Stroke Rehabilitation

Three Exercise Therapy Approaches
RUTH DICKSTEIN, SHRAGA HOCHERMAN, THOMAS PILLAR, and RACHEL SHAHAM The purpose of this study was to compare the therapeutic efficacy of three exercise therapy approaches. Three groups of adult stroke patients (N = 131) participated in the study. The first group received conventional treatment that consisted of traditional exercises and functional activities. The treatment of the second group was based on proprioceptive neuromuscular facilitation techniques. The third group was treated using the Bobath approach. The improvement of each patient was evaluated after six weeks of treatment in terms of 1) functional gains in activities of daily living as measured using the Barthel index, 2) changes in the muscle tone of the involved limbs as measured using a fivepoint ordinal scale, 3) changes in the isolated motor control of the ankle and wrist as measured by tests of muscle strength and range of motion, and 4) changes in the patients' ambulatory status as measured using a nominal scale of four categories. The therapeutic effects of exercise according to each of the three approaches were compared using descriptive and nonparametric statistical methods. No substantial advantage could be attributed to any one of the three therapeutic approaches. Key Words: Activities of daily living, Cerebrovascular disorders, Exercise therapy, Physical therapy.

Several methods of exercise therapy for the rehabilitation of stroke patients are in common use today. A generally accepted classification of these methods differentiates between the conventional versus the neurophysiological treatment approaches, the latter claiming a basis in neurophysiological principles. Even treatment methods that purportedly are based on neurophysiological principles, however, do not have a fully comprehensive and experimentally proven neurophysiological basis.1-3 Furthermore,

Dr. Dickstein was Supervisor, Physical Therapy Department, Flieman's Hospital, PO Box 2263, Haifa 31021, Israel, when this study was conducted. She is currently Director, School of Physiotherapy, Wingate, Institute, Department of Physical Therapy, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel. Dr. Hocherman is Senior Lecturer, Department of Physiology and Biophysics, Faculty of Medicine, Technion-Israel Institute of Technology, PO Box 9649, Haifa 31096, Israel. Dr. Pillar is Director, Flieman's Hospital, PO Box 2263, Haifa 31021, Israel. Ms. Shaham is a registered physical therapist, Flieman's Hospital, PO Box 2263, Haifa 31021, Israel. This study was supported by a grant from the Chief Scientist's Office, Israel Ministry of Health. This article was submitted December 12, 1984; was with the authors for revision 28 weeks; and was accepted December 5, 1985.

some stroke rehabilitation methods used by physical therapists have been criticized for their lack of evidence demonstrating a specific therapeutic benefit.4,5 The conventional approach to the treatment of stroke patients involves training such patients to use their remaining motor capabilities to compensate for those that were lost.6,7 Neurophysiological approaches, however, focus on rejuvenation of the lost motor capacities.8-10 In that sense, Knott and Voss referred to "hidden potentials" for recovery,9 and Bobath referred to "some untapped potential for more highly organized activity."10 This theoretical difference between the conventional and the neurophysiological approaches translates into a difference in the amount of time and effort devoted to treatment. Treatment sessions in which neurophysiological methods are used require closer physical therapistpatient contact than those in which conventional methods are used. Patients who are treated with neurophysiological methods usually are treated over longer periods of time than patients who are treated with conventional methods because a higher level of improvement is expected, and it is a slow, step-by-step

process. The developers of both the proprioceptive neuromuscular facilitation (PNF) and Bobath methods claim their methods have greater therapeutic effects than the conventional approach. Because Bobath rejected some of the main principles on which the PNF method is based,10 however, more than one alternative to the conventional treatment approach may exist. The need to compare the effectiveness of the main neurophysiological treatment procedures with each other and with the conventional approach has been emphasized frequently,1,11 but only two such comprehensive studies have been reported.12,13 Stern and his associates found comparable improvement in two groups of hemiplegic patients, one treated with conventional exercises and the other with techniques based on the PNF and Brunnstrom approaches.12 Logigian et al compared the effectiveness of the conventional techniques with that of facilitation techniques adapted from the methods of Rood and Bobath and also found that the different approaches yielded comparable results.13 Despite the substantial differences between these two studies, the inclusion of an index of activities of daily living (ADL) as a cri1233

Volume 66 / Number 8, August 1986

and the last five with the Bobath method. Functional independence was determined with the Barthel index (BI)16 (Tab. Each patient was assigned to one of the 13 physical therapists who participated in this study. and each therapist was required to be familiar with the professional textbooks used as guidelines for the correct application of the neurophysiological methods. but also to compare the improvement of the PNF-based treatment group with that of the Bobath-based treatment group. hemianopia. the next five with the PNF method. d) high.5 other week. Weekly meetings during the study period provided the physical therapists with further opportunities for discussion of problematic issues.0 36 30 54. This second measurement was obtained from patients in the supine position with the limb placed straight on the tabletop and with the measured joint at the table's edge. An outline of the most prominent features of each treatment procedure is provided in the Appendix. the exact range was measured with a goniometer) and b) strength of the ankle and wrist dorsiflexor muscles was measured twice in a pattern-free isolated movement. c) normal. PNF. Muscle tone of the involved extremities was checked by passive movements of the extremities while the patient was in the supine position. Physical Therapists and Therapeutic Approaches Mastery of the theory and practice of the three treatment methods was required of the physical therapists partic1234 TABLE 1 Subject Characteristics Variable Side of hemiplegia Right Left Bilateral Sensory deficiencies Present Absent Aphasia in right hemiplegics Present Absent Unilateral neglect in left hemiplegics with sensory deficits Present Absent Territory of cerebrovascular accident Internal carotid artery Posterior cerebral or vertebrobasilar artery N 66 62 3 89 42 % 50. Treatment with any of the three methods involved regular patient assessments. The distribution of patient characteristics. These updated variables related to two groups of functions: 1) sensory functions of touch.17. pressure. All of the therapists were experienced in applying these methods. which was examined by the tests of Oxbury et al.0 107 89.terion variable was common to both. The inclusion of this variable in both studies is not surprising.firstby manual muscle testing and second by the patient pulling a gauged spring. We used this index because of its simplicity. b) low. PHYSICAL THERAPY . the patients were not asked for their informed consent. based on combinations of variables adapted from those reported by Gordon et al. This assignment depended on the administrative procedures of the hospital and. The purpose of our study was to compare the effectiveness of the conventional. because gaining functional independence generally is acknowledged as the major goal of physical rehabilitation.0 30. The mean age was 70.5 2. therefore.14 is shown in Table 1.65 years). and each treatment session lasted 30 to 45 minutes. sex. METHOD Subjects One hundred and ninety-six consecutive hemiplegic patients who were referred to the physical therapy department of a geriatric-rehabilitation hospital over a period of 18 months were admitted to the study. Because the methods we used are well substantiated in physical therapy practice.0 13 11. An important difference between this study and its predecessors was our intent not only to compare the conventional approach with the neurophysiological approaches. which will be described separately in the following section.5 years (s = 7.19 3. Each physical therapist treated her first five patients with the conventional method. body side affected. during the study period two refresher courses in each of the two neurophysiological approaches were conducted.10 In addition. Sex distribution was equal. It was graded using an ordinal scale composed of five points: a) flaccid. and unilateral neglect. supplemented by other potential treatment-affected variables. Criterion Measurements 28 29 49. and location of the damaged artery. validity. The first part was used to record basic information regarding the patient's medical history. essentially was random. Procedure The data collection form for each patient consisted of two main parts. proprioception.5 45.9. and e) spastic. and reliability. and Bobath approaches by applying separately treatments based on these methods to three groups of patients who were hospitalized in the same institution. Isolated motor control over the involved ankle and wrist joints was determined with the following tests: a) Active range of motion of these joints was measured while the patient was in the supine position and was compared with that of the same joints on the sound side (for patients with limited ROM. 2). and was completed on admission to the program. All patients were treated at least five days a week. ensuring a review of these methods before shifting from one treatment method to another.0 ipating in the study.5 47. Only 131 of the patients completed the six-week treatment program and were included in the data analysis.13 2. The second part was used to record variable data and was updated by the physical therapist every The following criterion variables were measured for each patient on admission to the program and every other week thereafter: 1. Similar scales are used in other clinical settings for comparable purposes.0 51.18 The BI also has been used as a criterion measurement in a comparable study.0 70. stereognosis. such as age. which were an integral part of the approach practiced. All patients had had a recent cerebrovascular accident and came for a rehabilitation program after an average stay of 16 days (the mode was 8 days) in a general hospital.15 and 2) values of the criterion variables. We considered improvement in ADL to be the main criterion measurement. the patient was instructed to pull the spring from extreme plantar flexion or palmar flexion.

) 1235 . In the pilot study. L = low. A chi-square test was applied to a table constructed by these four categories according to the three treatment groups. and the between-group difference of this value also was not significant (KruskalWallis one-way ANOVA).5%) were treated with the conventional approach. if unable to walk. Improvement in Activities of Daily Living The summed scores of the BIs of the three groups compared after six weeks of treatment were not significantly different from each other (chi-square test). and d) patient walks independently. the muscle tone increased by a comparable magnitude in all patients. Data Analysis Descriptive statistics were used to report patient characteristics. also was observed to a lesser extent in the upper extremities. The Kruskal-Wallis one-way analysis of variance (ANOVA) was used to compare average changes among the three groups. To increase the resolution of the analysis. 3) scores of 21 to 60. propelling wheelchair Ascending and descending stairs Dressing Controlling bowel Controlling bladder 5 5. This pattern of muscle tone change. b) patient walks with an assistive device and another person's help. (F = flaccid. The second and third measurements were used as indicators of trends of change.90. Concurrently. c) patient walks with an assistive device. Results of the comparisons of the three groups will be reported separately for each criterion measurement. however. we found that after six weeks of treatment the percentage of patients attaining normal muscle tone in the PNFtreatment group was smaller than in the other two groups. 1. We also did not detect any differential influence of the compared approaches on the patients' improvement in ADL on the basis of a multiple regression analysis. August 1986 36 (27. 1). The treatment effects of the three methods also were compared in subgroups of patients characterized by each of the variables listed in Table 1. Extremity Muscle Tone Comparison of the muscle tone of the lower extremities in the three groups after six weeks of treatment yielded no significant results (chi-square test). S = spastic. Active Range of Motion and Strength of the Ankle and Wrist Dorsiflexor Muscles The results of the chi-square analysis and the Kruskal-Wallis one-way ANOVA for the six-week data of these variables showed no significant difference Fig.10 0 5 0 10 0 5 5 5 5 Independent 10 15 5 10 5 15 5 10 10 10 10 4. We used a multiple regression technique to study the relative contribution of each treatment method to the patients' improvement. Lower extremity muscle tone before (blank) and after (shaded) six weeks of treatment.RESEARCH TABLE 2 Barthel Index-Test Items and Scoring Possible Score Test Item With Help Feeding Moving from wheelchair to bed and return Personal hygiene Getting on and off toilet Bathing self Walking on level surface. In none of these subgroups did wefindany significant advantage to one of the approaches over the others (Kruskal-Wallis one-way ANOVA). The average six-week improvement for all patients was 24. and the uniformity of the evaluations was tested.5 points (s = 17. measurements of the criterion variables were rehearsed. Ambulatory status was assessed for indoor ambulation and classified with a nominal four-category scale: a) patient does not walk.20 RESULTS Fifty-seven patients (43.0). Only the first and fourth measurements were included in the data analysis. which was not statistically significant. and 38 (29%) with the Bobath approach. The chisquare test was used to study associations between the treatments and changes in the criterion measurements. H = high. Volume 66 / Number 8. N = normal. We found no significant between-group difference. The interrater reliability for measurements of all criterion variables was found to be greater than . The variables that constituted the criterion measurements were checked for randomization on admission to the program (by cross-tabulation and chisquare analysis) and were found to be distributed randomly among the three groups. The data were analyzed using the Statistical Package for the Social Sciences. Pilot Study A pilot study involving 20 patients and 8 physical therapists was conducted in preparation for this study. patients in each group were subdivided into four categories according to their BI scores: 1) score of 0. and 4) scores of 61 to 100. 2) scores of 1 to 20. the percentage of patients with high muscle tone in the PNF-treatment group surpassed their proportion in the rest of the patients.5%) with the PNF approach. either on admission to the program or after six weeks of treatment. By observing the nature of that increase (Fig.

9 7. similar to those of others.6% of those with limited ROM in the wrist joint. p = . thisfindingmay have practical implications for the physical rehabilitation of aged hemiplegic patients.003 (n = 130) x 2 = 13. 1) do not support Bobath's claims that her techniques exert a special influence on muscle tone. Because the difference in ambulation between the treatment groups stabilized after six weeks. The difference in walking ability between the left and right hemiplegic patients in the conventional-treatment group may have been because left hemiplegic patients suffer more often from sensory impairment and spatial agnosia than do right hemiplegic patients.22 Despite the immediate beneficial treatment effects of the neurophysiological approaches. the results of our study did not demonstrate that either the PNF or the Bobath approaches are superior to the conventional approach in enhancing the recovery of lost isolated distal movements or improving control over involved limbs.0 60. DISCUSSION cause these joints are the first to become involved and are among the last to recover after a CVA.0 28.03). 2. The large increase in high muscle tone in the PNF-treated patients (Fig. after six weeks of treatment.04 (n = 130) X2 = 7. no change in these variables was recorded at the end of six weeks (Figs. For example. does not explain the high percentage of PNF-treated patients who maintained lower muscle tone when compared with the subjects of the other groups. The side of hemiplegia was not found to be associated significantly with the ambulation of patients in the PNF-treatment and Bobath-treatment groups. however. p = NS a Figures indicate percentages of the row in each category. Because functional and motor improvement are closely related.21 the lack of significant differences in isolated limb functions among the treatment groups after the six-week treatment period may explain the lack of differences in the BI scores.3 2.9 42.between any of the treatment approaches.7 41. df=6.10 This interpretation.5%) cooperated in pulling the gauged spring using their ankle dorsiflexor muscles. Although our findings did not support the superiority of the Bobath approach in improving muscle tone when compared with the other approaches after the six-week treatment PHYSICAL THERAPY The walking ability of the patients in the three treatment groups was not significantly different at the end of the six weeks. Walking Ability versely in the three groups. The between-group differences in ambulatory status after two and four weeks of treatment (Tab.1 39. 1) may be related to the use of facilitation techniques.8% of the right hemiplegic patients.8 28.7 2. 55. only 91 patients (69.2 20.2 0.4 10. In the conventional-treatment group. 1236 .003 and p < . Because these measurements required some cooperation from the patients.0 31. The six-week improvement in the strength of the dorsiflexor muscles and the active ROM of these distal joints was minimal for all patients. df= 2.3 6.0 5. df = 6.2% of the left hemiplegic patients walked with an assistive device compared with 30. we believe that the two-week and fourweek differences were temporary and that none of the approaches contributed more than the others to ambulation. and six weeks of treatment.6 42. the findings are based on a smaller sample. in 65% of the patients who on admission to the program were limited in active ankle ROM and in 71. We found significant between-group differences after two and four weeks of treatment.3). the lack of sufficient sensory input through the left side of the body may have adversely affected their ability to walk.7 27. however.0 5. That is.6 3.0 31.6 10. whereas ambulation of those patients treated with the PNF approach and especially with the Bobath approach was delayed. Table 3 shows the changes in ambulation after two. We encouraged the patients treated with the conventional approach to walk as early as possible.12. p = .32.7 52.3 14. four. the six-week difference between the ambulation of right versus left hemiplegic patients was significant (x 2 = 8. none of the tested approaches had an advantageous treatment effect on patients with these limitations.88. We measured isolated control over the involved ankle and wrist joints be- TABLE 3 Patient Gait in the Three Groups Ambulatory Statusa Time from Admission (wk) 2 Therapeutic Approach Nonwalking 45.5 34.9 With Walking With Walking Independent Aid and Aid Assistance 37. respectively) resulted from the high percentage of nonwalking patients in the Bobath-treatment group and the concurrent high proportion of patients walking with an assistive device and the aid of another person in the conventional-treatment group. The increase over time in muscle tone of the extremities was expected. We found a higher percentage (23%) of independently walking patients with right hemiplegia compared with those with left hemiplegia (0%).73.9 25. These differences (p < . however.1 45. At the same time. The similar patterns of muscle tone change in the conventional-treatment and Bobath-treatment groups (Fig.7 28.9 Test Results Conventional PNF Bobath Conventional PNF Bobath Conventional PNF Bobath 4 6 (n = 129) x2 = 19. For the left hemiplegic patients.04.2 42. df=6. These differences stabilized. 3) may reflect the different principles of each approach.4 4.9 22. Further research is warranted to clarify this relationship. Because functional independence is the overall goal of each of these methods. p = . Sensory deficiency and limited ROM of the ankle joint were found to affect walking ability ad- The results of this study.5 13.13 did not demonstrate significant between-group differences in the improvement of the patients' performance of ADL.1 20.8 0.64.0 64.

During each treatment session. 3. evaluation of muscle strength by manual muscle testing. Third. Rapid acquisition of independence was given higher priority than the quality of movements by which it was achieved. they neither refuted nor substantiated the short-term benefits (during treatment or even several hours later) reported by Bobath. mass movements. Bobath Approach 1. 5. 6. although prevalent in clinical settings. the criterion variables almost always were measured using ordinal and nominal scales. Gait training usually was started near a horizontal rail that supported the patient at his sound side. Because of these shortcomings. postural activity was facilitated by touch and proprioceptive stimuli. Assessment was based on measurements of active and passive ROM of the affected joints. assessment of muscle tone by passive movement of the limbs. Such measurement scales. alternatively. Such studies should be based on large groups of patients and use a variety of objective measurement tools and time frames. discriminates only between major levels of performance and provides no information on the quality of that performance. 2. because the pace of improvement is individual. to discuss the effects of more than only a few of these variables in one study is practically impossible. Percentage of patients with limited active wrist ROM on admission (blank) and at the end of six weeks (shaded) in the three treatment groups. Passive movements were administered to immobile joints. and use of simple and abnormal reflexes were forbidden. 3. reflexes (most commonly the stretch reflex) frequently were used to elicit movements. 4. Appropriate basic procedures and specific techniques of the approach were incorporated into each treatment. Percentage of patients with limited active ankle ROM on admission (blank) and at the end of six weeks (shaded) in the three treatment groups. The BI. for example. suspensions. Practice of ADL began as early as possible. our decision to limit the treatment period arbitrarily to six weeks may be criticized. During treatment. Progress in treatment generally followed the normal developmental sequence. the first step was geared toward the inhibition of abnormal muscle tone.RESEARCH Fig. lackfinediscriminative power and introduce subjectivity into assessments. Progress was encouraged either by gradual increase in the number of joints involved or by increasing resistance to a requested movement. our choice of the treatment period as an equalizing variable or. 3. 4. although some latitude was allowed.9 2.10 2. The use of exercise gadgets such as pulleys. 4. Assessment was based on the format suggested by Knott and Voss. period. or weights was a permissible option. Fig. and evaluation of performance of functional activities. usually through the application of appropriate reflex-inhibiting patterns. 3. 1237 . We hope that through many such projects physical therapists Volume 66 / Number 8. Second. August 1986 APPENDIX Exercise Therapy Approaches Conventional Approach 1. PNF Approach 1. This process was performed concurrently with an effort to initiate normal movements (automatic and voluntary) through "key points of control" in the patients' bodies. These patterns included the diagonal and spiral patterns and the total patterns of the developmental sequence. because changes in CVA patients are influenced by numerous variables. additional evaluative studies are needed. Assessment was made according to the published guidelines of that method. Resistive exercises. First. Mass-movement patterns formed an integral part of the exercises. Exercises were performed in anatomical planes.10 The shortcomings of our study derive from several sources. Imposition of activity on the patients was accompanied by efforts to impose normal sensations of posture and movements in which weight-bearing exercises played an important role. 2. For patients with low or flaccid muscle tone.

Churchill Livingstone. Phys Ther 55:607-610. 1983 14. Hewer RL: Stroke rehabilitation. and the Bobath approaches. 1975 22. REFERENCES 1. Jordan C: Factors affecting balance and ambulation following stroke. rev ed 2. Gordon EE. et al: Neurophysiology syndromes in stroke as predictors of outcome. Nie NJ. St. Drenth V. 1967 18. Keshner EA: Reevaluating the theoretical model underlying the neurodevelopmental theory: A literature review. thus. Rusk HA: Rehabilitation of patients with stroke. Mcdowell FJ: Rehabilitation of patients with stroke. Jarvis L. Barthel DW: Functional evaluation: The Barthel index. Basmajian JV: Neuromuscular facilitation techniques. New York. 1978 15. 1976. Postgrad Med 59:145-153. in isolated motor control over the involved ankle and wrist joints. Stroke 6:34-41. NY. Samuels MA. 1975. McGraw-Hill Inc. pp 262-280 2. Richards B. 1975 19. Voss DE: Proprioceptive Neuromuscular Facilitation: Patterns and Techniques. Publishers Inc. CONCLUSIONS Despite the differences in theory and practice among the conventional. Kabat H: Studies on neuromuscular dysfunction. Fitzpatrick TE. Because some of the theoretical principles of the neurophysiological approaches have been questioned recently. Clin Orthop 182:165-171. Further studies are needed of the effects of exercise therapy procedures on hemiplegic patients. London. In Rusk HA (ed): Rehabilitation Medicine. Williams & Wilkins. found no important differences in improvements in ADL. Wolf PA. 1978 11. Arch Phys Med Rehabil 59:399403.23 objective evaluation of the effects of these treatments is required. Arch Phys Med Rehabil 64:364-367. William Heinemann Medical Books Ltd. User RN. Harper & Row. In Licht S (ed): Stroke and Its Rehabilitation. 1977. the PNF. MO. England.1965 17. Phys Ther 61:10351040. The Australian Journal of Physiotherapy 23:28-33. We. Wylie CM: Measuring end results of rehabilitation of patients with stroke. Stern PH. MD. Keenan MA. Arch Phys Med 33:521-533. Andrews K. ed 2. Brain 97:551564. 1977 6. Edinburgh. Arch Phys Med Rehabil 51:526531. Brain 74:443-480. Perry J. et al: How much physical therapy for patients with stroke? Br Med J 1:1307-1310. Mcdowell FJ. Arch Phys Med Rehabil 56:540. ed 4. pp 6 0 1 620 12.will be able to learn the relative therapeutic effects of the procedures they apply to CVA patients. Campbell DC. 1984 20. Although this result may be related to the use of facilitation techniques. Granger CV. Md State Med J 14:61 65. Knott M. chap 10 7.1981 1238 PHYSICAL THERAPY . Bobath B: Adult Hemiplegia: Evaluation and Treatment. 1968 10. et al: Clinical exercise trial for stroke patients. Baltimore.1970 13. et al: Stroke: The relationship of neurological deficit and co-morbid disease to dependence in AOL and mobility among survivors of the Framingham study. 1976 8. Hull CK. Jenkins JG. Scotland. Greer DS. New York. 1974 16. Public Health Rep 82:893-898. Arch Phys Med Rehabil 52:40-42. Louis. Falconer J. 1975 3. C V Mosby Co. NY. In Russell RWR (ed): Cerebral Arterial Disease. 1975 21. additional evidence is needed. and in gait among the three groups of subjects. Twitchell TE: Restoration of motor function following hemiplegia in man. 1978 5. et al: Effects of facilitation-exercise techniques in stroke rehabilitation. et al: Measurement of outcomes of care for stroke patients. 1952 9. The only outstanding result was the pattern of muscle tone improvement in the PNF-treatment group. Oxbury JM. Oxbury SM: Unilateral spatial neglect and impairment of spatial analysis and visual perception. 1971 4. 1951 23. Logigian MK. et al: Statistical Package for the Social Sciences. Mahoney Fl. Mayo MG: The evaluation of physical therapy in treatment of stroke: A preliminary investigation. Gresham GE. Basmajian JV: Research or retrench: The rehabilitation professions challenged. Miller JM. Brocklehurst JC. Friedland F: Physical therapy. we found no treatment-related variances in the outcomes of the patients after six weeks of treatment.

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