able to see their balance, strength, and function improve during their inpatient stay. And who doesn’t love having a hand in making someone’s life a little easier?
What was the study?
After a marathon search, I found an article comparing the effectiveness of NDT and structured task practice versus task practice alone in improving walking ability in patients 8-20 weeks post-stroke. All participants were able to walk a short distance indoor with supervision. The 26 subjects in the study were randomly assigned to the two intervention groups and participated in 6 sessions of 1 hour treatments. Group A (NDT/task practice) completed specific exercises targeting posture and hip/knee/ankle/core stability, with hands-on input and one session of task practice as follows. Group B (task practice only) performed walking activities focused on an environment similar to walking outdoors (slopes, rough ground, single step) with no hands-on assistance. Specific details about each intervention can be found in the article.
What was measured and what did they find?
Walking ability was assessed using an adapted six-minute walk test, which utilized walking up a ramp, up and down a step, and on unstable foam surfaces (much like every day encounters when walking). Walking speed, which is a measure of ability to walk in a community-setting, and balance were also assessed. Although significant differences were seen in the NDT/task practice group with walking speed only, both groups showed significant improvements in each outcome measure immediately after the interventions.
What were the limitations of this study?
The evidence supporting the use of NDT can be described as murky water. This study had limitations of its own that did not help clear those waters. The lack of detail regarding the parameters of the interventions provided makes this study unreproducible. While group A received hands-on assistance throughout the intervention, group B received only verbal guidance and cueing, so perhaps there is magic in the human touch. Also, according to the demographics table, the unbalanced difference between groups concerning side of weakness may have skewed the results. In group A, the majority of patients experienced left-sided weakness, which corresponds to a right-sided stroke, while the majority of group B consisted of subjects with right-sided weakness as a result of a left-sided stroke. To explain the huge importance this could play in terms of providing the intervention, we’ll turn to a very quick anatomy lesson: the left side of the brain houses the center for producing and understanding language. Therefore, the group whose majority experienced a left-sided stroke and performed only task practice may have been unable to fully understand instructions and guidance provided by the testers.
According to the CDC, stroke is the leading cause of long term disability in the United States. More than 795,000 Americans have a stroke every year and one American dies from stroke about every 4 minutes. That means by the time you log onto your computer and read this post, almost 4 minutes will be up. Stroke can be such a debilitating condition, so being able to give even an ounce of function back can make all the difference in the world. Even though this study had many limitations and did not find that NDT was a superior treatment for patients with stroke, the results have a silver lining – techniques from these interventions can be used from a physical therapist’s tool box to promote a better quality of life in this population.
Brock K, Haase G, et al. Does physiotherapy based on the Bobath concept, in conjunction with a task practice, achieve greater improvement in walking ability in people with stroke compared to physiotherapy focused on structured task practice alone? A pilot randomized controlled trial. Clin Rehabil. 2011 July 25; 25(10):903-912.
Stroke Facts [Internet]. Atlanta, GA: Centers for Disease Control; 2013 [updated 10 Dec 2013; cited 20 Jan 2014]. Available from: http://www.cdc.gov/stroke/facts.htm