Peppen Ebook Clinicalreahabilitation Stroke

Towards
evidence-based physiotherapy
for patients with stroke
Roland PS van Peppen

Towards evidence-based physiotherapy for patients with stroke
Thesis, Utrecht University & Hogeschool Utrecht, The Netherlands
ISBN 978-90-7138225-3
© 2008, Roland PS van Peppen

No part of this thesis may be reproduced, stored or transmitted
in any way or by any means, without prior permission of the author
The printing of this thesis was financially supported by:

Stichting Steunfonds Faculteit Gezondheidszorg Hogeschool Utrecht, Divisie
Hersenen (UMC Utrecht), Netherlands Heart Foundation (Nederlandse Hartstichting),
Stimuleringsfonds Wetenschappelijk College Fysiotherapie (WCF), Nederlandse
Vereniging voor Fysiotherapie in de Geriatrie (NVFG), Boehringer Ingelheim BV,
Livit Orthopedie, Abakus BV, Berkman & Van der Steeg, Electro Medico,
VanP&D Professional Development in de gezondheidszorg
Printed by: Gildeprint Drukkerijen, Enschede, The Netherlands
© Original Artwork cover: Arno Overdevest

© Cover design: Roland van Peppen
Towards
evidence-based physiotherapy
for patients with stroke
Op weg naar
evidence-based fysiotherapie
bij patiënten met een beroerte
(met een samenvatting in het Nederlands)
PROEFSCHRIFT
ter verkrijging van de graad van doctor
aan de Universiteit Utrecht
op gezag van de rector magnificus, prof. dr. J.C. Stoof,
ingevolge het besluit van het college voor promoties
in het openbaar te verdedigen op
vrijdag 30 mei 2008 des middags te 2.30 uur
door
Rolandus Petrus Stephanus van Peppen
geboren op 15 maart 1961 te Delft

Promotor: Prof. dr. E. Lindeman
Co-promotoren: Dr. G. Kwakkel
Dr. N.L.U. van Meeteren
Dr. M.J. Schuurmans

Voor Coby & Martin,
mijn lieve ouders

Contents
Chapter 1 Introduction 9

Chapter 2 The impact of physiotherapy on functional outcome after 23

stroke: What’s the evidence?

Chapter 3 Effects of augmented exercise therapy time after stroke: 67
A meta‐analysis

Chapter 4 Effects of visual feedback therapy on postural control in 91
bilateral standing after stroke: A systematic review

Chapter 5 The development of a clinical practice stroke guideline for 107
physiotherapists in The Netherlands: A systematic review of
available evidence

Chapter 6 Outcome measures in physiotherapy management of 137
patients with stroke: A survey into self‐reported use, and
barriers to and facilitators for use

Chapter 7 Feasibility and effectiveness of an educational program to 155
promote the use of measurement instruments by
physiotherapists involved in stroke rehabilitation: An RCT
on tutor expertise

Chapter 8 General discussion 177
Summary 201
Nederlandse samenvatting 209
Dankwoord 219
Publications 229
About the author 235
CHAPTER
Introduction

Chapter 1
Introduction

Stroke in the Netherlands
Stroke (or cerebrovascular accident) is defined as ‘a clinical syndrome
typified by rapidly developing signs of focal or global disturbance of
cerebral functions, lasting more than 24 hours or leading to death, with no
apparent causes other than of vascular origin’.1 Depending on the location of
the vascular defect(s), different functions are disturbed leading to temporary
or permanent impairments, activity limitations and participation
restrictions.1 Stroke is the leading cause of severe long term disability in
adults in the Western world, with high societal costs due to its increasing
prevalence and the long‐term disability it generally causes. For instance, in
the Netherlands, the incidence of cerebrovascular accidents is estimated at
about 34,500 per year (~2.2/1000/year) and the prevalence at 190,000 (~1.2%
of Dutch population) patients and this prevalence will increase with 27%
over the next decade.2
In the Netherlands, stroke is a highly disabling disease; about 70% of the
stroke surviving patients experience long term problems in their activities of
daily living (ADL) and social participation. Of these, 44% experienced mild
consequences of stroke, 21% moderate, 16% severe and 19% very severe
consequences of stroke.3

Physiotherapy as a part of stroke care
In the absence of any cure for the initial pathology, rehabilitation is the most
universally adopted treatment strategy to improve quality of life in patients
with stroke.4 Rehabilitation, as described by Stucki et al5 can be defined as
‘the health strategy that aims to enable people with health conditions
experiencing or likely to experience disability to achieve and maintain
optimal functioning in interaction with the environment’.5,p39 The main aim
of organised‐stroke rehabilitation is to achieve a level of functional
independence that enables patients to return home and reintegrate into
community life that lives up to their own expectations and desires as much
as possible.4 In the Netherlands patients with stroke generally rehabilitate in
different settings, usually started in an acute stroke‐unit care and continued
in a rehabilitation centre, a nursing home, or in the community by
physiotherapists employed in health centres or in private practices.6
In the Netherlands 55%‐61% of patients with a first‐ever stroke were
admitted to an acute care hospital. Recent studies showed that 40%‐68% of
surviving patients with stroke in Dutch acute care hospitals were discharged
home, 25%‐31% to a nursing home, 9% to 15% to a rehabilitation centre.7‐9
10
Introduction
Physiotherapy is perceived as one of the key disciplines in providing
organised‐stroke care.10 Physiotherapists involved in the management of
patients with stroke have to: 1) deal with establishing diagnosis of
functioning,11 and determine the factors for predicting functional
outcome,4,12,13 2) start remedial interventions to restore motor control in gait
and gait‐related activities and to improve upper limb activities, as well as to
learn to cope with existing deficits in ADL and to enhance participation in
general,14,15 and 3) monitor patients’ (progress in) functional health with help
of outcome measures.11,16,17 Physiotherapists involved in stroke‐management
often apply physical exercises and assistive devices for gait (canes and
walkers). Besides they employ other equipment such as treadmills and
electronic devices as therapeutic treatment interventions.6 In addition,
advice and instructions are provided to the patient, family and other
members of the in general interdisciplinary stroke team regarding treatment
and prevention of complications such as falls and shoulder pain.14,15

Functioning, Disability and Health
In 2001, the World Health Organization (WHO)18 published the International
Classification of Functioning, Disability and Health (ICF) as a model to
describe in a standardised language concerning human functioning in the
context of health and health related issues. The ICF holds the following
components: body functions and structures, activities, participation, and
environmental and personal factors (Figure 1). Meanwhile, this model is
widely used as a structuring framework for describing functioning of man
and related outcome research.5 The ICF and recently formulated linking
rules can be used for classifying the type of outcome measures in general,19
and in stroke‐management20‐22, and has been proven to be applicable in
physiotherapy‐management.23,24

Figure 1. International Classification of Functioning, Disability and Health (ICF)18
Health Condition
(disorder or disease)
Body Functions
Activities Participation
& Structures
Environmental Personal
Factors Factors

11
Chapter 1
Evidence‐Based Practice
Evidence Based Practice (EBP) is proclaimed to be a ‘new paradigm’ in
which evidence from health care research is the best basis for decisions for
individual patients and health systems.25 Evidence‐Based Medicine,
introduced in 1991 by Guyatt and colleagues,26 has evolved over the years
and was redefined recently as Evidence Based Practice in the ‘Sicily
Statement’.27 EBP demands that decisions in health care, in this thesis in
physiotherapy, are based on the best available, current, valid and relevant
evidence combined with optimal clinical experience. These decisions should
be made by those receiving care ‐the patients‐, informed by the care
providers, within the context of available resources.27 In the most recent
model for evidence‐based clinical decision making four aspects are
considered to be of importance: 1) best research evidence, 2) patientsʹ
circumstances, 3) patientsʹ preferences and actions, and 4) clinical expertise
to integrate the previous components (Figure 2).27,28

Figure 2. Model of the key elements for evidence‐based clinical decision making25
Clinical state
and circumstances
Clinical expertise
Patient preferences Research evidence

and actions

12
Introduction
Based on the model of Haynes concerning evidence‐based decision‐making,
available evidence ought to guide the clinical decision‐making process of
health care professionals,25 i.e. physiotherapists, dealing with the
rehabilitation of patients with stroke. As of recent years, the importance of
EBP, as a guide for the clinical decision making process, is increasingly being
recognised by physiotherapists.29,30 Although EBP is the standard in this
century and many interventions were underpinned with evidence, there are
a number of gaps in the research area of stroke rehabilitation.

Lack of evidence for treatment approaches
Before the 1950’s, physiotherapy for patients with neurological diseases was
considered to be a muscle re‐education technique with an ‘orthopedic’ point
of view. Since the advances of science in recent decades and the gradual
understanding of neurophysiological principles in movement control, new
concepts about the optimal physical treatment strategy for movement
disorders in patients with brain damage have been developed resulting in
new approaches. One of these approaches was the Bobath‐concept
developed by Bertha and Karl Bobath, later known as the neuro‐
developmental treatment (NDT). More than 50 years later, the revolutionary
ideas of ‘the Bobaths’ have become, in the Western world, the most common
approach for the treatment of neurologically impaired patients.31 Due to the
increasing knowledge about functional recovery after stroke.4 and the lack of
evidence for the training strategies used,32 the NDT developed and evolved
over the years and included new insights into the concept. The main change
was the awareness of therapists that effects of training focused on restitution
of body functions hardly generalises to activities that are not directly trained
in the treatment programme. Specificity of treatment effects includes also the
context specificity33 suggesting that treatment effects hardly generalise
beyond the environment in which the training is applied. This latter finding
suggests that exercise training regimes should preferably be applied in
patients own everyday surroundings.
Since the introduction of the Bobath approach there has been much
criticism on the effectiveness of the concept.32,34,35 A recent Cochrane
systematic review (14 trials; N=886 patients)32 critically appraised and
reviewed the literature about the effects of treatment approaches aimed at
promoting postural control and lower limb function, such as Bobath / NDT,
Brunnstrom, Proprioceptive Neuromuscular Facilitation (PNF) and Motor
Relearning Programme (MRP). They explored whether there was any
difference in functional independence depending on which physiotherapy
the patients with stroke received. Pollock and colleagues concluded that
13
Chapter 1
currently no evidence exists that one physiotherapy approach is superior in
promoting recovery of disability after stroke. A mix of components from
different approaches, an eclectic approach, seems to be more effective than
no treatment or placebo control in attaining functional independence
following stroke.32 Physiotherapists should therefore be encouraged to find
ways of integrating these findings into their daily practice. To date, about
80% of Dutch physiotherapists in stroke management treat patients based on
the principles of the NDT approach36, which is also comparable to that of
colleagues in Sweden37, Australia38 and the UK39,40. In the near future the
underpinning of physiotherapy stroke management has to be focused on
existing evidence rather than philosophies of different approaches.

Clinical practice guidelines on stroke care
Recently, the ‘best evidence’ for stroke management, derived from
methodologically sound clinical research, has been collected in systematic
reviews and converted into several multidisciplinary stroke guidelines.6,41‐47
However, these clinical practice guidelines, commonly defined as
‘systematically developed statements to assist practitioners and patient
decisions about appropriate health care for specific clinical circumstances’,48
do not review in depth all available evidence with regard to physiotherapy
practice. Physiotherapists still need to have more detailed information to
foster and enrich their clinical decisions where it concerns valid functional
prognosis and diagnosis, designing the most effective intervention
programme, and selecting the most appropriate measures to evaluate
functional outcome. These aspects have to be an integrated part of everyday
practice. International physiotherapy associations already stated that
assessing and monitoring the health status of patients is considered an
aspect of good clinical practice in physiotherapy.49,50 However, up to 2005,
no specific guidelines for physiotherapy in the management of patients with
stroke were published, even though physiotherapy accounts for a
substantial proportion of the total therapy time provided by stroke
rehabilitation services ranging from 44 to 90%.14,51 In other words, a detailed,
evidence‐based clinical practice guideline for physiotherapy‐management of
patients with stroke is needed.

Guideline implementation
The main benefit of clinical practice guidelines is to improve the quality of
care and change behaviour of professionals. In general, clinical practical
guidelines should recommend evidence based and feasible procedures to
determine: 1) prognostic factors; 2) therapeutic interventions and 3)
14
Introduction
evaluative outcome measures. Clinical practice guidelines are meant to be
combined with clinical experience,52,53 and are not to be seen as a magic
solution which resolves problems of effectiveness of health care. Up and
above, guidelines do not implement themselves spontaneously. Experts in
the field recommend explicit multifactor dissemination, implementation,
and audit strategies in order to integrate guidelines into daily practice of
health care professionals.54 Implementation can be described as ‘a planned
process and systematic introduction and/or change of proven value, with the
aim to give these a structural place in professional practice, in the
functioning of organisations or in the health care structure’.55,p10 In the
Netherlands a standard method of implementation for clinical practice
physiotherapy guidelines was developed.56 In the standard procedure of
implementing the clinical practice guidelines for physiotherapy a hard‐copy
of the guideline was disseminated to all members of the professional
organisation of physiotherapists, the Royal Dutch Society for Physical
Therapy (‘Koninklijk Nederlands Genootschap voor Fysiotherapie’: KNGF).
Besides, the physiotherapists were attended to the clinical practice
guidelines by publications in professional journals and platform
presentations at national conferences.57
There are many different strategies to change the behaviour of
practitioners in health care, and all strategies claimed to be effective.54 The
literature on implementation strategies of innovations in health care is large,
diverse, and complex.58 The majority of the implementation strategies, such
as audit and feedback, reminder systems, and educational meetings, has
been targeted at the individual professionals, particularly their knowledge,
attitude and behaviour.59 Multifaceted implementation interventions (i.e.,
combination of interventions) were recommended for many years,54 but
recently the advise about such composite‐interventions was criticised.59 Up
until today, mixed effects were found for educational strategies aiming at
knowledge transfer of evidence into daily practice. With respect to
interactive sessions, the change in clinical practice, and with that the
effectiveness of the implementation will increase.54 Jonathan Lomas
described an implementation model which integrates an educational
strategy in the process getting research evidence into daily practice.60,61 This
implementation model can be used to structure the complex process of
changing professional behaviour of physiotherapists (Figure 3).60,61 Lomas
mentioned that the implementation of research information in an
educational environment for practitioners and patients is a complex process,
influenced by several contextual factors (administrative environment),
processes (i.e. public pressure) and external factors (i.e. media).61 According
15
Chapter 1
to this model, evidence has to be disseminated in all its complexity by using
educational implementation strategies, by which health care professionals
have to be trained to integrate evidence into their clinical decision making
process. Hereby, the interactive sessions have to integrate the debate
between tutors and practitioners,54 in small group teaching‐sessions or
workshops based on problem‐based learning.62

Figure 3. The implementation model described by Lomas61
Research information
Credible dissemination
context
Educational
Administrative Economic
environment
environment environment
Practitioner
Personal Community
environment
Patient
context

Aims of the present thesis

The first aim of the present 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. On
the basis of these findings, recommendations were to be made, that
permitted guidance of the clinical decision‐making process of
physiotherapists involved in the (interdisciplinary) care of such patients. The
results of these review‐activities will be presented as a clinical practice
guideline on physiotherapy management of patients with stroke.
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
16
Introduction
a useful indicator of guideline adherence.16 Based on an analysis of barriers
and facilitators of implementation, an educational programme was
performed to implement the recommendations into daily practice in a
selected group of physiotherapists who were dedicated to the management
of patients with stroke. Emphasis was given to the selection of outcome
measures in practice.

Outline of the thesis

First, in Chapter 2, a systematic review was performed to establish the value
of the evidence of physiotherapy interventions related to improving
functional outcomes after stroke and to convert this evidence in an overview
of the efficacy of physiotherapy interventions in patients with stroke.
In Chapter 3, the effects of augmented exercise time were examined by
systematically reviewing studies evaluating the effects of intensity of
practice, expressed as time dedicated to practice, in patients with stroke on
ADL, walking and dexterity. A secondary goal of this systematic review was
to investigate the dose‐response relationship of augmented exercise training
to outcome of ADL.
In Chapter 4, the evidence for applying ‘visual feedback therapy’ (VFT)
on postural control in bilateral standing was systematically studied in
patients with stroke.
In Chapter 5 the available evidence was collected and described to guide
the clinical decision‐making process of physiotherapists dealing with the
rehabilitation of patients with stroke especially with respect to the selection
of prognostic factors, the appropriate physiotherapy interventions, and the
outcome measures of choice to assess patients’ progress in functional health.
This evidence is presented as a Clinical practice guideline on Physiotherapy
management of patients with Stroke (CPGPS) in the Netherlands.
Assessing and monitoring the health status of patients is considered an
aspect of good clinical practice in physiotherapy. Therefore, after
disseminating the clinical practice guideline, physiotherapists’ self‐reported
use of outcome measures as recommended in the CPGPS was investigated,
and perceived barriers to and facilitators for the use of outcome measures in
everyday practice were assessed in Chapter 6.
To enhance self‐reported use and actual use of the recommended
outcome measures by physiotherapists in stroke management a new
educational programme was developed, the Physiotherapists Educational
Programme on Clinimetrics in Stroke (PEPCiS). In Chapter 7 feasibility and
17
Chapter 1
effectiveness were determined in a randomised controlled trial with thirty

volunteering physiotherapists involved in stroke management who were
randomised into two numeric equal groups, an expert tutor group and a
non‐expert tutor group. Secondary to this aim, the influence of tutor style
will be explored.
In the general discussion (Chapter 8) the pro’s and con’s of the research
are discussed. Besides the possibilities and limitations of the applied
methods and the implications and directions for further research and
education are discussed concerning physiotherapy stroke management.

References

1. WHO. Stroke‐‐1989. Recommendations on stroke prevention, diagnosis, and therapy.
Report of the WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke
1989; 20:1407‐1431.
2. Struijs JN, van Genugten ML, Evers SM et al. Modeling the future burden of stroke in The
Netherlands: impact of aging, smoking, and hypertension. Stroke 2005; 36:1648‐1655.
3. Koek HL, Van Dis SJ, Peters RJG et al. Hart‐en vaatziekten in Nederland. In: Van Leest
LATM, Koek HL, Van Trijp MJCA et al, editors. Hart‐en vaatziekten in Nederland 2005,
cijfers over risicofactoren, ziekte, behandeling en sterfte [dutch]. Den Haag: Nederlandse
Hartstichting, 2005: 6‐12.
4. Kwakkel G, Kollen B, Lindeman E. Understanding the pattern of functional recovery after
stroke: facts and theories. Restor Neurol Neurosci 2004; 22:281‐299.
5. Stucki G, Cieza A, Melvin J. The international classification of functioning, disability and
health (ICF): A unifying model for the conceptual description of the rehabilitation strategy.
J Rehabil Med 2007; 39:279‐285.
6. Commissie CVA‐Revalidatie. Rehabilitation after a stroke, guidelines and

recommendations for health care professionals (in Dutch: Revalidatie na een beroerte:
richtlijnen en aanbevelingen voor zorgverleners). Franke EAM, editor. 2001. Den Haag,
Dutch Heart Foundation (in Dutch: Nederlandse Hartstichting).
7. Bots ML, Looman SJ, Koudstaal PJ et al. Prevalence of stroke in the general population. The
Rotterdam Study. Stroke 1996; 27:1499‐1501.
8. Koek HL, Grobbee DE, Bots ML. [Trends in cardiovascular morbidity and mortality in the
Netherlands, 1980‐2000]. Ned Tijdschr Geneeskd 2004; 148:27‐32.
9. Van Exel J, Koopmanschap MA, Van Wijngaarden JD et al. Costs of stroke and stroke
services: Determinants of patient costs and a comparison of costs of regular care and care
organised in stroke services. Cost Eff Resour Alloc 2003; 1:2‐13.
10. Langhorne P, Legg L, Pollock A et al. Evidence‐based stroke rehabilitation. Age Ageing
2002; 31 Suppl 3:17‐20.
18
Introduction
11. Jette AM. Outcomes research: shifting the dominant research paradigm in physical
therapy. Phys Ther 1995; 75:965‐970.
12. Kollen B, Van de Port I, Lindeman E et al. Predicting improvement in gait after stroke: a
longitudinal prospective study. Stroke 2005; 36:2676‐2680.
13. Schenkman M, Deutsch JE, Gill‐Body KM. An integrated framework for decision making in
neurologic physical therapist practice. Phys Ther 2006; 86:1681‐1702.
14. Jette DU, Latham NK, Smout RJ et al. Physical therapy interventions for patients with
stroke in inpatient rehabilitation facilities. Phys Ther 2005; 85:238‐248.
15. Pomeroy VM, Tallis RC. Physical therapy to improve movement performance and
functional ability poststroke. Part 1. Existing evidence. Reviews of Clinical Gerontology
2000; 10:261‐290.
16. Glasziou P, Irwig L, Mant D. Monitoring in chronic disease: a rational approach. BMJ 2005;
330:644‐648.
17. Jette AM. Assessing disability in studies on physical activity. Am J Prev Med 2003; 25
Suppl 2:122‐128.
18. WHO. ICF‐introduction, the International Classification of Functioning Disability and
Health. 2001. Geneve. http://www.who.int/classification/icf/intros/ICF‐Eng‐Intro.pdf
19. Cieza A, Geyh S, Chatterji S et al. ICF linking rules: an update based on lessons learned. J
Rehabil Med 2005; 37:212‐218.
20. Salter K, Jutai JW, Teasell R et al. Issues for selection of outcome measures in stroke
rehabilitation: ICF Participation. Disabil Rehabil 2005; 27:507‐528.
rehabilitation: ICF Activity. Disabil Rehabil 2005; 27:315‐340.
22. Salter K, Jutai JW, Teasell R, et al. Issues for selection of outcome measures in stroke
rehabilitation: ICF Body Functions. Disabil Rehabil 2005; 27:191‐207.
23. Jette AM. Physical disablement concepts for physical therapy research and practice. Phys
Ther 1994; 74:380‐386.
24. Jette AM. Toward a common language for function, disability, and health. Phys Ther 2006;
86:726‐734.
25. Haynes RB. What kind of evidence is it that Evidence‐Based Medicine advocates want
health care providers and consumers to pay attention to? BMC Health Serv Res 2002; 2:3‐
10.
26. Guyatt G. Evidence‐Based Medicine. ACP J Club 1991;A‐16:114.
27. Dawes M, Summerskill W, Glasziou P et al. Sicily statement on evidence‐based practice.
BMC Med Educ 2005; 5:1‐7.
28. Haynes RB, Devereaux PJ, Guyatt GH. Clinical expertise in the era of evidence‐based
medicine and patient choice. Vox Sang 2002; 83 Suppl 1:383‐386.
29. Holm M. Our mandate for the new millennium: evidence based practice. Am J Occup Ther
2000; 54:575‐585.
19
Chapter 1
30. Parker‐Taillon D. CPA initiatives put the spotlight on evidence‐based practice in
physiotherapy. Physiother Can 2002; 24:12‐15.
31. Lennon S, Ashburn A, Baxter D. Gait outcome following outpatient physiotherapy based
on the Bobath concept in people post stroke. Disabil Rehabil 2006; 28:873‐881.
32. Pollock A, Baer G, Langhorne P et al. Physiotherapy treatment approaches for the recovery
of postural control and lower limb function following stroke: a systematic review. Clin
Rehabil 2007; 21:395‐410.
33. Lennon S, Ashburn A. The Bobath concept in stroke rehabilitation: a focus group study of
the experienced physiotherapistsʹ perspective. Disabil Rehabil 2000; 22:665‐674.
34. Luke C, Dodd KJ, Brock K. Outcomes of the Bobath concept on upper limb recovery
following stroke. Clin Rehabil 2004; 18:888‐898.
35. Paci M. Physiotherapy based on the Bobath concept for adults with post‐stroke hemiplegia:
a review of effectiveness studies. J Rehabil Med 2003; 35:2‐7.
36. Hafsteinsdottir TB, Algra A, Kappelle LJ et al. Neurodevelopmental treatment after stroke:
a comparative study. J Neurol Neurosurg Psychiatry 2005; 76:788‐792.
37. Nilsson LM, Nordholm LA. Physical therapy in stroke rehabilitation: basis for Swedish
physiotherapistsʹ choice of treatment. Physiotherapy Theory and Practice 1992; 8:49‐55.
38. Carr JH, Mungovan SF, Shepherd RB et al. Physiotherapy in stroke rehabilitation: a basis
for Australian physiotherapistsʹ choice of treatment. Physiotherapy Theory and Practice
1994; 10:201‐209.
39. Davidson I, Waters K. Physiotherapists working with stroke patients: a national survey.
Physiotherapy 2000; 86:69‐80.
40. Lennon S, Baxter D, Ashburn A. Physiotherapy based on the Bobath concept in stroke
rehabilitation: a survey within the UK. Disabil Rehabil 2001; 23:254‐262.
41. Dutch Institute for Quality in Health Care (in Dutch: Kwaliteitsinstituut voor de
gezondheidszorg Utrecht‐CBO‐). CBO Richtlijn Beroerte (Stroke Guidelines 2000, in
Dutch). 2000. Den Haag, Nederlandse Hartstichting.
42. Scottish Intercollegiate Guidelines Network. Management of patients with stroke,
rehabilitation, prevention and management of complications and discharge planning ‐ a
national clinical guideline (no: 64). 2002. Edinburgh, SIGN.
43. Agency for Health Care Policy and Research. Post‐Stroke Rehabilitation: clinical practice
guideline. No.16. 1995. Rockville, AHCPR Publication 95‐0662.
44. Royal College of Physicians ‐ the intercollegiate working party for stroke. National Clinical
Guidelines for Stroke. 1999. London.
45. Hanger HC, Wilkinson T, Keeling S, Sainbury R. New Zealand guideline for management
of stroke. N Z Med J 2004; 117:U863.
46. National Stroke Foundation. Clinical Guidelines for Stroke Rehabilitation and Recovery
(Australian Government). 2005.
47. Khadilkar A, Phillips K, Jean N et al. Ottawa panel evidence‐based clinical practice
guidelines for post‐stroke rehabilitation. Top Stroke Rehabil 2006; 13:1‐269.
20
Introduction
48. Field MJ, Lohr KN. Guidelines for clinical practice. From development to use. Washington
DC: National Academy Press, 1992.
49. American Physical Therapy Association. Guide to Physical Therapist Practice. Second
Edition. Phys Ther 2001; 81(1):9‐746.
50. Australian Physiotherapy Association. APA Position Statement ‐ Clinical justification and
outcome measures 2003:
https://apa.advsol.com.au/staticcontent/staticpages/position_statements/public/ClinicalJust
ification&Outcome%20Measures.pdf
51. De Wit L, Putman K, Dejaeger E et al. Use of time by stroke patients: a comparison of four
European rehabilitation centers. Stroke 2005; 36:1977‐1983.
52. Davidoff F. In the teeth of the evidence: the curious case of evidence based medicine. Mt
Sinai J Med 1999; 66:75‐83.
53. Mulrow CD, Cook DJ, Davidoff F. Systematic reviews: critical links in the great chain of
evidence. Ann Intern Med 1997; 126:389‐391.
54. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of
change in patientsʹ care. Lancet 2003; 362:1225‐1230.
55. Grol R, Wensing M, Eccles M. Improving patient care. The implementation of change in
clinical practice. London: Elsevier Butterworth Heinemann, 2005.
56. Hendriks HJM, Bekkering GE, van Ettekoven H et al. Development and implementation of
national practice guidelines: a prospect for continuous quality improvement in
physiotherapy. Physiotherapy 2000; 86:535‐547.
57. Bekkering GE, Engers AJ, Wensing M et al. Development of an implementation strategy for
physiotherapy guidelines on low back pain. Aust J Physiother 2003; 49:208‐214.
58. Greenhalgh T, Robert G, Macfarlane F et al. Diffusion of innovations in service
organizations: systematic review and recommendations. Milbank Q 2004; 82:581‐629.
59. Grimshaw JM, Thomas RE, MacLennan G et al. Effectiveness and efficiency of guideline
dissemination and implementation strategies. Health Technol Assess 2004; 8:iii‐72.
60. Lomas J. Teaching old (and not so old) does new tricks: effective ways to implement
research findings. In: Dunn EV, Norton PG, Steward M, Tudiver F, Bass MJ, editors.
Volume 6: Disseminating research / changing practice. London: Sage, 1993.
61. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based
practice: a conceptual framework. Qual Health Care 1998; 7:149‐158.
62. Davis WK, Nairn R, Paine ME et al. Effects of expert and non‐expert facilitators on the
small‐group process and on student performance. Acad Med 1992; 67:470‐474.
21
Chapter 1
22
CHAPTER
The impact of physiotherapy on functional outcome
after stroke: What’s the evidence?
Roland PS Van Peppen
Gert Kwakkel
Sharon Wood‐Dauphinee
Erik JM Hendriks
Philip J Van der Wees
Joost Dekker
Clinical Rehabilitation 2004; 18(8): 833‐862
Chapter 2
Abstract

Objective: To determine the evidence for physiotherapy interventions
aimed at improving functional outcome after stroke.
Methods: MEDLINE, CINAHL, Cochrane Central Register of Controlled
Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE
and DocOnline were searched for controlled studies. Physiotherapy was
divided into 10 intervention categories, which were analysed separately. If
statistical pooling (weighted summary effect sizes) was not possible due to
lack of comparability between interventions, patient characteristics and
measures of outcome, a best‐research synthesis was performed. This best‐
research synthesis was based on methodological quality (PEDro score).
Results: In total, 151 studies were included in this systematic review; 123
were randomised controlled trials (RCTs) and 28 controlled clinical trials
(CCTs). Methodological quality of all RCTs had a median of 5 points on the
10‐point PEDro scale (range 2‐8 points). Based on high‐quality RCTs strong
evidence was found in favour of task‐oriented exercise training to restore
balance and gait, and for strengthening the lower paretic limb. Summary
effect sizes (SES) for functional outcomes ranged from 0.13 (95% CI: 0.03 –
0.23) for effects of high intensity of exercise training to 0.92 (95% CI: 0.54 –
1.29) for improving symmetry when moving from sitting to standing. Strong
evidence was also found for therapies that were focused on functional
training of the upper limb such as constraint‐induced movement therapy
(SES 0.46; 95% CI: 0.07 – 0.91), treadmill training with or without body
weight support, respectively 0.70 (95% CI: 0.29 – 1.10) and 1.09 (95% CI: 0.56
– 1.61), aerobics (SES 0.39; 95% CI: 0.05 – 0.74), external auditory rhythms
during gait (SES 0.91; 95% CI: 0.40 – 1.42) and neuromuscular stimulation for
glenohumeral subluxation (SES 1.41; 95% CI: 0.76 – 2.06). No or insufficient
evidence in terms of functional outcome was found for: traditional
neurological treatment approaches; exercises for the upper limb;
biofeedback; functional and neuromuscular electrical stimulation aimed at
improving dexterity or gait performance; orthotics and assistive devices; and
physiotherapy interventions for reducing hemiplegic shoulder pain and
hand oedema.
Conclusions: This review showed small to large effect sizes for task‐oriented
exercise training, in particular when applied intensively and early after
stroke onset. In almost all high‐quality RCTs, effects were mainly restricted
to tasks directly trained in the exercise program.

24
Impact of physiotherapy on functional outcome
Introduction

Systematic research has shown that organised multidisciplinary care and
rehabilitation after stroke enhance patient survival and independence, as
well as reducing the length of inpatient stay.1‐3 It remains unclear, however,
why specialised stroke units are more effective than usual care. A number of
components have been identified as contributing to the efficacious care
delivered in such units. These include the comprehensive assessment of
medical problems, impairments and disabilities; active physiological
management; early mobilisation and avoidance of bedrest; skilled nursing
care; early setting of rehabilitation plans involving carers; and early
assessment and planning for discharge needs.1,4 Several of these factors are
closely related to physiotherapy which is often perceived as one of the key
disciplines in organised stroke care.5 In addition, a recent Cochrane review
of 14 trials (N=1617) showed that outpatient services, including
physiotherapy, may prevent deterioration in seven of 100 stroke patients
residing in the community.6 The main foci of physiotherapy after stroke are
to restore motor control in gait and gait‐related activities and to improve
upper limb function, as well as to learn to cope with existing deficits in
activities of daily living (ADL) and to enhance participation in general.
Besides using physical exercises, physiotherapists often apply assistive
devices for gait, and employ other equipment such as treadmills and
electronic devices to support their treatments. In addition, advice and
instructions are provided to the patient, family and other members of the
stroke team regarding prevention of complications such as falls and
shoulder pain. Today, the importance of evidence based medicine, as a
guide for the clinical decision making process, is increasingly being
recognised by physiotherapists.7,8 However, the efficacy of physiotherapy
interventions for stroke has not been summarised in a systematic review.
The objective of the present systematic review was to establish the evidence
of physiotherapy interventions related to improving functional outcomes
after stroke.

Material and Methods

Literature search
A computerised literature search was conducted in MEDLINE, CINAHL,
Cochrane Central Register of Controlled Trials, Cochrane Database of
Systematic Reviews, DARE, PEDro, EMBASE and DocOnline (Database of
25
Chapter 2
the Dutch Institute of Allied Health Care). Two researchers (RPSvP and
JCFK) independently searched these electronic databases for relevant
articles. The search strategy was built on cerebrovascular disease (patient
type) and physiotherapy interventions (treatment type). Randomised
controlled trials (RCTs) as well as controlled clinical trials (CCTs) were
included for review. Excluded were noncontrolled pre‐experimental studies
and controlled studies that investigated robotics or the effects of
physiotherapy in combination with acupuncture or drug therapies. Studies
were collected up to January 2004. The following MeSH and keywords were
used for the electronic databases: cerebrovascular disorders, cerebrovascular
accident, stroke, hemiplegia, physiotherapy, occupational therapy, exercise
therapy, and rehabilitation. Bibliographies of review articles, narrative
reviews and abstracts published in conference proceedings were also
evaluated for relevant publications. In addition, citation tracking of all article
references was conducted. Only articles written in English, German or Dutch
were included for review. Inclusion of articles was based on agreement
between the two independent reviewers. The full search strategy is available
on request from the corresponding author.
Subsequently, the two reviewers independently determined from the title
and the abstract if the papers satisfied the following criteria: population of
adults (18 years or older) diagnosed with stroke and studies evaluating
effectiveness of physiotherapy interventions.

Intervention categories
For the present review, physiotherapy was classified into 10 intervention
categories to evaluate the effectiveness of: 1) traditional neurological
treatment approaches; 2) programs for training sensorimotor function or
influencing muscle tone; 3) cardiovascular fitness and aerobic programs; 4)
methods for training mobility and mobility‐related activities; 5) exercises for
the upper limb; 6) biofeedback therapy for the upper and lower limb; 7)
functional and neuromuscular electrical stimulation for both limbs; 8)
orthotics and assistive devices for both limbs; 9) treatments for hemiplegic
shoulder pain and hand oedema; and 10) intensity of exercise therapy.
This classification was based on the International Classification of
Functioning, Disability and Health (ICF) of the World Health Organization9
and the American Physical Therapy Association guide to physical therapist practice
(2nd edition)10. A group of eight physiotherapists and two reviewers (GK and
RPSvP) reached consensus about the categories.

26
Methodological quality
The methodological quality of the RCTs was rated with the PEDro scale.11
RCTs were scored by two independent reviewers (RPSvP and GK). Inter‐
rater reliabilities of individual items of the PEDro scale were calculated by
Cohen’s kappa. In case of disagreement, consensus was sought, but when
disagreement persisted, a third independent reviewer (SWD) made the final
decision. PEDro scores of 4 points or higher were classified as ‘high‐quality’,
whereas studies with 3 points or lower were ‘low‐quality’. PEDro scores
were not used as inclusion/exclusion criteria, but rather as a basis for best‐
evidence synthesis and to discuss the strengths and weaknesses of studies.

Quantitative analysis
Analysis of the results was performed separately for each intervention and
restricted to RCTs. When they were comparable in terms of interventions,
patient characteristics and outcome measures, statistical pooling was
performed. Randomised studies using a cross‐over design were judged as an
RCT by calculating effects before the point of cross‐over. The data were
reanalysed by pooling the individual effect sizes using fixed effect sizes.12,13
Fixed effect sizes gu (Hedges’ g), were calculated for each study by finding
the difference between mean changes in the experimental group and in the
control group and dividing by the average population standard deviation
(SDi). To estimate SDi for gu, baseline estimates and standard deviations of
the control and experimental groups were pooled. The impact of sample size
was addressed by estimating a weighting factor (wi) for each study, and
assigning larger effect‐weights in studies with bigger samples. Subsequently,
gu of individual studies were averaged, resulting in a weighted SES, whereas
the weights of each study were combined to estimate the variance of the
SES.14 If significant between‐study variation existed (statistical
heterogeneity) a random effects model was applied.15 Based on the
classification of Cohen, effect sizes below 0.2 were classified as small, from
0.2 to 0.5 as medium and above 0.5 as large.16

Best‐evidence synthesis
If pooling of studies was not possible due to differences in outcomes,
intervention types, patient characteristics or lack of point estimates (means
and medians) and/or measures of variability (e.g. standard deviations and
confidence intervals) a best research synthesis was applied. For this purpose
we used the criteria set out by Van Tulder et al17 based on the
methodological quality score of the PEDro scale. Subsequently, studies were
categorised into five levels of evidence: 1) strong evidence, 2) moderate
27
Chapter 2
evidence, 3) limited evidence, 4) indicative findings, 5) no or insufficient
evidence (Table 1).37

Table 1 – Best-evidence synthesis
Strong evidence provided by statistically significant findings in outcome measures in

a
• at least 2 high-quality RCTs, with PEDro scores of at least 4 points
Moderate evidence provided by statistically significant findings in outcome measures in

• at least one high-quality RCT and
a
• at least one low-quality RCT (< 3 points on PEDro) or one high-quality CCT
Limited evidence provided by statistically significant findings in outcome measures in

• at least one high-quality RCT or
a
• at least two high-quality CCTs (in the absence of high-quality RCTs)
Indicative findings provided by statistically significant findings in outcome measures in at least

• one high-quality CCT or low-quality RCTs* (in the absence of high-quality
RCTs), or
• two studies of a non-experimental nature with sufficient quality (in absence of
a
RCTs and CCTs)
No or insufficient evidence • in the case that results of eligible studies do not meet the criteria for one of the
above stated levels of evidence, or
• in the case of conflicting (statistically significant positive and statistically
significant negative) results among RCTs and CCTs, or
• in the case of no eligible studies
a
If the number of studies that show evidence is < 50% of the total number of studies found within the same category of
methodological quality and study design (RCT, CCT or non-experimental studies), no evidence will be classified.
28
Results

Literature search using multiple databases yielded 8024 citations on 29
January, 2004. After restricting these to the publication type ʹclinical trialʹ,
735 remained. Following the exclusion of: 1) pre‐experimental studies and 2)
controlled studies investigating the effects of physiotherapy interventions
that included people with nonstroke as a diagnosis or interventions with
acupuncture, drugs or robotics, 204 relevant studies were selected by title
and abstract. Twenty‐two of these articles were systematic reviews,13,18‐38 and
20 were critical or narrative reviews.39‐58 Eleven of the remaining 162 studies
had been published in more than one article.59‐80 A total of 151 publications
(123 RCTs and 28 CCTs) that focused on the effectiveness of physiotherapy
interventions in people with stroke were included for further analysis.
Cohen’s κ, as an estimate of agreement between the two raters for
methodological quality of the 123 RCTs, was 0.81.
For each intervention category the results of the studies that contributed to
the meta‐analysis or best‐evidence synthesis are presented in Tables 2 and 3.
The methodological quality of the RCTs is reported in Table 4.

1. Evidence related to the effects of the traditional neurological treatment
approaches
Eight RCTs67,81‐87 and 2 CCTs88,89 investigated the effects of using a specific
neurological treatment approach. Numbers of patients, characteristics of the
interventions, measures of outcome and observed effects are shown in Table
2. Different neurological treatment approaches including Bobath,67,81‐83,86,88
Brunnstrom,85,87,89 Rood,82,83 Johnstone,84 Proprioceptive Neuromuscular
Facilitation (PNF),85,88 Motor Relearning Programme (MRP),67 Ayres82 or
combinations of the above89 were investigated. With exception of 2 RCTs84,85
all studies evaluated the effects of Bobath in one of the treatment arms,
whereas one study used two experimental groups.86 Eight studies measured
ADL with the Barthel Index (BI),67,82,83,86,88 the Functional Independence
Measure (FIM)87 or other ADL scales85,89 as an outcome, and four studies
evaluated strength,83,85 synergism84 or muscle tone88. Three studies assessed
the effects of a neurological approach on length of stay (LOS)67,85,89 and
compared the effects of MRP and Bobath,67 PNF and Brunnstrom85 or
neuromuscular retraining techniques,89 whereas one CCT compared an
impairment orientated with a disability focused approach.90
The quality score of the RCTs ranged from 382,83 to 667. Due to differences in
both aims and outcomes, pooling of the studies was not possible. Best‐
29

Table 2 Physiotherapy intervention categories
30
Intervention Type of N Mean time Intensity of Results M.Q. References
categories intervention post-stroke intervention (PEDro)
Chapter 2
(range) mean (range) range

1. Neurological Traditional RCTs:369 ~ 1 w – 4.8y 30 – 90 min/d Moderate evidence found for 3 – 6 p. 8 RCTs: 67,81-87
treatment neurological CCTs:170 3 – 5 x p/w reducing LOS in favour of control 2 CCTs: 88,89
approaches treatment during 2 – 8 w groups. No evidence found for
approaches improving muscle strength,
synergism, muscle tone, walking
ability, dexterity or ADL.
2. Programs for Strengthening RCTs:294 ~ 3 mo – 4 y 30 – 90 min/d Strong evidence found for 4 – 7 p. 6 RCTs: 91-96
training sensory- paretic muscles CCTs:47 2 – 5 x p/w improving muscle strength of 2 CCTs: 97,98
motor function or during 2 – 6 w lower extremity in favour of
influencing muscle experimental groups.
tone Limited evidence found for
improving gait performance or
walking endurance. No evidence
found for improving handgrip
force, dexterity, symmetry of
weight distribution, transferring,
gait speed, stair-walking or
physical and mental health.
Training sensory CCT: 39 6.2 y 20 – 45 min/d Indicative findings found for 4 p. 1 CCT: 99
integrity 3 – 5 x p/w, improving somatosensory
during 4 – 6 w perception.
Influencing RCTs: 245 < 11 w – 6.7 y 5 – 60 min/d Strong evidence found for 2 – 7 p. 9 RCTs: 71,84,100-
muscle tone and CCT: 8 2 – 5 x p/w reducing muscle tone in favour 106
stiffness during 3 – 12 w of TENS. Limited evidence found 1 CCT: 107
for AROM in favour of slow
stretch techniques.
Insufficient evidence found for
improving PROM in favour of
TENS and casts or splints.
3.Cardiovascular Training RCTs:154 > 30d - > 6 mo 30 – 90 min/d Strong evidence found for 4 – 7 p. 3 RCTs: 109-111
fitness and aerobic endurance CCT: 9 3 – 5 x p/w maximal workload, gait speed or 1 CCT: 112
programs during 8 – 10 w walking distance in favour of
experimental groups. Limited
evidence found for aerobic
capacity. No evidence found for
synergism, basic ADL or
instrumental ADL.

Table 2 - Continued -

Training RCTs: 197 10 d – 8 y 60 – 90 min/d Strong evidence found for aerobic 3 – 7 p. 5 RCTs: 80,113-116
aerobics 3 – 10 x p/w capacity and muscle strength of the
during 4 – 12 w lower extremity in favour of the
experimental groups. No evidence
found for synergism, walking
endurance and gait speed.
4. Methods for Training sitting RCTs: 108 2 w – 6.3 y 30 – 120 min/d Strong evidence found for weight 5 – 7 p. 4 RCTs: 86,117-119
training mobility balance 5 x p/w, distribution between paretic and
and mobility during 2 – 4 w nonparetic side in favour of
related activities experimental groups.
Training RCTs: 156 38 d – 6.3 y 15 – 30 min/d Strong evidence found for 5 – 7 p. 5 RCTs:
transfers from 5 – 15 x p/w symmetry between both legs during 61,113,117,119,120
sit-to-stand and during 2-6 w sit-to-stand and stand-to-sit or time
visa versa needed to stand up or sit-down in
favour of experimental group.
Limited evidence found for reducing
the occurrence of falls.
Training RCTs: 212 33 d – 18 mo 15 – 60 min/d Strong evidence found for reducing 4 – 6 p. 8 RCTs: 121-127,
standing balance CCT: 42 3 – 10 x p/w postural sway or increasing 129
during 2 – 8 w symmetry of weight distribution 1 CCT: 128
during stance in favour of
experimental groups.
No evidence found for balance
measured with the Berg Balance
Scale, whereas negative effects
found for timed up-and-go.
Body-weight RCTs: 268 17 d – 26 mo 20 – 45 min/d Strong evidence found for 4 – 7 p. 5 RCTs: 77,130-133
supported CCT: 43 3 – 5 x p/w improving walking endurance in 2 CCT: 134,135
treadmill training during 2 – 11 w favour of BWSTT. No evidence
found for improving postural
control, walking ability or
comfortable gait speed.
31

32
Chapter 2

Treadmill RCTs: 163 10 d – (> 6 mo) 5 – 60 min/d Strong evidence found for 4 – 7 p. 5 RCTs: 80,136-139
training without 3 – 5 x p/w improving walking ability in
body weight during 3 – 6 w favour of treadmill training
support without body weight support. No
evidence found for increasing
comfortable gait speed.
External auditory RCTs: 80 16 d – 32 mo 20 – 30 min/d Strong evidence found for 3 – 6 p. 3 RCTs: 140-142
rhythms 2 – 10 x p/w improving stride length and
during 3 – 12 w comfortable gait speed in favour
of external auditory rhythms.
Limb loading RCT: 24 > 6 mo 10 min/d No evidence found in favour of 7 p. 1 RCT: 143
7 d/w, limb loading for improving lance
during 6 w control or gait speed.
Wheelchair self- RCT: 16 d RCT: 16 d RCT: during 8 w No evidence found for 7 p. 1 RCT: 144
propelling CCT: ? CCT: ? CCT: ? influencing muscle tone or 1 CCT: 145
improving ADL.
5.Exercises for the Exercising the RCTs: 971 7 d – 4.8 y 30 – 90 min/d Insufficient evidence found for 3 – 7 p. 11 RCTs:
upper limb paretic arm 3 – 5 x p/w improving dexterity or ADL in 65,69,73,82,83,87,
during 5 – 20 w favour of the experimental 110,146-149
groups. No evidence found for
muscle strength and synergism.
Constraint- RCTs: 134 6 d – 4.8 y 2 – 10 hrs Strong evidence found for 4 – 7 p. 6 RCTs: 150-155
induced immobilisation p/d; dexterity of the paretic arm in
movement 1-6 hrs training/day favour of CIMT. No evidence
therapy 3 – 7 x p/w found for the amount of (paretic)
during 2 – 10 w arm use or ADL.
Bilateral arm RCT: 7 8.4 w – 6.5 y 15 – 20 min/d Indicative findings found for 3 p. 1 RCT: 156
training CCT: 27 3 – 10 x p/w improving grip strength or 1 CCT: 97
during 2 – 6 w dexterity of the paretic arm in
favour of bilateral arm training-
programs.
Mirror therapy RCTs: 25 10 mo – 4.8 y 15 – 30 min/d Limited evidence found for 4 – 5 p. 2 RCTs: 146,157
2 – 6 x p/w improving dexterity of the paretic
during 5 – 8 w arm in favour of mirror therapy.


6.Biofeedback Biofeedback to RCTs: 262 36 d – 33.6 mo 20 – 60 min/d No evidence found for improving 2 – 6 p. 12 RCTs: 140,158-
therapy the paretic lower CCTs: 92 2 – 5 x p/w active ROM ankle or comfortable 168
limb during 2 – 12 w gait speed in favour of 4 CCTs: 169-172
biofeedback therapy.
Biofeedback to RCTs: 247 7 w – 3.1 y 2 0 – 60 min/d Insufficient evidence found for 2 – 7 p. 10 RCTs:
the paretic upper CCTs: 60 2 – 5 x p/w improving dexterity in favour of 81,163,173-180
limb during 1 – 10 w biofeedback therapy. No eviden- 3 CCTs: 181-183
ce found for improving muscle
strength and active ROM.
7.Functional Effects of FES RCTs: 176 26 d – 4.5 y 20 – 60 min/d Limited evidence found for 4 – 6 p. 5 RCTs: 162,184-
Electrical on the lower limb 3 – 5 x p/w improving muscle strength, 187
Stimulation and during 4 – 6 w physiological cost index or
Neuromuscular walking ability in favour of FES.
stimulation No evidence found for improving
synergism of lower extremity,
gait speed or ADL.
NMS of the RCTs: 154 16 d – 3 mo 30 – 90 min/d Limited evidence found for 3 – 7 p. 4 RCTs: 188-191
paretic forearm 1 – 3 x p/d improving muscle strength of the
without EMG- during 3 – 8 w extensors of the paretic forearm
triggering or dexterity. The evidence for
dexterity was restricted only for
patients with voluntary move-
ment control of extension of wrist
and fingers. No evidence found
for dexterity in patient without
voluntary movement control.
Indicative findings found for
improving active ROM in favour
of the experimental groups.
NMS of the RCTs: 81 18 d – 3.5 y 30 – 90 min/d Insufficient evidence found for 3 – 5 p. 4 RCTs: 192-195
paretic forearm CCT: 22 3 – 5 x p/w improving muscle strength or 1 CCT: 196
with EMG- during 2 – 12 w dexterity of the paretic arm. No
triggering evidence found for improving
synergism in favour of the
experimental groups.
33

34
categories intervention post- intervention (PEDro)
Chapter 2
stroke mean (range) range

( )
NMS for RCTs: 161 2 d – 430 d 30 min/day to 6-7 Strong evidence found for 4 – 7 p. 4 RCTs:
glenohumeral CCTs: 144 hours/day; increasing passive ROM (lateral 63,75,197,198
subluxation and resp. 4 to 1 x p/d rotation of paretic shoulder) and 2 CCTs: 199,200
hemiplegic during 4 – 8 w education of caudal subluxation
shoulder pain in favour of NMS. Insufficient
evidence found for reducing
hemiplegic shoulder pain.
8.Applying orthotics Applying Ankle- RCT: 60 3 mo – 3 y 1 day– 3 mo No evidence found for improving 7 p. 1 RCT: 59
and assistive devices Foot-Orthosis gait speed in favour of applying
for the lower and upper an AFO.
extremities
Slings, supportive RCT: 98 15 d – 8mo daily during No evidence found for reducing 7 p. 1 RCT: 202
devices and strap- CCTs: 22 6 – 12 w glenohumeral subluxation or 2 CCTs: 201,203
ping techniques for decreasing hemiplegic shoulder
reducing GHS and pain to support the effectiveness
HSP of hemi- slings or strapping
techniques.
9.Treatment of Exercises for the RCTs: 98 15 d – 8.2mo 15– 30 min/d No evidence found for 4 – 5 p. 2 RCTs: 204,205
hemiplegic shoulder hemiplegic CCTs: 76 3 – 5 x p/w decreasing hemiplegic shoulder 2 CCTs: 206,207
pain and hand oedema shoulder during 4 w – 3mo pain or improving active ROM.
Treatment of hand RCT: 37 RCT: 3.7 w 2 x 2 hours/d No evidence found for 7 p. 1 RCT: 208
oedema during 4 w intermittent pneumatic
compression for reducing hand
volume.
10.Intensity of exercise Intensity of RCTs:2686 7d – 4.7y 132 – 6816 min Strong evidence found for 4 – 8 p. 20 RCTs:
therapy exercise therapy CCTs : 813 improving comfortable gait 65,69,73,80,85,147-
speed, basic ADL and 149,209-220
instrumental ADL in favour of 3 CCTs: 221-223
augmented exercise therapy.
No evidence found for improving
dexterity of the paretic arm.
ADL indicates activities of daily living; AFO, ankle foot orthosis; AROM, active range of motion; BWSTT, body weight supported treadmill training; CCT, controlled clinical trial;
CIMT, constraint-induced movement therapy; d, day(s); EMG, electromyography; FES, functional electrical stimulation; GHS, glenohumeral subluxation; HSP, hemiplegic shoulder pain;
LOS, length of stay; min, minute(s); mo, month(s); M.Q., methodological quality (points on PEDro scale); N, number of patients involved; NMS, neuro muscular stimulation;
PEDro, physiotherapy evidence database; RCT, randomised controlled trial; PROM, passive range of motion; ROM, range of motion; TENS, transcutaneous electrical nerve stimulation;
w, week(s); y, year(s)
evidence synthesis showed moderate evidence for a reduced LOS in favour
of MRP or traditional care compared to an impairment‐focused
neuromuscular treatment approach such as Bobath.67,89,90 No evidence was
found for applying a specific neurological treatment programs in terms of
muscle strength,83,85 synergism,84 muscle tone,88 walking ability,88
dexterity67,81,87 or ADL67,82,83,85‐89.

2. Programs for training sensory‐motor function or influencing muscle
tone
‘Sensory motor training’ was defined as exercises for improving motor
performance, strength, power, and endurance,10(S72) as well as sensory
integrity (proprioception, pallaesthesia, stereognosis and topognosis)10(S90).

Strengthening paretic muscles
Six RCTs91‐96 and two CCTs97,98 investigated eccentric98 and concentric
strengthening exercises for the lower91‐94,96‐98 and upper limbs92,97. Treatment
sessions ranged from 3096 to 9095 min per day, and were applied 291 to 595
times a week for 295 to 693,94 weeks (Table 2). Methodological quality ranged
from 491,93 to 794. A meta‐analysis was possible for 3 RCTs91,92,94 that assessed
self‐selected comfortable walking speed. A homogeneous nonsignificant SES
was found in favour of strengthening muscles of the paretic lower limb on
gait speed (Table 3). By weighting the quality of the studies, a best‐evidence
synthesis showed strong evidence for the value of increasing the muscle
strength of the lower limb in terms of maximal voluntary efforts,92 mass
motion (on an Elgin‐table)93 or maximal isokinetic strength (on a Kin‐Com)94.
Limited evidence was found for increasing walking endurance91,92 and gait
performance (average torque of muscle groups of paretic and nonparetic
leg)94,98. No evidence was found for strengthening exercises to improve
handgrip force,92,97 to support strengthening muscles for climbing stairs,94
transferring,92 establishing symmetry of weight distribution between
hemiplegic and nonhemiplegic sides,98 dexterity92,97 or for physical and
mental health94.

Training sensory integrity
In one CCT99 the effectiveness of sensory re‐education of arm and hand was
investigated of the paretic limb. Training was provided 45 min, three times a
week for six weeks (Table 2). Cutaneous stimulation contained tasks such as
identificating letters, discriminating objects and localising body parts on the
hemiplegic side. While significant effects were reported for somatosensory
perception, evaluation of treatment effects for functional outcomes was
35
Chapter 2
lacking. Based on one CCT,99 there were indicative findings that sensory
training may improve somatosensory perception.

Influencing muscle tone and stiffness
In nine RCTs71,84,100‐106 and one CCT107 the effects of different interventions for
the treatment of spasticity of the paretic limbs were investigated by
applying: an inflatable pressure splint84; reflex inhibiting positioning100,108;
spastic muscle stretchings101; inhibitory casts or thermoplastic splints to the
upper limbs102,103,107; and transcutaneous electrical nerve stimulation
(TENS)71,104‐106 (Table 2). The quality scores of these RCTs ranged from 2103 to
7100.
Due to differences in outcomes and treatment modalities, pooling of the
studies was only possible for TENS, and showed a significant homogeneous
SES for reducing muscle tone according to a (modified) Ashworth scale71,105
(Table 3). In addition, best‐evidence synthesis showed limited evidence for
slow stretch techniques in improving active ROM.101 Insufficient evidence
was found for TENS71,104 and inhibitory casts or thermoplastic splints102,103,107
in improving passive ROM. No evidence was found that stretching
techniques, splinting or TENS improved functional outcome.

3. Cardiovascular fitness and aerobic programs
Aerobic capacity and physical endurance were defined as the ability to
perform work or participate in activity over time using body’s oxygen
uptake, delivery and energy release mechanisms.10(S48)
Three RCTs109‐111 and one CCT112 investigated the effects of cardiovascular
fitness training after stroke. They studied the use of a home based exercise
program110 incorporating a leg cycle ergometer109,111 or muscle
strengthening110, in terms of synergism109,110, aerobic capacity109, gait
speed110,111, walking endurance110,111 and instrumental ADL110,111.
Treatment sessions ranged from 30109 to 90110 min and were applied 3109,110 to
5111 times a week for 8110,111 to 10109 weeks (Table 2). The quality of the RCTs
ranged from 4109 to 7110,111. Due to differences in measurements, pooling was
only possible for the Fugl‐Meyer (FM) motor scores and gait speed. It
showed a statistically significant homogeneous SES for gait speed110,111 and a
nonsignificant heterogeneous SES for FM‐motor score109,110 (Table 3). Best‐
evidence synthesis demonstrated strong evidence for maximal
workload109,111 and walking distance110,111, whereas limited evidence was
found for aerobic capacity (VO2, Ve and VCO2)109. No evidence was found
for basic110 or instrumental110,111 ADL.

36
Five RCTs80,113‐116 investigated the effects of interventions combining muscle
strengthening and endurance training. Outcomes were reported for lower
limb strength114‐116, synergism of the lower extremity80,114, balance80,114, aerobic
capacity114,115, endurance113,114, rising from sitting to standing113, gait
speed80,113,114,116, dexterity114 and ADL80. Training sessions ranged from 60113,115
to 90114,116 min per day, and were applied 3113‐116 to 10 times a week for 4113 to
12114,115 weeks (Table 2). Methodological quality ranged from 3113,115,116 to 7114
points.
Pooling was possible for muscle strength, synergism, aerobic capacity,
walking endurance and gait speed. A homogeneous statistically significant
SES was calculated for aerobic capacity114,115 and a heterogeneous statistically
significant SES for muscle strength of the lower extremity114‐116. No
statistically significant homogeneous SESs were found for synergism in the
lower extremity80,114, walking endurance113,114 or gait speed80,113,114,116 (Table 3).

4. Methods for training mobility and mobility related activities
Training mobility and mobility‐related activities was divided into three
subcategories: balance, gait, and wheelchair propulsion.

Training balance and postural control
Fourteen RCTs and one CCT studied the effects of balance training on
improving sitting balance (four RCTs86,117‐119), rising from sitting to standing
(five RCTs61,113,117,119,120), and standing balance with visual feedback (seven
RCTs121‐127 and one CCT128) or perceptual feedback (1 RCT)129. Treatment
sessions ranged from 1561 to 120118 min per day, 3123,127 to 15 times a week61
for 286,117,121,129 to 8124,126 weeks (Table 2). The goals of these interventions were
to reduce postural sway121‐127,129, to increase the symmetry of weight
distribution between paretic and nonparetic sides61,86,113,117‐120,122‐124 and to
reduce number of falls120. Outcomes of these studies were evaluated in terms
of weight distribution between paretic and nonparetic side, while sitting86,117‐
119 or standing up61,113,117,120, the time to rise from the sitting to standing
position61,120 the Timed Up&Go124,126,127, postural sway/symmetry121‐125,129 and

gait speed128. The methodological quality ranged from 4121,126 to 7117 points.
Pooling was possible for those studies that aimed to improve transfers and
standing balance. Statistically significant homogeneous SESs were found for
postural symmetry of rising from sitting to standing61,113,117,120, sitting down
from standing61,120, and time needed to rise61,120, whereas training standing
balance resulted in a significant reduction in postural sway and an increase
in the symmetry of weight distribution between paretic and non paretic
sides121‐125 (Table 3). A significant heterogeneous SES was found for time
37
Chapter 2
needed to sit in making transfers61,120, whereas the Timed Up&Go test
showed a heterogeneous significant negative SES for those patients who had
received training for standing balance124,126,127. Moreover no significant effects
were found in those studies124,126,127 that measured control of balance by the
Berg Balance Scale (Table 3).
The best‐evidence synthesis for evaluating effects of training sitting balance
showed strong evidence that this intervention improves the ability to reach
forward with the arm when in a seated position86,117‐119; limited evidence was
observed for reducing the occurrence of falls in programs aimed at
improving transfers.

Treadmill training
Treadmill training was applied 1) with body weight support and 2) without
body weight support. Five RCTs77,130‐133 and two CCTs134,135 investigated the
effects of body weighted supported treadmill training (BWSTT) on recovery
of balance77,131,134, gait77,130‐134, and walking endurance77,130,133. Amount of body
weight support ranged from 0%77 to more than 40%134 and was applied 3132,134
to 5130,131,133 times a week for 2077,132,133 to 45130 min per day for 2134 to 11131
weeks (Table 2). The methodological quality ranged from 4130,133 to 7131
points.
Meta‐analysis demonstrated large effect sizes for walking endurance77,130,133,
whereas no significant effect sizes were found for postural control as
measured by the Berg Balance Scale77,131, walking ability131,133 or gait
speed77,130‐133 (Table 3).
Five RCTs80,80,136‐139, with methodological quality ranging from 580 to 8139
points, investigated the effects of treadmill training without body weighted
support. Treatment sessions lasted from 5 min136 to 1 h137 per day, and were
applied 3137‐139 to 580,80 times a week for 380 to 680 weeks (Table 2). The RCTs
showed significant homogeneous SES for walking ability136,138, whereas a
heterogeneous nonsignificant SES was found for gait speed80,136‐138 (Table 3).

External auditory rhythms (EAR)
Three RCTs140‐142 investigated the effects of EAR on tempero‐spatial
parameters of gait including stride length, cadence, symmetry of gait and
gait speed140‐142. Training sessions ranged from 20142 to 30141 min per day,
occurred 2140 to 10141 times a week for 3142 to 12140 weeks (Table 2). The
methodological quality varied from 3140,141 to 6142 points on the PEDro scale.
Pooling these studies showed a homogeneous significant SES for stride
length140,142 and gait speed140‐142 (Table 3).

38
Limb loading
One RCT143 investigated the effects of exercise training with weighted
garments to improve balance and gait (Table 2). Home training with
weighted garments was compared to a training program without garments.
The study showed no statistically significant effects, and thus, no evidence
to support limb loading in terms of balance or gait speed.

Wheelchair propulsion
One RCT144 and one CCT145 investigated the effects of self‐propelling a
wheelchair on muscle tone144, control in accuracy of wheelchair driving145
and ADL144. Best‐evidence synthesis of the studies showed no evidence that
wheelchair propulsion with only the nonhemiplegic hand and foot resulted
in better ADL, or that it influenced spasticity (Table 2).

5. Exercises for the upper limb
Effectiveness of exercising the paretic arm
Eleven RCTs65,69,73,82,83,87,110,146‐149 studied the effects of exercise therapy aimed
at improving function of the paretic arm. Exercise training included the use
of specific neurological treatment approaches or task‐oriented training
programs. Therapy time ranged from 30147 to 90110,149 min per day, 3110 to
565,82,147,149 days a week for 569 to 2065 weeks (Table 2). Outcomes were
evaluated in terms of muscle strength73,83,149, synergism110,147,
dexterity65,69,73,87,147,149 or ADL65,69,73,82,83,87,110,147‐149. In some studies the specific
exercise program was added to a conventional treatment program.65,69,73,147‐149
Methodological quality ranged from 382,83 to 765,110 points. Due to differences
in outcomes, study pooling was not possible. Further, best‐evidence
synthesis showed insufficient evidence for the use of exercise programs
aimed at enhancing dexterity of the paretic arm or improving ADL. No
evidence was found for improving muscle strength or synergism from
exercise programs for the paretic arm.

Constraint‐ induced movement therapy (CIMT)
Six RCTs150‐155 investigated the effects of CIMT on motor performance151,152,155,
dexterity of the paretic arm150‐155 and ADL150,155. The nonparetic arm was
constrained for 5151,152 to 10153 h per day over a 2150,154,155 to 10151,152 week
period. In addition, exercise training was provided for 1151,152 to 6153‐155 h a
day for 3 times a week151,152 to every weekday153 (Table 2). Quality of the
RCTs ranged from 4153 to 7155 points on the PEDro scale.
The meta‐analysis using dexterity measured with the Arm Motor Activity
Test (AMAT) or Action Research Arm Test (ARAT) as an outcome showed a
39
Chapter 2
statistically significant SES150‐152,154,155 in support of CIMT. No significant

effects were found for the Motor Activity Log that evaluates the amount of
use in daily living 154,155 (Table 3). Best‐evidence synthesis showed no
differential effects due to CIMT for ADL as measured by Barthel Index150,
Rehabilitation Activities Profile (RAP)155 or the Functional Independence
Measure150.

Bilateral arm training
One RCT156 and one CCT97 investigated the effects of high repetitive bilateral
cyclic training of the upper limb. Outcomes were muscle strength and
dexterity97,156 (Table 2). Due to relatively poor methodological quality as well
as differences in outcomes, pooling was not possible. Best‐evidence
synthesis showed indicative findings in favour of bilateral arm training on
grip strength97 and dexterity of the paretic arm97.

Mirror Therapy
Using subjects with stroke, two RCTs146,157 investigated the effects of mirror
therapy on active ROM146, muscle tone157 and dexterity as assessed with the
ARAT157. Patients were asked to move the nonparetic arm while looking in a
mirror that gave the impression that the paretic limb was moving. Therapy
sessions ranged from 15146 to 30157 min per day, 2157 to 6146 times a week for
5157 to 8146 weeks (Table 2). Based on studies of moderate quality (scores of
4146 to 5157 points), a best‐evidence synthesis suggested limited support for
improving dexterity through the use of mirror therapy.

6. Biofeedback therapy
Biofeedback to the paretic lower limb
Twelve RCTs140,158‐168 and four CCTs169‐172 investigated the effects of
biofeedback including EMG feedback158‐160,162‐167 and positional feedback140,161.
Biofeedback was aimed at improving knee flexion165, knee extension167, ankle
dorsiflexion158,159,162,163,166 or ankle plantar flexion140 or reducing
hyperextension of the knee168 of the paretic leg during gait. In six
RCTs158,159,161,164,165,167,168 biofeedback was applied in adjunct to basic exercises,
whereas in five studies the control group received a specific neurological
treatment approach159,161,164,166,167, gait training158, placebo biofeedback160 or no
treatment at all140. The intensity of biofeedback training ranged from 20163 to
60164 min per day, 2140,161 to 5 times a week163,164,167,168 for 2163 to 12140 weeks
(Table 2). The quality of the RCTs ranged from 2165 to 6162‐164,168 points.
Pooling of studies was only possible for two outcomes. Homogeneous non
40
significant SESs were found for active ROM of the paretic ankle140,158,159,166
and gait speed140,159,161,162,164‐166 (Table 3).

Biofeedback to the paretic upper limb
Ten RCTs81,163,173‐180 and three CCTs181‐183 studied the effects of EMG feedback
on motor control and dexterity of the paretic upper limb. In 3 of 10 studies
EMG feedback was applied as an adjunct to a basic exercise program173,175,177
and compared to a neurological treatment approach81,173,176‐178,181, placebo
EMG163,175,180 or no treatment182. In terms of intensity, biofeedback was given
for 30179 to 60177,178,181 min per day, 2176,178 to 5 times a week163,179 for between
one week179 and six months182 (Table 2). Study quality ranged from 2174 to 7
points175. Due to different aims and outcomes across the studies, pooling of
data was not possible. Most of the RCTs showed no statistically significant
effects. Best‐evidence synthesis showed no evidence to support the use of
biofeedback for improving strength177 or increasing active ROM163,176,177,179,
whereas there was insufficient evidence to determine its effect on dexterity
of the paretic upper limb173,175.

7. Functional Electrical Stimulation (FES) and Neuromuscular
Stimulation (NMS)
Effects of FES on the lower limb
Five RCTs162,184‐187 investigated the effects of FES on muscle strength187,
synergism184,186, Physiological Cost Index (PCI)185, walking ability186, gait
speed162,184,185 and ADL186 in stroke patients. A nonsignificant homogeneous
SES was found for studies investigating synergism of the lower limb
measured with the Fugl Meyer motor assesment184,186, whereas a non
significant heterogeneous SES was observed for gait speed184,185 (Table 3).
Based on best‐evidence syntheses, limited evidence was found in support of
FES for muscle strengthening187, PCI185 and walking ability186. No evidence
was found for ADL as measured with the Barthel Index.

Neuromuscular stimulation of the paretic forearm, with and without EMG
triggering
Four RCTs188‐191 investigated the effects of NMS without EMG triggering on
active ROM of the wrist and dexterity in stroke patients. NMS of the
extensors of the wrist and fingers of the paretic forearm was applied 30188 to
90191 min per day during 3189 to 8191 weeks. Outcome was evaluated in terms
of muscle strength of the wrist extensors188,191, synergism189, active ROM188,
dexterity191 or ADL189,191 (Table 2). Methodological quality ranged from 3188 to
7191. Pooling was not possible due to differences in outcomes and in the
41
Chapter 2
parameters of NMS that were used. Best‐evidence synthesis showed

indicative findings in favour of NMS for active ROM188 and limited evidence
for muscle strength188,191 and dexterity191. However, the evidence for
dexterity was restricted to only those patients with some voluntary control
of wrist and finger extension at baseline of the study191.
Four RCTs192‐195 and one CCT196 studied the effects of NMS with EMG
triggering for improvement of finger and hand‐extension in stroke patients.
In two trials only patients with some voluntary wrist extension192 or strength
in the forearm extensors193 were included. Stimulation ranged from 30193,194 to
90195 min per day, 2195 to 5193,194,196 times a week for 2192,195 to 12194,196 weeks
(Table 2). Outcome was evaluated on the basis of strength of forearm
extensors192 and flexors196, synergism192‐194,196, dexterity192,194,195 and ADL193.
Methodological quality of the studies ranged from 3192 to 5193‐195 PEDro
points.
Pooling individual RCTs for synergism showed a non significant
homogenous SES193,194 (Table 3). Insufficient evidence was found for EMG‐
triggered NMS for muscle strength192,196 and dexterity192,194.

Neuromuscular stimulation for glenohumeral subluxation (GHS) and hemiplegic
shoulder pain (HSP)
Four RCTs63,75,197,198 and two CCTs199,200 investigated the effects of NMS on the
subluxated hemiplegic shoulder. NMS was restricted to the supraspinatus
and dorsal deltoid muscles of the paretic shoulder. Treatment sessions
ranged from 30 min198,200to 6 hours a day63,75,197, 575,197,200 to 763,198 days a week
for 4198 to 663,75,197,200 weeks (Table 2). Study quality ranged from 463,75,197 to 7198
points. Meta‐analysis of the RCTs showed a heterogeneous, statistically
significant SES for reduction in caudal subluxation63,75,197,198, and a
homogeneous statistically significant SES for the increase in lateral passive
ROM63,198 (Table 3). The best‐evidence synthesis showed insufficient
evidence for effects of NMS on reducing HSP.

8. Applying orthotics and assistive devices for the lower and upper
Extremities
Assistive, supportive and adaptive devices for the lower limb were defined
as equipment used to aid patients in ambulation. Assistive and supportive
devices included crutches, canes, walkers, electric neuromuscular devices,
static and dynamic (knee) ankle‐foot orthosis (AFO), whereas adaptive
devices included environmental controls and seating systems.10(S54) Orthotic,
assistive and supportive devices for the upper limb included braces, casts,
42
slings, splints and supportive taping, neuromuscular stimulation and kinetic
and EMG feedback equipment.10(S76)

Applying ankle‐foot orthosis (AFOs)
One RCT59 investigated the effects of an AFO on walking ability and gait
speed59. Best‐evidence synthesis based on one high‐quality RCT59 showed no
evidence for increased gait speed when an AFO was provided after stroke
(Table 2).

Slings, supportive devices and strapping for reducing glenohumeral subluxation
(GHS)
Several techniques, aimed at reducing GHS, and thereby, decreasing
hemiplegic shoulder pain, have been studied. One CCT201 investigated the
effectiveness of using a hemi‐sling. In addition, one RCT202 and one CCT203
investigated the impact of supportive taping for the hemiplegic shoulder
(strapping). The quality of the RCT202 was 7 points (Table 2). Undertaken
because of lack of comparability between studies, a best‐evidence synthesis
revealed no evidence for reducing a glenohumeral subluxation or decreasing
hemiplegic shoulder pain to support the effectiveness of hemi‐slings and
strapping techniques.

9. Treatment of hemiplegic shoulder pain and hand oedema
Effectiveness of exercises for the hemiplegic shoulder
Two RCTs204,205 and two CCTs206,207 studied the effects of an exercise program
for a painful hemiplegic shoulder. Comparisons were made with
ultrasound204, cryotherapy205, nonsteroid anti‐inflammatory drugs207 or
pulley exercises for the paretic shoulder206. The exercise programs were
given for 15‐30 min per day, 3204,207 to 5206 times a week for four weeks204,205 to
3 months207 (Table 2)206. The quality of the studies ranged from 4206 to 5204
points205. Best‐evidence synthesis showed no positive effects of exercising
the hemiplegic shoulder in terms of decreasing shoulder pain204‐207 or
improving active ROM204‐207.

Treatment of hand oedema
One RCT208 studied the effects of Intermittent Pneumatic Compression
(IPC)208 on oedema of the paretic hand. IPC was offered for 2 h two times per
workday for four weeks208. Best‐evidence synthesis showed no evidence for
IPC in terms of reduction of oedema of the paretic hand (Table 2).

43

Table 3 Quantitative analysis of RCTs
44
Intervention Type of Pooling possible for: Ref. Measure- N Type SES [ 95% CI ] Calculated
categories intervention ments (pooling) effects mean
Chapter 2
model# change
(direction effect)
91,92,94
Programs for training Strengthening a. Comfortable gait a: a: 4MW, 10MW a: 84 a: fixed a: 0.32 [-0.18 – 0.81] a: –
sensory-motor paretic speed
function or influencing muscles
muscle tone
71,105
Influencing a: Muscle tone a: a: MAS, AS a: 104 a: fixed a: 0.44 [0.04 – 0.83]* a: 11% ↑
muscle tone
and stiffness
(TENS)
109,110
Cardiovascular fitness Training a: Synergism a: a: BFM a: 62 a: random a: -0.56 [-0.64 – 1.76] a: –
and aerobic programs endurance b: Gait speed 110,111 b: 10MW b: 112 b: fixed b: 0.65 [0.27 – 1.04] * b: 0.08 m/s ↑
b:
80,114
Training a: Synergism a: a: BFM-leg a: 117 a: fixed a: 0.28 [-0.08 – 0.65] a: –
aerobics b: Muscle strength 114-116 b: Cybex II legpr. b: 148 b: random b: 0.99 [0.49 – 1.50] b: –
b:
c: Aerobic capacity 114,115 c: peak VO2 c: 135 c: fixed c: 0.39 [0.05 – 0.74] * c: 11 % ↑
c:
d: Walking endurance 113,114 d: 6 min walk d: 109 d: fixed d: 0.27 [-0.11 – 0.65] d: –
e: Gait speed d: e: 4MW, 10MW, e: 139 e: fixed e: 0.25 [-0.08 – 0.59] e: –
80,113,114,116
e: 22MW
61,113,117,120
Methods for training Training sit- a: Postural symmetry sit- a: a: RBWD, VFD a: 128 a: fixed a: 0.92 [0.54 – 1.29] * a: 15% ↑
mobility and mobility to-stand to-stand 61,120 LR, PV GRF
b:
related activities transfers and b: Postural symmetry b: RBWD, VFD b: 96 b: fixed b: 0.92 [0.50 – 1.35] * b: 18% ↑
visa versa stand-to-sit : 61,120 LR
c
c: Time needed to 61,120 c: time (sec) c: 84 c: fixed c: 0.74 [0.30 – 1.19] * c: 9% ↑
stand-up d: d: time (sec) d: 84 d: random d: 0.68 [0.23 – 1.13] * d : 8% ↑
d: Time needed to sit-
down
121-125
Training a: Postural a: a: postural sway a: 126 a: fixed a: 0.50 [0.14 – 0.87] * a: 5% ↑
standing sway/symmetry / symmetry
balance b: Balance 124,126,127 b: BBS b: 59 b: fixed b: -0.16 [-0.68 – 0.35] b: –
b:
c: Timed Up&Go 124,126,127 c: TUG c: 59 c: random c:-0.72[-1.28-(-0.17)]* c: - 15 sec ↓
c:
77,131
Body-weight a: Balance a: a: BBS a: 145 a: fixed a: 0.27 [- 0.07 – 0.61] a: –
supported b: Walking endurance 77,130,133 b: 5 min. walk, b: 148 b: fixed b: 0.70 [0.29 – 1.10] * b: 31% ↑
b:
treadmill MDUF
training c: Walking ability 131,133 c: FAC c: 79 c: fixed c: 0.33 [- 0.09 – 0.76] c: –
c:
d: Comfortable gait 77,130-133 d: 5MW, 10MW, d: 220 d: fixed d: 0.10 [- 0.17 – 0.37] d:–
speed d: 2 min. walk

model# change
(direction effect)
136,138
Treadmill a: Walking ability a: a: FAC a: 65 a: fixed a: 1.09 [ 0.56 – 1.61]* a: 17% ↑
training b: Gait speed 80,136-138 b: 10MW b: 102 b: random b: 0.58 [- 0.45 – 1.62] b: –
b:
without BWS
140,142
External a: Stride length a: a: gait a: 43 a: fixed a: 0.68 [0.06 – 1.30] a: 0.18 m ↑
auditory b: Gait speed 140-142 analysis b: 67 b: fixed b: 0.91 [0.40 – 1.42] b: 0.22m/s ↑
b:
rhythms b: 10MW, 30
sec walk
150-52,154,155
Exercises for the upper CIMT a: Dexterity a: a: ARAT, a: 104 a: fixed a: 0.46 [0.07 – 0.85] * a: 13.5% ↑
limb b: Amount of use 154,155 AMAT b: 71 b: fixed b: 0.23 [- 0.24 – 0.70] b: –
b:
(paretic arm) b: MAL
140,158,159,166
Biofeedback therapy Biofeedback a: Active ROM a: a: ROM, a: 66 a: fixed a: 0.41 [- 0.10 – 0.91] a: –
to the lower b: Comfortable gait 140,159,161,162,164- AROM b: 98 b: fixed b: 0.35 [- 0.04 – 0.73] b: –
b:
limb speed 166 b: Gait
analysis,
6MW, 15MW
184,186
Functional electrical FES for lower a: Synergism a: a: BFM a: 58 a: fixed a: 0.01 [- 0.51 – 0.53] a: –
stimulation (FES) and limb b: Gait speed 184,185 b: 10MW, b: 52 b: random b: 0.73 [- 0.93 – 2.40] b: –
b:
Neuromuscular 20MW
stimulation (NMS)
193,194
NMS with a: Synergism a: a: BFM a: 44 a: fixed a: -0.06 [-0.76 – 0.63] a: –
EMG-
triggering
63,75,197,198
NMS for GHS a: Reduction subluxation a: a: X-rays a: 161 a: random a: 1.41 [0.76 – 2.06] * a: 5 mm ↑
and HSP b: Passive ROM (lateral 63,198 b: PROM b: 66 b: fixed b: 0.55 [0.05 – 1.04] * b: 13º lat.rot. ↑
b:
rotation)
45

46
Chapter 2
model# change
(direction effect)
65,69,73,80,85,147-
Intensity of exercise a: ADL a: a: BI, FIM a: 2686 a: random a: 0.13 [0.03 – 0.23] * a: 4.5% ↑
therapy 149,209-220
b: Gait speed 65,80,210,214,215,218 b: 10MW b: 576 b: fixed b: 0.19 [0.01 – 0.36] * b: 0.07 m/s ↑
b:
c: Dexterity 65,69,147,149,218 c: ARAT c: 676 c: fixed c: 0.03 [-0.13 – 0.19] c: –
d: Instrumental ADL c: d: NEADL d: 1570 d: fixed d: 0.23 [0.13 – 0.33] * d: 5% ↑
65,69,149,210,212,213,
d:
216,218,219
* statistical significant summary effect size (SES):p < 0.05 ;

# in case of a random effects model, no sensitivity analysis took place
AMAT indicates arm motor activity test; ARAT, action research arm test; AROM, active range of motion; AS, ashworth scale; BBS, berg balance scale;
BFM, brunnstrom fugl-meyer assessment; BI, barthel index; BWS, body-weight support; CIMT, constraint-induced movement therapy; FAC, functional ambulation categories;
FIM, functional independence measure; GHS, glenohumeral subluxation; HSP, hemiplegic shoulder pain; MAL, motor activity log; MAS, modified ashworth scale;
MDUF, maximal distance until fatigue; MW, metre walk; N, number of patients; NEADL, nottingham extended ADL; PROM, passive range of motion;
PV GRF, peak vertical ground reaction force through affected foot; RBWD, ratio body weight distribution; RCT, randomised controlled trial; ROM, range of motion;
TUG, timed up&go-test; VFD LR, vertical force difference between left + right
Table 4 Methodological quality analysis of the RCTs based on the PEDro scale
Intervention N Item on PEDro scale Median/

categories Mean
(range)
1* 2 3 4 5 6 7 8 9 10 11
Eligibi- Random Concealed Similarity Blinding Blinding Blinding Outcome Inten- Between PM
lity alloca- allocation baseline patients thera- asses- > 85% tion-to- group and MV
criteria tion pists sors patients treat compa-
risons
67,81- 67,81-87 67,81,84-86 67,81,82,86 67,84,87 67,81-87 67,81,83-85,87

1. 8 - - - - 4 / 3.8
(Traditional) 83,86,87
(3 – 6)
neurological
treatment
approaches
92-94,96,100- 71,84,91- 92- 71,84,91- 94-96,100,104- 84,92,94- 100,102,106 71,84,91- 71,84,91,

2. 15 - - 4 / 4.7
Programs for 102, 96,100-106 94,96,100,102 94,96,100,101,104 106 96,101,105,106 94,100,101, 92,94,96,
(2 – 7)
training sensory- 104-106 103,105 100,101,
motor function or 104-106
influencing muscle
tone
80,110, 80,109- 110,111,113, 80,109-111, 80,114 110,111,114, 110,114 80,109-111, 80,109-111,
3.Cardiovascular 8 - - 5 / 5.3
fitness and aerobic 111, 111,113-116 114 113-115 115 113-116 113,115,116
(3 – 7)
programs 113-116
61,77,80,86,1 61,77,80,86, 113,117,124, 61,77,80,86,113, 77,80,86,117- 61,117,118, 137,139,144 61,77,80,86,113, 61,77,80,113,

4.Methods for 29 - - 5 / 5.3
training mobility and 13,117- 113,117-124, 129,131,139, 117-120,122-124, 120,123,129, 120-123,127, 117-124,126,127, 117-124,126,
(3 – 8)
mobility related 121,123,124, 126,127,129- 142,143 126,127,129-133, 131-133,136- 129-131,136- 129-133,136-143 127,131,133,
activities 126,127,129- 133,136-144 136-139,141-144 140,143,144 139,142-144 136-139,142-144
65,69,7 65,69,73,82, 65,69,110, 65,69,73,110, 65,69,73,82, 65,73,87,110, 110,151,152, 65,69,73,82,83,87, 65,69,73,83,87,

5.Exercises for the 19 - - 5 / 5.0
upper limb 3, 83,87,110, 149,155 146-154,156,157 146-148,150- 147,149-157 155 110,147-150, 110,146,147,
(3 – 7)
82,83,8 146-157 155,157 154,155,157 149,155
7,
110,147
81,160- 81,140, 162,168,175 81,162-164, 81,140,159, 158-160,163, 81,140,159- 81,158,159,

6.Biofeedback 21 - - - 4 / 4.2
therapy for the lower 165,167,168, 158-168, 167,168, 160,163- 164,173,175, 164,166-168, 161-164,166-
(2 – 7)
and upper limb 173-175,179 173-180 173,175-177 165,173,175, 176,178,179 173-177,179,180 168,173,175,
178,179 176,179,180
47

48
Intervention N Item on PEDro scale Median/
categories Mean
Chapter 2
(range)
1* 2 3 4 5 6 7 8 9 10 11
Eligibi- Random Concealed Similarity Blinding Blinding Blinding Outcome Inten- Between PM
lity alloca- allocation baseline patients thera- asses- > 85% tion-to- group and MV
criteria tion pists sors patients treat compa-
risons
75,162,184- 63,75,162, 162,184,185, 63,162,184,186, 75,186,188,189, 184,185,189- 185,198 63,75,162,184- 63,75,162,184-

7.Functional 17 - - 5 / 4.9
electrical and 187,189,191- 184-195, 191,195 187,189,191,193, 191,193,198 192,194,195, 187,189- 191,193-
(3 – 7)
neuromuscular 194,197,198 197,198 194,197,198 198 195,197,198 195,197,198
stimulation
59,202 59,202 59,202 59,202 59,202 59 202 59,202 59,202

8.Applying 2 - - 7/7
orthotics and (7 – 7)
assistive devices
for the lower and
upper extremity
204,205, 204,205, 208 204,205 204,205,208 208 204,205,208 204,205,208
9.Treatment of 3 - - - 5 / 5.6
hemiplegic 208 208 ,208
(5 – 7)
shoulder pain and
hand oedema
65,69,73,80, 65,69,73,80, 65,69,149,209, 65,69,73,80,85, 65,69,73,80, 65,73,147,149, 212,215-219 65,69,73,80,85, 65,69,73,80,85,
10.Intensity of 20 - - 6 / 5.9
exercise therapy 147-149, 85,147- 211-216, 147-149,209, 147,148,210, 210,211,213- 147-149,209-220 147,149,
(4 – 8)
210-220 149,209-220 219,220 210,212- 212-216,218, 215,217-219 209-219
217,219,220 219
TOTAL (RCTs) 142 116 142 46 108 0 0 83 81 21 127 111 -
TOTAL without 123 100 123 39 93 0 0 72 74 19 109 97 5 / 5.1

doubles of RCTs (2 – 8)
* PEDro-item 1 evaluates the external validity and is not included in the sumscore of the Pedro. Sumscore of the PEDro is based on the items 2 - 11.
N indicates number of RCTs; PEDro, physiotherapy evidence database; PM and MV, point measures and measures of variability; RCTs, randomised controlled trials
10. Intensity of exercise therapy
Intensity of exercise therapy was defined as the additional time spent (in
minutes) in exercise training when the experimental group was compared to
the control group. Twenty RCTs65,69,73,80,85,147‐149,209‐220 and three CCTs221‐223
investigated the effect of augmented exercise therapy on functional
outcomes (Table 2). In RCTs, the contrast in therapy time spent between the
intervention and control groups ranged from 132215 to 6816 min209. Outcomes
were evaluated in terms of comfortable walking speed65,80,210,214,215,218,
dexterity65,69,147,149,218, ADL65,69,73,80,85,147‐149,209‐220 and instrumental
ADL 69,149,210,212,213,216,218,219. The quality of the RCTs ranged from 4 85,148 to 8215,219.
Pooling the RCTs for differences in treatment contrast showed statistical
significant SESs for ADL65,69,73,80,85,147‐149,209‐220, comfortable walking
speed65,80,210,214,215,218 and instrumental ADL65,69,149,210,212,213,216,218,219. A
homogeneous non‐significant SES was found for dexterity65,69,147,149,218 (Table
3).(See ref. 224 for an up‐to‐date review).

The methodological quality for all 123 RCTs is presented in Table 4. The
median score of these studies was 5 points (mean 5.1; range 2‐8 points on a
scale from 0 – 10 points). Only 39 RCTs mentioned a concealed allocation,
whereas just 19 RCTs described an intention‐to‐treat analysis. In none of the
studies was blinding possible for patient or therapist, and only 72 of the 123
RCTs had blinded the observer (Table 4).

Discussion

Evidence for physiotherapy interventions
The present review showed small but statistically significant SESs
supporting the intensity of exercise training. This represented a mean
improvement of 5% on ADL. Significant medium‐sized SESs were found for
aerobic training, TENS and constraint‐induced movement therapy. Large
SESs were found for training sit‐to‐stand transfers, applying neuromuscular
stimulation for glenohumeral subluxation, external auditory rhythms during
gait and treadmill training with and without body weight support. The
small to large effect sizes in high‐quality RCTs represent a mean
improvement favouring the experimental group ranging from 5% for
intensity of exercise therapy to 31% for BWSTT on walking endurance. The
clinical meaning of effects in favour of physiotherapy is difficult to judge.
The present findings however, support the use of physiotherapy to improve
performance as well as the capacity to perform regular daily activities after
49
Chapter 2
stroke, in particular when studies started early after stroke.224 It should be
noted that all the effective studies were characterised by focused exercise
programs within which the functional tasks were directly trained. In several
studies task‐oriented exercise training was intensified by offering a gait
program on a treadmill30, by constraining the nonparetic arm for several
hours per day225 or by offering patients a progressive series of different
workstations aimed at improving strength and endurance in a functional
way114. In contrast, impairment focused programs such as muscle
strengthening, muscular re‐education with support of biofeedback21,
neuromuscular22 or transcutaneous105 nerve stimulation showed significant
improvement in range of motion, muscle power and reduction in muscle
tone, however these changes failed to generalise to the activities themselves.
Interestingly, a similar trend was found for studies designed to improve
cardiovascular fitness by a cycle ergometer.27 Despite significant
improvements in workload in the high‐quality RCTs27, general fitness failed
to change. Strong evidence was found that neuromuscular stimulation
aimed at reducing the amount of glenohumeral subluxation, had no positive
impact on hemiplegic shoulder pain.
It was also noted that significant outcomes were most frequently found
for those variables measured by continuous parameters defined at interval
or ratio levels, such as gait speed77, walking distance110, postural sway and
symmetry in weight bearing between hemiplegic and nonhemiplegic side61.
Although these findings are perceived as important for functional
avtivities226, their real impact on performance of gait‐related activities needs
further clarification in future research.
The present review revealed no evidence in terms of functional outcomes
to support the use of neurological treatment approaches, compared to usual
care regimes. To the contrary, there was moderate evidence that patients
receiving conventional functional treatment regimens needed less time to
achieve their functional goals88 or had a shorter length of stay compared to
those provided with specific neurological treatment approaches, such as
Bobath.67,85,89 This discovery is in agreement with the criticism that these
traditional approaches are too impairment focused.33,47,49 In addition, several
treatment approaches have been criticised for having a weak theoretical
framework49,227,228 that is in conflict with recent theories of motor control229,230.
For the development of more effective exercise strategies, a better theoretical
understanding of the underlying mechanisms of disordered movement co‐
ordination in terms of perception and action is needed.49 Moreover, best‐
evidence synthesis showed no support for providing orthotics, such as AFOs
to the lower limb,59 or for decreasing hand oedema208. Neither was evidence
50
found for providing walking aids perhaps due to the lack of controlled
studies. Insufficient evidence was found for interventions designed to
reduce hemiplegic shoulder pain204,205 or to correct the spastic hand24.

Limitations of this study
The present review has a number of shortcomings in terms of the studies
investigating the diversity of treatments used in physiotherapy. First, most
studies exhibited methodological flaws such as lack of randomisation, or
intention‐to‐treat analyses and the use of unblinded observers. A negative
trend was found between the unbiased effect sizes of the selected RCTs and
the methodological quality based on the PEDro scale (r = ‐0.19; p = 0.08). This
finding suggests that bias due to the previously mentioned problems as well
as the disregard for systematic dropouts tends to overestimate observed
effects. On a more positive note, there was a significant association between
year of publication and PEDro score (r = 0.42; p < 0.01) suggesting an
increased awareness by researchers to aim for high‐quality studies that will
provide an unbiased assessment of the effectiveness of physiotherapy.
Another major problem in most RCTs was the small numbers of patients
involved, and with that, the low statistical power to reveal statistically
significant effects. Due to the diversity of selected outcomes and
interventions, pooling of RCTs was limited in the present review. In
contrast, there are few RCTs aimed at investigating the effects of
physiotherapy interventions on stair climbing, use of walking aids or
instructions for fall prevention in the literature. These shortcomings
emphasises both the need for more high‐quality RCTs and for a consensus
about using the same core set of measures in stroke rehabilitation studies in
the future.
Due to lack of comparability of many interventions, and the small
number of high‐quality RCTs, a qualitative best‐evidence synthesis was
often used in the present study to analyse the results. Although this
approach may be criticised as being based on arbitrary criteria, it seems
justified when pooling is not appropriate or severely hampered.37
Finally, in the present review only studies written in English, Dutch or
German were included. The classification of ‘physiotherapy’ into 10 different
intervention categories was an arbitrary choice to deal with the
heterogeneity of study objectives in the field.

51
Chapter 2
Clinical messages

• There is strong evidence that patients benefit from exercise programs in
which functional tasks are directly and intensively trained.

• Impairment‐focused programs such as biofeedback, neuromuscular or
transcutaneous nerve stimulation, cardiovascular fitness training and
muscle strengthening, fail to generalise to functional improvements.

• The rational for different treatment approaches is still weak and needs a
better understanding of the ‘nature’ of coordination deficits in functional
tasks after stroke.

Acknowledgments and Funding
This part is a research project supported by a grant from the Royal Dutch
Society of Physical Therapy (KNGF), grant reference number:
IKPZ/KNGF/05/2000. We would like to thank M Heldoorn (KNGF), JCF Ket
(VU Medical Library) and the physiotherapy members of the working
group: BC Harmeling‐van der Wel, BJ Kollen, JSM Hobbelen, JH Buurke, J
Halfens, L Wagenborg, MJ Vogel and M Berns.
52
Referenties

1. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke.
Cochrane Database Syst Rev 2002; 1: CD000197.
2. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs,
and effects on individuals and populations. Lancet 1999; 354: 457‐1463.
3. Langhorne P, Duncan P. Does the organization of postacute stroke care really matter?
Stroke 2001; 32: 268‐274.
4. Langhorne P, Pollock A. What are the components of effective stroke unit care? Age
Ageing 2002; 31: 365‐371.
5. Langhorne P, Legg L, Pollock A et al. Evidence‐based stroke rehabilitation. Age Ageing
2002; 31 (Suppl 3):17‐20.
6. Outpatient Service Trialists. Therapy‐based rehabilitation services for stroke patients at
home. Cochrane Database Syst Rev 2003; 1: CD002925.
7. Holm M. Our mandate for the new millennium: evidence based practice. Am J Occup Ther
2000; 54: 575‐585.
Health. 2002. Assessed 15 January 2004 from
http://www.who.int/classification/icf/intros/ICF‐Eng‐Intro.pdf
10. American Physical Therapy Association. Guide to Physical Therapist Practice. Second
Edition. Phys Ther 2001; 81: 9‐746.
11. Sherrington C, Herbert RD, Maher CG, Moseley AM. PEDro. A database of randomized
trials and systematic reviews in physiotherapy. Man Ther 2000; 5: 223‐226
12. Hedges LV. Fixed effects models. In: Cooper LV, Hedges LV, editors. The handbook of
research synthesis. New York: Russell Sage Foundation, 1994: 285‐300.
13. Kwakkel G, Wagenaar RC, Koelman TW et al. Effects of intensity of rehabilitation after
stroke. A research synthesis. Stroke 1997; 28: 1550‐1556.
14. Shadish WR, Haddock CK. Combining estimates of effect size. In: Cooper HM, Hedges LV,
editors. The handbook of research synthesis. New York: Russell Sage Foundation, 1994:
261‐282.
15. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Control Clin Trials 1986; 7: 177‐
188.
16. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ:
Lawrence Earlbaum Associates, 1988.
17. Van Tulder MW, Cherkin DC, Berman B et al. The effectiveness of acupuncture in the
management of acute and chronic low back pain. A systematic review within the
framework of the Cochrane Collaboration Back Review Group. Spine 1999; 24: 1113‐1123.
53
Chapter 2
18. Ada L, Foongchomcheay A. Efficacy of electrical stimulation in preventing or reducing
subluxation of the shoulder after stroke: a meta‐analysis. Aust J Physiother 2002; 48: 257‐
267.
19. De Kroon JR, van der Lee JH, IJzerman MJ et al. Therapeutic electrical stimulation to
improve motor control and functional abilities of the upper extremity after stroke: a
systematic review. Clin Rehabil 2002; 16: 350‐360.
20. Geurts AC, Visschers BA, van Limbeek J et al. Systematic review of aetiology and
treatment of post‐stroke hand oedema and shoulder‐hand syndrome. Scand J Rehabil Med
2000; 32: 4‐10.
21. Glanz M, Klawansky S, Stason W et al. Biofeedback therapy in poststroke rehabilitation: a
meta‐analysis of the randomized controlled trials. Arch Phys Med Rehabil 1995; 76: 508‐
515.
22. Glanz M, Klawansky S, Stason W et al. Functional electrostimulation in poststroke
rehabilitation: a meta‐analysis of the randomized controlled trials. Arch Phys Med Rehabil
1996; 77: 549‐553.
23. Langhorne P, Wagenaar R, Partridge C. Physiotherapy after stroke: more is better?
Physiother Res Int 1996; 1: 75‐88.
24. Lannin NA, Herbert RD. Is hand splinting effective for adults following stroke? A
systematic review and methodological critique of published research. Clin Rehabil 2003;
17:807‐816.
25. Leung J, Moseley A. Impact of Ankle‐Foot‐Orthoses on gait and leg muscle activity in
adults with hemiplegia ‐ systematic literature review. Physiotherapy 2003; 89: 39‐55.
26. Manning CD, Pomeroy VM. Effectiveness of treadmill retraining on gait of hemiparetic
stroke patients; systematic review of current literature. Physiotherapy 2003; 89: 337‐349.
27. Meek C, Pollock A, Potter J et al. A systematic review of exercise trials post stroke. Clin
Rehabil 2003; 17: 6‐13.
28. Moreland J, Thomson MA. Efficacy of electromyographic biofeedback compared with
conventional physical therapy for upper‐extremity function in patients following stroke: a
research overview and meta‐analysis. Phys Ther 1994; 74: 534‐543.
29. Moreland JD, Thomson MA, Fuoco AR. Electromyographic biofeedback to improve lower
extremity function after stroke: a meta‐analysis. Arch Phys Med Rehabil 1998; 79: 134‐140.
30. Moseley AM, Stark A, Cameron ID, Pollock A. Treadmill training and body weight
support for walking after stroke. Cochrane Database Syst Rev 2003; 3: CD002840.
31. Paci M. Physiotherapy based on the Bobath concept for adults with post‐stroke hemiplegia:
a review of effectiveness studies. J Rehabil Med 2003; 35: 2‐7.
32. Pollock A, Baer G, Pomeroy V et al. Physiotherapy treatment approaches for the recovery
of postural control and lower limb function following stroke. Cochrane Database Syst Rev
2003; 2: CD001920.
33. Pomeroy VM, Tallis RC. Physical therapy to improve movement performance and
functional ability poststroke. Part 1. Existing evidence. Reviews of Clinical Gerontology
2000; 10: 261‐290.
54
34. Price CI, Pandyan AD. Electrical stimulation for preventing and treating post‐stroke
shoulder pain: a systematic Cochrane review. Clin Rehabil 2001; 15: 5‐19.
35. Schleenbaker RE, Mainous AG, III. Electromyographic biofeedback for neuromuscular
reeducation in the hemiplegic stroke patient: a meta‐analysis. Arch Phys Med Rehabil 1993;
74: 1301‐1304.
36. Snels IA, Dekker JH, van der Lee JH et al. Treating patients with hemiplegic shoulder pain.
Am J Phys Med Rehabil 2002; 81: 150‐160.
37. Steultjens EM, Dekker J, Bouter LM et al. Occupational therapy for stroke patients: a
systematic review. Stroke 2003; 34: 676‐687.
38. Van der Lee JH, Snels IA, Beckerman H et al. Exercise therapy for arm function in stroke
patients: a systematic review of randomized controlled trials. Clin Rehabil 2001; 15: 20‐31.
39. Barbeau H. Locomotor training in neurorehabilitation: emerging rehabilitation concepts.
Neurorehabilitation and Neural Repair 2003; 17: 3‐11.
40. Burridge JH, Swain ID, Taylor PN. Functional electrical stimulation: a review of the
literature published on common peoneal vnerve stimulation for the correction of dropped
foot. Reviews of Clinical Gerontology 1998; 8: 155‐161.
41. Carr EK, Kenney FD. Positioning of the stroke patient: a review of the literature. Int J Nurs
Stud 1992; 29: 355‐369.
42. Chae J, Yu B. Neuromuscular stimulation for motor relearning in hemiplegia. Critical
Reviews in Physical and Rehabilitation Medicine 1999; 11: 279‐297.
43. Cifu DX, Stewart DG. Factors affecting functional outcome after stroke: a critical review of
rehabilitation interventions. Arch Phys Med Rehabil 1999; 80(5 Suppl 1): S35‐S39.
44. De Weerdt W, Harrison MA. The efficacy of electromyographic feedback for stroke
patients: a critical review of the main literature. Physiotherapy 1986; 72: 108‐118.
45. Dombovy ML, Sandok BA, Basford JR. Rehabilitation for stroke: a review. Stroke 1986; 17:
363‐369.
46. Duncan PW. Synthesis of intervention trials to improve motor recovery following stroke.
Topics in Stroke Rehabilitation 1997; 3: 1‐20.
47. Ernst E. A review of stroke rehabilitation and physiotherapy. Stroke 1990; 21(7):1081‐1085.
48. Gowland CA, Basmajian JV. In Clinical Decision Making in Rehabilitation. In: Basmajian
JV, Banerjee SN, editors. New York: Churchill Livingstone, 1996: 5‐17.
49. Kwakkel G, Kollen BJ, Wagenaar R. Therapy impact on functional recovery in stroke
rehabilitation: a critical review of literature. Physiotherapy 1999; 85: 377‐391.
50. Ottenbacher KJ, Jannell S. The results of clinical trials in stroke rehabilitation research. Arch
Neurol 1993; 50: 37‐44.
51. Reding MJ, McDowell FH. Focused stroke rehabilitation programs improve outcome. Arch
Neurol 1989; 46: 700‐701.
52. Turner‐Stokes L, Jackson D. Shoulder pain after stroke: a review of the evidence base to
inform the development of an integrated care pathway. Clin Rehabil 2002; 16: 276‐298.
55
Chapter 2
53. Van der Lee JH. Constraint‐induced therapy for stroke: more of the same or something
completely different? Curr Opin Neurol 2001; 14: 741‐744.
54. Wagenaar RC. Functional recovery after stroke. J Rehabil Sci 1991; 4: 13‐17.
55. Wagenaar RC, Meijer OG. Effects of stroke rehabilitation (2) ‐ a critical review of the
literature. J Rehabil Sci 1991; 4: 97‐109.
56. Wagenaar RC, Meijer OG. Effects of stroke rehabilitation (1). J Rehabil Sci 1991; 4: 61‐73.
57. Barreca S, Wolf SL, Fasoli S et al. Treatment interventions for the paretic upper limb of
stroke survivors: a critical review. Neurorehabil Neural Repair 2003; 17: 220‐226.
58. Ince LP, Leon MS, Christidis D. EMG biofeedback with upper extremity musculature for
relaxation training: a critical review of the literature. J Behav Ther Exp Psychiatry 1985; 16:
133‐137.
59. Beckerman H, Becher J, Lankhorst GJ et al. Walking ability of stroke patients: efficacy of
tibial nerve blocking and a polypropylene ankle‐foot orthosis. Arch Phys Med Rehabil
1996; 77(11):1144‐1151.
60. Beckerman H, Becher J, Lankhorst GJ et al. The efficacy of thermocoagulation of the tibial
nerve and a polypropylene ankle‐foot‐orthosis on spasticity of the leg in stroke patients:
results of a randomized clinical trial. Clin Rehabil 1996; 10: 112‐120.
61. Engardt M, Ribbe T, Olsson E. Vertical ground reaction force feedback to enhance stroke
patientsʹ symmetrical body‐weight distribution while rising/sitting down. Scand J Rehabil
Med 1993; 25: 41‐48.
62. Engardt M. Long‐term effects of auditory feedback training on relearned symmetrical body
weight distribution in stroke patients. A follow‐up study. Scand J Rehabil Med 1994; 26: 65‐
69.
63. Faghri PD, Rodgers MM, Glaser RM et al. The effects of functional electrical stimulation on
shoulder subluxation, arm function recovery, and shoulder pain in hemiplegic stroke
patients. Arch Phys Med Rehabil 1994; 75: 73‐79.
64. Faghri PD, Rodgers MM. The effects of functional neuromuscular stimulation‐augmented
physical therapy program in the functional recovery of hemiplegic arm in stroke patients.
Clinical Kinesiology: Journal of the American Kinesiotherapy Association 1997; 51: 9‐15.
65. Kwakkel G, Wagenaar RC, Twisk JW et al. Intensity of leg and arm training after primary
middle‐cerebral‐artery stroke: a randomised trial. Lancet 1999; 354: 191‐196.
66. Kwakkel G, Kollen BJ, Wagenaar RC. Long term effects of intensity of upper and lower
limb training after stroke: a randomised trial. J Neurol Neurosurg Psychiatry 2002; 72: 473‐
479.
67. Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A comparison of
two different approaches of physiotherapy in stroke rehabilitation: a randomized
controlled study. Clin Rehabil 2000; 14: 361‐369.
68. Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A follow‐up one
and four years post stroke. Clin Rehabil 2003; 17: 731‐734.
69. Lincoln NB, Parry RH, Vass CD. Randomized, controlled trial to evaluate increased
intensity of physiotherapy treatment of arm function after stroke. Stroke 1999; 30: 573‐579.
56
70. Parry RH, Lincoln NB, Vass CD. Effect of severity of arm impairment on response to
additional physiotherapy early after stroke. Clin Rehabil 1999; 13: 187‐198.
71. Sonde L, Gip C, Fernaeus SE et al. Stimulation with low frequency (1.7 Hz) transcutaneous
electric nerve stimulation (low‐tens) increases motor function of the post‐stroke paretic
arm. Scand J Rehabil Med 1998; 30: 95‐99.
72. Sonde L, Kalimo H, Fernaeus SE et al. Low TENS treatment on post‐stroke paretic arm: a
three‐year follow‐up. Clin Rehabil 2000; 14: 14‐19.
73. Sunderland A, Tinson DJ, Bradley EL et al. Enhanced physical therapy improves recovery
of arm function after stroke. A randomised controlled trial. J Neurol Neurosurg Psychiatry
1992; 55: 530‐535.
74. Sunderland A, Fletcher D, Bradley L et al. Enhanced physical therapy for arm function
after stroke: a one year follow up study. J Neurol Neurosurg Psychiatry 1994; 57: 856‐858.
75. Wang RY, Chan RC, Tsai MW. Functional electrical stimulation on chronic and acute
hemiplegic shoulder subluxation. Am J Phys Med Rehabil 2000; 79: 385‐390.
76. Wang RY, Yang YR, Tsai MW et al. Effects of functional electric stimulation on upper limb
motor function and shoulder range of motion in hemiplegic patients. Am J Phys Med
Rehabil 2002; 81: 283‐290.
77. Visintin M, Barbeau H, Korner‐Bitensky N et al. A new approach to retrain gait in stroke
patients through body weight support and treadmill stimulation. Stroke 1998; 29: 1122‐
1128.
78. Barbeau H, Visintin M. Optimal outcomes obtained with body‐weight support combined
with treadmill training in stroke subjects. Arch Phys Med Rehabil 2003; 84: 1458‐1465.
79. Malouin F, Potvin M, Prevost J et al. Use of an intensive task‐oriented gait training
program in a series of patients with acute cerebrovascular accidents. Phys Ther 1992; 72:
781‐789.
80. Richards CL, Malouin F, Wood‐Dauphinee S et al. Task‐specific physical therapy for
optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil 1993; 74:
612‐620.
81. Basmajian JV, Gowland CA, Finlayson MA et al. Stroke treatment: comparison of
integrated behavioral‐physical therapy vs traditional physical therapy programs. Arch
Phys Med Rehabil 1987; 68: 267‐272.
82. Jongbloed L, Stacey S, Brighton C. Stroke rehabilitation: sensorimotor integrative treatment
versus functional treatment. Am J Occup Ther 1989; 43: 391‐397.
83. Logigian MK, Samuels MA, Falconer J et al. Clinical exercise trial for stroke patients. Arch
84. Poole JL, Whitney SL, Hangeland N et al. The effectiveness of inflatable pressure splints on
motor function in stroke patients. Occupational Therapy Journal of Research 1990; 10: 360‐
366.
85. Stern PH, McDowell F, Miller JM et al. Effects of facilitation exercise techniques in stroke
rehabilitation. Arch Phys Med Rehabil 1970; 51: 526‐531.
57
Chapter 2
86. Mudie MH, Winzeler‐Mercay U, Radwan S et al. Training symmetry of weight distribution
after stroke: a randomized controlled pilot study comparing task‐related reach, Bobath and
feedback training approaches. Clin Rehabil 2002; 16: 582‐592.
87. Gelber DA, Josefczyk PB, Herrman D et al. Comparison of two therapy approaches in the
rehabilitation of the pure motor hemiparetic stroke patients. J Neuro Rehab 1995; 9: 191‐
196.
88. Dickstein R, Hocherman S, Pillar T et al. Stroke rehabilitation. Three exercise therapy
approaches. Phys Ther 1986; 66: 1233‐1238.
89. Lord JP, Hall K. Neuromuscular reeducation versus traditional programs for stroke
90. Patel M, Potter J, Perez I et al. The process of rehabilitation and discharge planning in
stroke: a controlled comparison between stroke units. Stroke 1998; 29: 2484‐2487.
91. Glasser L. Effects of isokinetic training on the rate of movement during ambulation in
hemiparetic patients. Phys Ther 1986; 66: 673‐676.
92. Bourbonnais D, Bilodeau S, Lepage Y et al. Effect of force‐feedback treatments in patients
with chronic motor deficits after a stroke. Am J Phys Med Rehabil 2002; 81: 890‐897.
93. Inaba M, Edberg E, Montgomery J et al. Effectiveness of functional training, active exercise,
and resistive exercise for patients with hemiplegia. Phys Ther 1973; 53: 28‐35.
94. Kim CM, Eng JJ, MacIntyre DL et al. Effects of isokinetic strength training on walking in
persons with stroke: a double‐blind controlled pilot study. Journal of Stroke &
Cerebrovascular Diseases 2001; 10: 265‐273.
95. Lindsley HG, Musser L, Steward MR et al. The effects of Kinetron training on gait patterns
with strokes. Neurology Report 1994; 19: 29‐34. (Abstract)
96. Moreland JD, Goldsmith CH, Huijbregts MP et al. Progressive resistance strengthening
exercises after stroke: a single‐blind randomized controlled trial. Arch Phys Med Rehabil
2003; 84: 1433‐1440.
97. Butefisch C, Hummelsheim H, Denzler P et al. Repetitive training of isolated movements
improves the outcome of motor rehabilitation of the centrally paretic hand. J Neurol Sci
1995; 130: 59‐68.
98. Engardt M, Knutsson E, Jonsson M et al. Dynamic muscle strength training in stroke
patients: effects on knee extension torque, electromyographic activity, and motor function.
Arch Phys Med Rehabil 1995; 76: 419‐425.
99. Yekutiel M, Guttman E. A controlled trial of the retraining of the sensory function of the
hand in stroke patients. J Neurol Neurosurg Psychiatry 1993; 56: 241‐244.
100. Dean CM, Mackey FH, Katrak P. Examination of shoulder positioning after stroke: A
randomised controlled pilot trial. Aust J Physiother 2000; 46: 35‐40.
101. Carey JR. Manual stretch: effect on finger movement control and force control in stroke
subjects with spastic extrinsic finger flexor muscles. Arch Phys Med Rehabil 1990; 71: 888‐
894.
102. Langlois S, Pederson L, MacKinnon JR. The effects of splinting on the spastic hemiplegic
hand: report of a feasible study. Can J Occup Ther 1991; 58: 17‐25.
58
103. Rose V, Shah S. A comparitive study on the immediate effects of hand orthosis on
reduction of hypertonus. Aust Occup Ther J 1980; 34: 59‐64.
104. Leandri M, Parodi CI, Corrieri N et al. Comparison of TENS treatments in hemiplegic
shoulder pain. Scand J Rehabil Med 1990; 22: 69‐71.
105. Tekeoglu Y, Adak B, Goksoy T. Effect of transcutaneous electrical nerve stimulation
(TENS) on Barthel Activities of Daily Living (ADL) index score following stroke. Clin
Rehabil 1998; 12: 277‐280.
106. Conforto AB, Kaelin‐Lang A, Cohen LG. Increase in hand muscle strength of stroke
patients after somatosensory stimulation. Ann Neurol 2002; 51: 122‐125.
107. McPherson JJ, Becker AH, Franszczak N. Dynamic splint to reduce the passive component
of hypertonicity. Arch Phys Med Rehabil 1985; 66: 249‐252.
108. Dickstein R, Pillar T. Evaluating the effects of reflex‐inhibiting patterns among hemiplegic
patients using EMG biofeedback. Physiother Can 1983; 35: 141‐143.
109. Potempa K, Braun LT, Tinknell T et al. Benefits of aerobic exercise after stroke. Sports Med
1996; 21: 337‐346.
110. Duncan P, Richards L, Wallace D et al. A randomized, controlled pilot study of a home‐
based exercise program for individuals with mild and moderate stroke. Stroke 1998; 29:
2055‐2060.
111. Katz‐Leurer M, Shochina M, Carmeli E et al. The influence of early aerobic training on the
functional capacity in patients with cerebrovascular accident at the subacute stage. Arch
Phys Med Rehabil 2003; 84: 1609‐1614.
112. Kelly JO, Davis GM, Kilbreath SL et al. Exercise training improves walking endurance in
chronic stroke patients: a pilot study. Research conference ‐ From cell to society 2002;
(Abstract)
113. Dean CM, Richards CL, Malouin F. Task‐related circuit training improves performance of
locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med
Rehabil 2000; 81: 409‐417.
114. Duncan P, Studenski S, Richards L et al. Randomized clinical trial of therapeutic exercise in
subacute stroke. Stroke 2003; 34: 2173‐2180.
115. Rimmer JH, Riley B, Creviston T et al. Exercise training in a predominantly African‐
American group of stroke survivors. Med Sci Sports Exerc 2000; 32: 1990‐1996.
116. Teixeira‐Salmela LF, Olney SJ, Nadeau S et al. Muscle strengthening and physical
conditioning to reduce impairment and disability in chronic stroke survivors. Arch Phys
Med Rehabil 1999; 80: 1211‐1218.
117. Dean CM, Shepherd RB. Task‐related training improves performance of seated reaching
tasks after stroke. A randomized controlled trial. Stroke 1997; 28: 722‐728.
118. De Seze M, Wiart L, Bon‐Saint‐Come A et al. Rehabilitation of postural disturbances of
hemiplegic patients by using trunk control retraining during exploratory exercises. Arch
119. Pollock AS, Durward BR, Rowe PJ et al. The effect of independent practice of motor tasks
by stroke patients: a pilot randomized controlled trial. Clin Rehabil 2002; 16: 473‐480.
59
Chapter 2
120. Cheng PT, Wu SH, Liaw MY et al. Symmetrical body‐weight distribution training in stroke
patients and its effect on fall prevention. Arch Phys Med Rehabil 2001; 82: 1650‐1654.
121. Shumway‐Cook A, Anson D, Haller S. Postural sway biofeedback: its effect on
reestablishing stance stability in hemiplegic patients. Arch Phys Med Rehabil 1988; 69: 395‐
400.
122. Wong AM, Lee MY, Kuo JK et al. The development and clinical evaluation of a standing
biofeedback trainer. J Rehabil Res Dev 1997; 34: 322‐327.
123. Sackley CM, Lincoln NB. Single blind randomized controlled trial of visual feedback after
stroke: effects on stance symmetry and function. Disabil Rehabil 1997; 19: 536‐546.
124. Grant T, Brouwer BJ, Culham EG et al. Balance retraining following acute stroke: a
comparison of two methods. Canadian Journal of Rehabilitation 1997; 11: 69‐73.
125. Lin JJ, Chung KC. Evaluate a biofeedback training on the dynamic and static balance for
preambulation in hemiplegic patients. Chinese Journal of Medical and Biological
Engineering 1998; 18: 59‐65.
126. Walker C, Brouwer BJ, Culham EG. Use of visual feedback in retraining balance following
acute stroke. Phys Ther 2000; 80: 886‐895.
127. Geiger RA, Allen JB, OʹKeefe J et al. Balance and mobility following stroke: effects of
physical therapy interventions with and without biofeedback/forceplate training. Phys
Ther 2001; 81: 995‐1005.
128. Winstein CJ, Gardner ER, McNeal DR et al. Standing balance training: effect on balance
and locomotion in hemiparetic adults. Arch Phys Med Rehabil 1989; 70: 755‐762.
129. Morioka S, Yagi F. Effects of perceptual learning exercises on standing balance using a
hardness discrimination task in hemiplegic patients following stroke: a randomized
controlled pilot trial. Clin Rehabil 2003; 17: 600‐607.
130. Kosak MC, Reding MJ. Comparison of partial body weight‐supported treadmill gait
training versus aggressive bracing assisted walking post stroke. Neurorehabil Neural
Repair 2000; 14: 13‐19.
131. Nilsson L, Carlsson J, Danielsson A et al. Walking training of patients with hemiparesis at
an early stage after stroke: a comparison of walking training on a treadmill with body
weight support and walking training on the ground. Clin Rehabil 2001; 15: 515‐527.
132. Sullivan KJ, Knowlton BJ, Dobkin BH. Step training with body weight support: Effect of
treadmill speed and practice paradigms on poststroke locomotor recovery. Arch Phys Med
Rehabil 2002; 83: 683‐691.
133. Da Cunha IT Jr, Lim PA, Qureshy H et al. Gait outcomes after acute stroke rehabilitation
with supported treadmill ambulation training: a randomized controlled pilot study. Arch
Phys Med Rehabil 2002; 83: 1258‐1265.
134. Trueblood PR. Partial body weight treadmill training in persons with chronic stroke.
NeuroRehabilitation 2001; 16: 141‐153.
135. Scheidtmann K, Brunner H, Muller F et al. ʹSequenzeffekte in der laufbandtherapieʹ.
Neurologie und Rehabilitation 1999; 5: 198‐202.
60
136. Laufer Y, Dickstein R, Chefez Y et al. The effect of treadmill training on the ambulation of
stroke survivors in the early stages of rehabilitation: a randomized study. J Rehabil Res
Dev 2001; 38: 69‐78.
137. Liston R, Mickelborough J, Harris B et al. Conventional physiotherapy and treadmill re‐
training for higher‐level gait disorders in cerebrovascular disease. Age Ageing 2000; 29:
311‐318.
138. Pohl M, Mehrholz J, Ritschel C et al. Speed‐dependent treadmill training in ambulatory
hemiparetic stroke patients: a randomized controlled trial. Stroke 2002; 33: 553‐558.
139. Ada L, Dean CM, Hall JM et al. A treadmill and overground walking program improves
walking in persons residing in the community after stroke: a placebo‐controlled,
randomized trial. Arch Phys Med Rehabil 2003; 84: 1486‐1491.
140. Mandel AR, Nymark JR, Balmer SJ et al. Electromyographic versus rhythmic positional
biofeedback in computerized gait retraining with stroke patients. Arch Phys Med Rehabil
1990; 71: 649‐654.
141. Thaut MH, McIntosh GC, Rice RR. Rhythmic facilitation of gait training in hemiparetic
stroke rehabilitation. J Neurol Sci 1997; 151: 207‐212.
142. Schauer M, Mauritz KH. Musical motor feedback (MMF) in walking hemiparetic stroke
patients: randomized trials of gait improvement. Clin Rehabil 2003; 17: 713‐722.
143. Pomeroy VM, Evans B, Falconer M et al. An exploration of the effects of weighted
garments on balance and gait of stroke patients with residual disability. Clin Rehabil 2001;
15: 390‐397.
144. Barrett JA, Watkins C, Plant R et al. The COSTAR wheelchair study: a two‐centre pilot
study of self‐propulsion in a wheelchair in early stroke rehabilitation. Collaborative Stroke
Audit and Research. Clin Rehabil 2001; 15: 32‐41.
145. Kirby RL, Ethans KD, Duggan RE et al. Wheelchair propulsion: descriptive comparison of
hemiplegic and two‐hand patterns during selected activities. Am J Phys Med Rehabil 1999;
78: 131‐135.
146. Altschuler EL, Wisdom SB, Stone L et al. Rehabilitation of hemiparesis after stroke with a
mirror. Lancet 1999; 353: 2035‐2036.
147. Feys HM, De Weerdt WJ, Selz BE et al. Effect of a therapeutic intervention for the
hemiplegic upper limb in the acute phase after stroke: a single‐blind, randomized,
controlled multicenter trial. Stroke 1998; 29: 785‐792.
148. Werner RA, Kessler S. Effectiveness of an intensive outpatient rehabilitation program for
postacute stroke patients. Am J Phys Med Rehabil 1996; 75: 114‐120.
149. Rodgers H, Mackintosh J, Price C et al. Does an early increased‐intensity interdisciplinary
upper limb therapy programme following acute stroke improve outcome? Clin Rehabil
2003; 17: 579‐589.
150. Dromerick AW, Edwards DF, Hahn M. Does the application of constraint‐induced
movement therapy during acute rehabilitation reduce arm impairment after ischemic
stroke? Stroke 2000; 31: 2984‐2988.
151. Page SJ, Sisto SA, Levine P et al. Modified constraint induced therapy: a randomized
feasibility and efficacy study. J Rehabil Res Dev 2001; 38: 583‐590.
61
Chapter 2
152. Page SJ, Sisto S, Johnston MV et al. Modified constraint‐induced therapy after subacute
stroke: a preliminary study. Neurorehabil Neural Repair 2002; 16: 290‐295.
153. Sterr A, Elbert T, Berthold I et al. Longer versus shorter daily constraint‐induced
movement therapy of chronic hemiparesis: an exploratory study. Arch Phys Med Rehabil
2002; 83: 1374‐1377.
154. Taub E, Miller NE, Novack TA et al. Technique to improve chronic motor deficit after
stroke. Arch Phys Med Rehabil 1993; 74: 347‐354.
155. Van der Lee JH, Wagenaar RC, Lankhorst GJ et al. Forced use of the upper extremity in
chronic stroke patients: results from a single‐blind randomized clinical trial. Stroke 1999;
30: 2369‐2375.
156. Luft AR, McCombe Waller S, Whitall J et al. Repetitive bilateral arm training in long‐term
stroke survivors induces cortical reorganisation. Stroke 2002; 33: 416‐417. (Abstract)
157. Rothgangel AS, Morton A, Van de Hout JWE, Beurskens AJHM. Phantoms in the brain:
spiegeltherapie bij chronische CVA‐patiënten; een pilot‐study. Ned Tijdschr v Fysioth 2004;
114: 36‐40.
158. Basmajian JV, Kukulka CG, Narayan MG et al. Biofeedback treatment of foot‐drop after
stroke compared with standard rehabilitation technique: effects on voluntary control and
strength. Arch Phys Med Rehabil 1975; 56: 231‐236.
159. Binder SA, Moll CB, Wolf SL. Evaluation of electromyographic biofeedback as an adjunct
to therapeutic exercise in treating the lower extremities of hemiplegic patients. Phys Ther
1981; 61: 886‐893.
160. Bradley L, Hart BB, Mandana S et al. Electromyographic biofeedback for gait training after
stroke. Clin Rehabil 1998; 12: 11‐22.
161. Colborne GR, Olney SJ, Griffin MP. Feedback of ankle joint angle and soleus
electromyography in the rehabilitation of hemiplegic gait. Arch Phys Med Rehabil 1993; 74:
1100‐1106.
162. Cozean CD, Pease WS, Hubbell SL. Biofeedback and functional electric stimulation in
stroke rehabilitation. Arch Phys Med Rehabil 1988; 69: 401‐405.
163. Hurd WW, Pegram V, Nepomuceno C. Comparison of actual and simulated EMG
biofeedback in the treatment of hemiplegic patients. Am J Phys Med 1980; 59: 73‐82.
164. Intiso D, Santilli V, Grasso MG et al. Rehabilitation of walking with electromyographic
biofeedback in foot‐drop after stroke. Stroke 1994; 25: 1189‐1192.
165. John J. Failure of electrical myofeedback to augment the effects of physiotherapy in stroke.
Int J Rehabil Res 1986; 9: 35‐45.
166. Mulder T, Hulstijn W, van der Meer J. EMG feedback and the restoration of motor control.
A controlled group study of 12 hemiparetic patients. Am J Phys Med 1986; 65: 173‐188.
167. Winchester P, Montgomery J, Bowman B et al. Effects of feedback stimulation training and
cyclical electrical stimulation on knee extension in hemiparetic patients. Phys Ther 1983; 63:
1096‐1103.
168. Morris ME, Matyas TA, Bach TM et al. Electrogoniometric feedback: its effect on genu
recurvatum in stroke. Arch Phys Med Rehabil 1992; 73: 1147‐1154.
62
169. Burnside IG, Tobias HS, Bursill D. Electromyographic feedback in the remobilization of
stroke patients: a controlled trial. Arch Phys Med Rehabil 1982; 63: 217‐222.
170. Dursun E, Hamamci N, Donmez S et al. Angular biofeedback device for sitting balance of
stroke patients. Stroke 1996; 27: 1354‐1357.
171. Montoya R, Dupui P, Pages B et al. Step‐length biofeedback device for walk rehabilitation.
Med Biol Eng Comput 1994; 32: 416‐420.
172. Wolf SL, Binder‐MacLeod SA. Electromyographic biofeedback applications to the

hemiplegic patient. Changes in lower extremity neuromuscular and functional status. Phys
Ther 1983; 63: 1404‐1413.
173. Basmajian JV, Gowland C, Brandstater ME et al. EMG feedback treatment of upper limb in
hemiplegic stroke patients: a pilot study. Arch Phys Med Rehabil 1982; 63: 613‐616.
174. Bate PJ, Matyas TA. Negative transfer of training following brief practice of elbow tracking
movements with electromyographic feedback from spastic antagonists. Arch Phys Med
Rehabil 1992; 73: 1050‐1058.
175. Crow JL, Lincoln NB, Nouri FM et al. The effectiveness of EMG biofeedback in the
treatment of arm function after stroke. Int Disabil Stud 1989; 11: 155‐160.
176. Greenberg S, Fowler RS, Jr. Kinesthetic biofeedback: a treatment modality for elbow range
of motion in hemiplegia. Am J Occup Ther 1980; 34: 738‐743.
177. Inglis J, Donald MW, Monga TN et al. Electromyographic biofeedback and physical
therapy of the hemiplegic upper limb. Arch Phys Med Rehabil 1984; 65: 755‐759.
178. Smith KN. Biofeedback in strokes. Aust J Physiother 1979; 25: 155‐161.
179. Williams JM. Use of electromyographic biofeedback for pain reduction in the spastic
hemiplegic shoulder: a pilot study. Physiotherapy Canada 1982; 34: 327‐333.
180. Lee KH, Hill E, Johnston R et al. Myofeedback for muscle retraining in hemiplegic patients.
Arch Phys Med Rehabil 1976; 57: 588‐591.
181. Prevo AJ, Visser SL, Vogelaar TW. Effect of EMG feedback on paretic muscles and
abnormal co‐contraction in the hemiplegic arm, compared with conventional physical
therapy. Scand J Rehabil Med 1982; 14: 121‐131.
182. Wolf SL, Binder‐MacLeod SA. Electromyographic biofeedback applications to the

hemiplegic patient. Changes in upper extremity neuromuscular and functional status. Phys
Ther 1983; 63: 1393‐1403.
183. Skelly AM, Kenedi RM. EMG biofeedback therapy in the re‐education of the hemiplegic
shoulder in patients with sensory loss. Physiotherapy 1982; 68: 34‐38.
184. Bogataj U, Gros N, Kljajic M et al. The rehabilitation of gait in patients with hemiplegia: a
comparison between conventional therapy and multichannel functional electrical
stimulation therapy. Phys Ther 1995; 75: 490‐502.
185. Burridge JH, Taylor PN, Hagan SA et al. The effects of common peroneal stimulation on
the effort and speed of walking: a randomized controlled trial with chronic hemiplegic
patients. Clin Rehabil 1997; 11: 201‐210.
63
Chapter 2
186. Macdonell RAL, Triggs WJ, Leikauskas J et al. Functional electrical stimulation to the
affected lower limb and recovery after cerebral infarction. Journal of Stroke &
Cerebrovascular Diseases 1994; 4: 155‐160.
187. Merletti R, Zelaschi F, Latella D et al. A control study of muscle force recovery in
hemiparetic patients during treatment with functional electrical stimulation. Scand J
Rehabil Med 1978; 10: 147‐154.
188. Bowman BR, Baker LL, Waters RL. Positional feedback and electrical stimulation: an
automated treatment for the hemiplegic wrist. Arch Phys Med Rehabil 1979; 60: 497‐502.
189. Chae J, Bethoux F, Bohine T et al. Neuromuscular stimulation for upper extremity motor
and functional recovery in acute hemiplegia. Stroke 1998; 29: 975‐979.
190. Packman‐Braun R. Relationship between functional electrical stimulation duty cycle and
fatigue in wrist extensor muscles of patients with hemiparesis. Phys Ther 1988; 68: 51‐56.
191. Powell J, Pandyan AD, Granat M et al. Electrical stimulation of wrist extensors in
poststroke hemiplegia. Stroke 1999; 30: 1384‐1389.
192. Cauraugh J, Light K, Kim S et al. Chronic motor dysfunction after stroke: recovering wrist
and finger extension by electromyography‐triggered neuromuscular stimulation. Stroke
2000; 31: 1360‐1364.
193. Francisco G, Chae J, Chawla H et al. Electromyogram‐triggered neuromuscular stimulation
for improving the arm function of acute stroke survivors: a randomized pilot study. Arch
194. Hemmen B, Seelen H, Moennekens M et al. Effect van EMG‐triggered feedback op arm‐
handfunctie bij CVA‐patiënten. Revalidatie na een beroerte‐Congres Zwolle 2002;
(Abstract)
195. Cauraugh JH, Kim SB. Stroke motor recovery: active neuromuscular stimulation and
repetitive practice schedules. J Neurol Neurosurg Psychiatry 2003; 74: 1562‐1566.
196. Kraft GH, Fitts SS, Hammond MC. Techniques to improve function of the arm and hand in
chronic hemiplegia. Arch Phys Med Rehabil 1992; 73(3):220‐227.
197. Baker LL, Parker K. Neuromuscular electrical stimulation of the muscles surrounding the
shoulder. Phys Ther 1986; 66(12):1930‐1937.
198. Linn SL, Granat MH, Lees KR. Prevention of shoulder subluxation after stroke with
electrical stimulation. Stroke 1999; 30: 963‐968.
199. Chantraine A, Baribeault A, Uebelhart D et al. Shoulder pain and dysfunction in
hemiplegia: effects of functional electrical stimulation. Arch Phys Med Rehabil 1999; 80:
328‐331.
200. Kobayashi H, Onishi H, Ihashi K et al. Reduction in subluxation and improved muscle
function of the hemiplegic shoulder joint after therapeutic electrical stimulation. J
Electromyogr Kinesiol 1999; 9: 327‐336.
201. Hurd MM, Farrell KH, Waylonis GW. Shoulder sling for hemiplegia: friend or foe? Arch
202. Hanger HC, Whitewood P, Brown G et al. A randomized controlled trial of strapping to
prevent post‐stroke shoulder pain. Clin Rehabil 2000; 14: 370‐380.
64
203. Ancliffe J. Strapping the shoulder in patients following a cerebrovascular accident (CVA): a
pilot study. Aust J Physiother 1992; 38: 37‐41.
204. Inaba MK, Piorkowski M. Ultrasound in treatment of painful shoulders in patients with
hemiplegia. Phys Ther 1972; 52: 737‐742.
205. Partridge CJ, Edwards SM, Mee R et al. Hemiplegic shoulder pain: a study of two methods
of physiotherapy treatment. Clin Rehabil 1990; 4: 43‐49.
206. Kumar R, Metter EJ, Mehta AJ et al. Shoulder pain in hemiplegia. The role of exercise. Am J
207. Poduri KR. Shoulder pain in stroke patients and its effects on rehabilitation. J Stroke
Cerebrovasc Dis 1993; 3: 261‐266.
208. Roper TA, Redford S, Tallis RC. Intermittent compression for the treatment of the
oedematous hand in hemiplegic stroke: a randomized controlled trial. Age Ageing 1999;
28: 9‐13.
209. Smith DS, Goldenberg E, Ashburn A et al. Remedial therapy after stroke: a randomised
controlled trial. Br Med J (Clin Res Ed) 1981; 282: 517‐520.
210. Wade DT, Collen FM, Robb GF et al. Physiotherapy intervention late after stroke and
mobility. BMJ 1992; 304: 609‐613.
211. Sivenius J, Pyorala K, Heinonen OP et al. The significance of intensity of rehabilitation of
stroke‐‐a controlled trial. Stroke 1985; 16: 928‐931.
212. Logan PA, Ahern J, Gladman JR et al. A randomized controlled trial of enhanced Social
Service occupational therapy for stroke patients. Clin Rehabil 1997; 11: 107‐113.
213. Walker MF, Gladman JR, Lincoln NB et al. Occupational therapy for stroke patients not
admitted to hospital: a randomised controlled trial. Lancet 1999; 354: 278‐280.
214. Partridge C, Mackenzie M, Edwards S et al. Is dosage of physiotherapy a critical factor in
deciding patterns of recovery from stroke: a pragmatic randomized controlled trial.
215. Green J, Forster A, Bogle S et al. Physiotherapy for patients with mobility problems more
than 1 year after stroke: a randomised controlled trial. Lancet 2002; 359: 199‐203.
216. Parker CJ, Gladman JR, Drummond AE et al. A multicentre randomized controlled trial of
leisure therapy and conventional occupational therapy after stroke. TOTAL Study Group.
Trial of Occupational Therapy and Leisure. Clin Rehabil 2001; 15: 42‐52.
217. Slade A, Tennant A, Chamberlain MA. A randomised controlled trial to determine the
effect of intensity of therapy upon length of stay in a neurological rehabilitation setting. J
Rehabil Med 2002; 34: 260‐266.
218. The Glasgow Augmented Physiotherapy Stroke Group. Can augmented physiotherapy

input enhance recovery of mobility after stroke? A randomized controlled trial. Clin
Rehabil 2004; 18: 529‐537.
219. Gilbertson L, Langhorne P, Walker A et al. Domiciliary occupational therapy for patients
with stroke discharged from hospital: randomised controlled trial. BMJ 2000; 320: 603‐606.
220. Fang Y, Chen X, Li H et al. A study on additional early physiotherapy after stroke and
factors affecting functional recovery. Clin Rehabil 2003; 17: 608‐617.
65
Chapter 2
221. Keith RA, Wilson DB, Gutierrez P. Acute and subacute rehabilitation for stroke: a
comparison. Arch Phys Med Rehabil 1995; 76: 495‐500.
222. Rapoport J, Judd‐Van Eerd M. Impact of physical therapy weekend coverage on length of
stay in an acute care community hospital. Phys Ther 1989; 69: 32‐37.
223. Ruff RM, Yarnell S, Marinos JM. Are stroke patients discharged sooner if in‐patient
rehabilitation services are provided seven v six days per week? Am J Phys Med Rehabil
1999; 78(2):143‐146.
224. Kwakkel G, Van Peppen RPS, Wagenaar RC et al. Effects of augmented exercise time after
stroke: A meta‐analysis. Stroke 2004; 35: 2529‐2536
225. Van der Lee JH, Kwakkel G, Lankhorst GJ et al: ‘Woldag H, Hummelsheim H: evidence‐
based physiotherapeutic concepts for improving arm and hand function in stroke patients:
a review J Neurol (2002) 249:518‐528. J Neurol 2003; 250: 119.
226. Salbach NM, Mayo NE, Higgins J et al. Responsiveness and predictability of gait speed and
other disability measures in acute stroke. Arch Phys Med Rehabil 2001; 82: 1204‐1212.
227. Lennon S. The Bobath concept: a critical review of the theoretical assumptions that guide
physiotherapy practice in stroke rehabilitation. Phys Ther Review 1996; 1: 35‐45.
228. Wagenaar RC, Meijer OG, van Wieringen PC et al. The functional recovery of stroke: a
comparison between neuro‐developmental treatment and the Brunnstrom method. Scand J
Rehabil Med 1990; 22: 1‐8.
229. Latash ML, Anson JG. What are ʹnormal movementsʹ in atypical populations? Behavioral
and Brain Science 1996; 19: 55‐106.
230. Kwakkel G, Wagenaar RC. Effect of duration of upper‐ and lower‐extremity rehabilitation
sessions and walking speed on recovery of interlimb coordination in hemiplegic gait. Phys
Ther 2002; 82: 432‐448.

66
CHAPTER

Effects of augmented exercise therapy time after
stroke: A meta‐analysis

Gert Kwakkel
Robert C Wagenaar
Sharon Wood‐Dauphinee
Carol Richards
Ann Ashburn
Kimberly Miller
Nadina B Lincoln
Cecily Partridge
Ian Wellwood
Peter Langhorne

Stroke 2004; 35(11): 2529‐2536
Chapter 3
Abstract

Background: To present a systematic review of studies that addresses the
effects of intensity of augmented exercise therapy time (AETT) on activities
of daily living (ADL), walking and dexterity in patients with stroke.
Summary of review: A database of articles published from 1966 to May 2003
was compiled from MEDLINE, CINAHL, Cochrane Central Register of
Controlled Trials, PEDro, DARE and PiCarta using combinations of the
relevant keywords. References presented in relevant publications were
examined as well as abstracts in proceedings. Studies that satisfied the
following selection criteria were included: 1) patients had a diagnosis of
stroke; 2) effects of intensity of exercise training were investigated; and 3)
design of the study was a randomised controlled trial (RCT). For each
outcome measure the estimated effect size (ES) and the summary effect size
(SES) expressed in standard deviation units (SDU) were calculated for ADL,
walking speed and dexterity, using fixed and random effect models.
Correlation coefficients were calculated between, observed individual effect
sizes on ADL of each study, additional time spent on exercise training and
methodological quality. Cumulative meta‐analyses (random effects model)
adjusted for the difference in treatment intensity in each study was used for
the trials evaluating the effects of AETT provided. Twenty of the 31
candidate studies, involving 2686 stroke patients, were included in the
synthesis. The methodological quality ranged from 2 to 11 out of the
maximum score of 14 points. The meta‐analysis resulted in a small, but
statistically significant SES with regard to ADL measured at the end of the
intervention phase. Further analysis showed a significant homogeneous SES
for 17 studies that investigated effects of increased exercise intensity within
the first 6 months post stroke. No significant homogeneous SES was
observed for the 3 studies conducted in the chronic phase. Cumulative meta‐
analysis strongly suggests that at least a 16 hour difference in treatment time
between experimental and control groups provided in the first 6 months
after stroke is needed to obtain significant differences in ADL. A significant
SES supporting a higher intensity was also observed for instrumental ADL
and walking speed, whereas no significant SES was found for dexterity.
Conclusions: The results of the present research synthesis support the
hypothesis that augmented exercise therapy has a small, but favourable
effect on ADL, particularly if therapy input is augmented at least 16 hours
within the first 6 months post stroke. This meta‐analysis also suggests that
clinically relevant treatment effects may be achieved on instrumental ADL
and gait speed.
68
Effects of augmented exercise therapy time

Introduction

Stroke is a leading cause of disability among adults in developed countries.
Any treatment that improves functional outcome can significantly reduce
suffering and the financial burden of this illness on the individual, the
family and society. Rehabilitation is recognized as a corner stone of
multidisciplinary stroke care.1 Two systematic reviews2,3 suggested that early
implementation of intensive stroke rehabilitation is associated with
enhanced and faster improvement of the performance of activities after
stroke. Both groups found small but statistically significant summary effect
sizes (SES) in favour of the group that spent more treatment time focused on
activities of daily living (ADL). In a sensitivity analysis, larger overall effect
sizes were found in studies that weighted individual effect sizes for the
differences in amount of rehabilitation between experimental and control
groups.3 In these 2 systematic reviews, however, methodological limitations
of the primary studies, differences in organisational settings as well as
marked heterogeneity of patient characteristics proved to be major
confounding factors.
In the last few years, new trials that provided augmented exercise
training by physiotherapists and occupational therapists have been
conducted. The results of these trials show results that range from no
measurable benefits4‐7 to significant effects on ADL.8‐11 This discrepancy can
be related to differences in: 1) methodological quality of the trials, 2) patient
selection, 3) amount of contrast between the intensity of treatment in
experimental and control groups, 4) differences in type, focus and timing of
intervention post stroke, 5) differences in outcome measures and 6)
statistical power to show true effects. In particular, there is much debate
about the amount of therapy that is needed and whether or not there is a
minimum threshold below which there is no benefit.
The purpose of the present research synthesis was to examine the effects
of treatment time by reviewing studies evaluating the effects of intensity of
exercise therapy in patients with stroke on ADL, gait and dexterity. The
hypothesis was that the extra treatment time provided to the augmented
therapy group would result in clinically relevant improvements in ADL,
walking speed and dexterity. A secondary goal was to determine whether or
not there is a minimum threshold of additional time provided to the
experimental group below which no clinically relevant benefit might be
expected.
69
Chapter 3

Material and Methods

Definitions
Stroke has been defined by the World Health Organization (WHO) as ‘a
clinical syndrome typified by rapidly developing signs of focal or global
disturbance of cerebral functions, lasting more than 24 hours or leading to
death, with no apparent causes other than of vascular origin’.(12, page 1407)
Exercise therapy was defined as ‘physical activity that is usually regular
and done with the intention of improving or maintaining physical fitness or
health’ (Pubmed [Medline], MeSH database, 2003) and included both
physiotherapy and occupational therapy. ADL was defined as performance
of the basic activities of self care, such as dressing, ambulation and eating)in
rehabilitation, and instrumental ADL (IADL), such as shopping, preparing
meals, washing clothes and pursuing hobbies. Both outcomes were included
in the present analysis. Finally, treatment contrast was defined as the
amount of time spent on exercise training for the experimental group minus
that for the control group.3 Studies that investigated the effectiveness of
constraint induced movement therapy or application of special equipment to
augment exercise therapy such as balance platforms, treadmills, biofeedback
equipment or robotics, were excluded from the present study. Two
independent reviewers (GK and RPSvP) selected articles based on the title
and abstract.

Study identification
Potentially relevant literature was identified through computerised and
manual searches. Two independent literature searches (RPSvP and JCFK)
were conducted in the following data bases: MEDLINE (1966 through
November 2003), CINAHL (1982 through November 2003), Cochrane
Central Register of Controlled Trials, EMBASE (1988 through November
2003), PEDro, DARE, SCISEARCH (1974 through November 2003) and
Picarta. The search was performed for the period 1966 to November 2003
using the following keywords (MesH): cerebrovascular disorders, stroke,
physical therapy, physiotherapy, occupational therapy, exercise therapy,
rehabilitation, intensity, dose‐response relationship, effectiveness,
randomised controlled trial. Bibliographies of review articles, empirical
articles and abstracts published in proceedings of conferences were also
evaluated. Only articles written in English, German or Dutch were included.
Studies were included when: 1) patients had a diagnosis of stroke, 2) effects
of the intensity of physiotherapy and/or occupational therapy were
70
presented in the article, 3) the outcome was measured in terms of ADL
(including walking ability, dexterity or IADL such as leisure therapy), and 4)
the study was a randomised controlled trial.
Table 1 – Operationalisation of validity criteria (modification of list Kwakkel et al 3)
Methodological Criteria for operationalisation: Operationalisation:

aspect: (yes = 1 / no = 0)
A. Randomisation 1. concealed allocation is applied (i.e. sealed envelopes) 1. yes / no

procedure is
adequate if:
B. Blinding procedure 2. observer(s) are kept unaware of the groups to which patients 2. yes / no
is adequate if: have been assigned:
3. those performing statistical analysis are kept unaware of the 3. yes / no

groups to which patients have been assigned:
4. patients are kept unaware with respect to the condition to 4. yes / no

which they have been assigned:
C: Drop-outs and 5. the number of drop-outs are described for each group 5. yes / no
intention-to-treat separately:
analysis are
adequate if:
6. the number of intercurrent drop-outs are described for each 6. yes / no

group separately:
7. intention-to-treat analysis has been applied: 7. yes / no
D. Measurement 8. statistically significant test-retest correlation coefficient(s) 8. yes / no

instruments are and/or intra-, inter-observer reliability of relevant measurement
adequate if: instruments have been reported by the authors or have been
established in studies which are cited by the authors:
9. the relevant measurement instruments are compared 9. yes / no

statistically with other instrument(s) measuring the same
modality by the authors or in studies reported by the authors:
E. Control for co- 10. other co-interventions leading to systematic differences 10. yes / no
intervention(s) is between groups are avoided:
adequate if:
11. yes / no
11. adjunctive (medical) interventions are reported for each
group separately:
F. Comparability of 12. relevant patient characteristics (i.e. initial ADL-score, type of 12. yes / no
patient stroke, age and time since stroke onset) are not statistically
characteristics is significant different between experimental and control group(s):
adequate if:
G. Control for dose of 13. predetermined rehabilitation time (in minutes or hours) 13. yes / no
therapy is adequate and/or number of exercises and/or dosage of applied exercises
if: have been reported in experimental and control group(s):
14. predetermined rehabilitation time (in minutes or hours) 14. yes / no

and/or number of exercises and/or dosage of applied exercises
have been reported in experimental and control group(s):
71
Chapter 3
The methodological quality of each study was assessed by 2 independent
reviewers (RPSvP and GK) by applying an adapted methodological scoring
list derived from a list developed by Kwakkel et al3 and Cambach.13 The
original list contained 16 items, with each scored on a binary scale. Because
the present review was focused only on RCTs, items 2 and 3 were deleted so
that 14 questions remained to be addressed. (Table 1). The revised tool
showed good inter‐rater reliability according to Cohenʹs kappa (κ=0.85).
When disagreement between the 2 reviewers persisted, a third reviewer
made the final decision. Reviewers were not blind to author(s), institution(s)
or journal. One reviewer (RvP) extracted all relevant data. The following
items were evaluated: 1) randomisation and blinding procedures; 2)
descriptions of drop‐outs and intention‐to‐treat analysis; 3) reliability and
validity of assessment instruments; 4) control for co‐intervention(s); 5)
comparability of baseline patient characteristics; and 6) presentation of
amount of therapy provided.

The abstracted data (mean age, type of stroke, numbers of patients in
experimental and control group, days of treatment, average length of daily
treatment in minutes, mean difference in change scores in ADL and
standard deviation [SD] of ADL scores in experimental and control groups
at baseline) were entered into Excel for Windows. The formal statistical
methods used to test the results of different trials have been described
elsewhere.3 The effect size gi (Hedgesʹ g) for individual studies was
established by calculating the difference between means of the experimental
and control groups divided by the average population SDi.14 If necessary,
means and SDi were requested from the respective authors. Otherwise point
estimates were obtained from the graphs of included articles by recording
the bitmap coordinates after scanning the graphs into Microsoft Paint.
To estimate SDi for gi, baseline SDs of control and experimental groups
were pooled (eg, Hedges, 1985). As the gi tend to overestimate the
population effect size in studies with a small number of patients, a
correction was implemented to obtain an unbiased estimation gu. The impact
of sample size was addressed by estimating a weighting factor wi for each
study and applying more weight to effect sizes from studies with larger
samples that resulted in smaller variances. Subsequently, gu of individual
studies were averaged to obtain a weighted SES (Ť). Finally, the wi of each
study were combined to estimate the variance of the SES.15 When
information about point estimates and standard errors was lacking the
72
original authors were consulted. The effect size gu for individual studies was
computed for degree of disability in day‐to‐day activities, walking speed
and dexterity. In addition, SESs expressed as number of standard deviation
units (SDUs) were calculated for studies comparing effects of different
intensities in rehabilitation in the chronic stage of stroke (>6 months after
onset), and those initiated within 6 months of stroke. The fixed effects model
was used to decide whether or not a SES was statistically significant. The
homogeneity (or heterogeneity) test statistic (Q‐statistic) of each set of effect
sizes was examined to determine whether or not studies shared a common
effect size from which the variance could be explained by sampling error
alone.14,16 Although the Q‐statistic underestimate the existing heterogeneity
in meta‐analysis, the percentage of total variation across studies was used by
calculating I2 which reveals a better measure of the consistency between
trials.17 When significant heterogeneity was found on the Q‐statistic (or I2
values >50%),17 a random effects model was applied.18,19 Pearson correlation
coefficients were calculated between, individual effect sizes, and additional
time exercising in the experimental groups, as well as the methodological
quality of the studies. To investigate the effects of differences in treatment
contrast in selected studies a cumulative meta‐analysis adjusted for
treatment contrast was applied for the ADL outcome, using a random effects
model. Finally, a sensitivity analysis was performed for studies with high
and low treatment contrasts. Effect sizes were calculated in Excel for
Windows XP, whereas SPSS 11.5 for Windows was used for statistical
analysis. For all outcome variables, the critical value for rejecting H0 (ie,
there is no evidence for augmented therapy time) was set at 0.05.

Results

The search strategy resulted in a list of 7483 citations. After selection, based
on title and abstract, 507 full articles were obtained. Thirty‐two studies were
identified as being relevant. Five studies used a pretest – posttest assessment
design;20‐24 3 studies included a control condition but no randomisation;25‐27
and 24 studies were RCTs.4‐11,28‐44 Despite being a RCT the article by Peacock
et al29 was also excluded due to lack of information about treatment contrast
as well as missing point measures and estimates of variability. Four studies
referred to the same patients, who had been reported in 3 RCTs which had
already been included in this meta‐analysis.35,38,39,40 One study included
patients with traumatic brain injury;41 only the patients with stroke were
included in the present analysis.
73

Table 2 Study characteristics of trials on intensity of stroke rehabilitation
74
Reference N (E/C) Stroke type Start of Type of intervention Mean Duration of Daily (min) Daily (min) Contrast
rehabilitation (E/C) age, rehabilitation PT† OT† (min)
(E/C) y (E/C) (E/C) (E/C)
Chapter 3
Stern, 1970 62 (31/31) TEI 29/33 d PNF vs 64/64 63/56 d 100/60 - 2100
conventional
Smith, 1981 133 (46/43/44) ? 31/41/37 d Intensive conventional 63/66/65 3 mo E1: 73/14 E1: 41/14 E1: 6816
care vs self-care E2: 36/14 E2: 25/14 E2: 3324
Sivenius, 1985 95 (50/45) TEI (89%), <1/<1 wk Intensive vs 72/70 46/37 d 40/24 0.06/0.06 657
ICH, (11%) normal
Sunderland, 1992 132 (65/67) SAH and brain 9/9 d* Enhanced vs 66/69* 18/10 wk* 45/28║ - 1185
stem excluded conventional
Wade, 1992 94 (49/45) All types 4.4/5.0 y Treatment vs 72/72 3 mo 8/0 - 496
no treatment¶
Richards, 1993‡ 27 (18/9) Middle band 8.5/13 d Intensive vs 69/70 5 wk 53/22 - 1933
strokes conventional
Werner, 1996 40 (28/12) MCA strokes 2.9/3.3 y Treatment vs 59/66 12 wk 48/0 48/0 4608
no treatment
Logan, 1997 111 (53/58) All types (first 39/45 d Enhanced vs 71/74 <3 mo - 22/37 167
strokes) usual service
Feys, 1998 100 (50/50) TEI or ICH 21/24 d Enhanced vs 66/63 6 wk 48/18 - 900
(SAH excluded) sensorimotor stimulation
Kwakkel, 1999 101 (33/31/37) MCA (first ever 7/7 d Intensive vs 67/65 20 wk 70/44 69/44 PT: 2620
stroke) immobilisation OT: 2460
Lincoln, 1999 282 (94/93/95) All types 12/12 d* Intensive vs 73/73* 5 wk QPT:65/42 - QPT: 575
routine APT:59/42 APT: 430
Walker, 1999 185 (94/91) All types <1/<1 mo Treatment (OT) vs 74/75 5 mo - 3/0 302
no treatment
Partridge, 2000 114 (54/60) All types ?/? Intensive vs 77§ 6 wk 60/30 - 900
standard

Reference N (E/C) Stroke type Start of Type of intervention Mean Duration of Daily Daily Contrast
rehabilitation (E/C) age, rehabilitation (min) (min) (min)
(E/C) y (E/C) (E/C) PT† OT† (E/C)
Gilbertson, 2000 138 (67/71) SAH excluded 31/23 d Domiciliary program vs 71/71 6 wk - 13/0 380
routine service
Parker, 2001 466 (153/156/157) All types <6/<6 mo Leisure/ADL treatment 72/72 6 mo - ADL: 4/0 442
vs no treatment Leisure: 502
4/0
Green, 2002 170 (85/85) All types >1/>1 y Routine treatment vs no 72/74 13 wk 2/0 - 132
treatment
Slade, 2002 87 (47/40) All types 47/45 d Intensive (OT+PT) vs 52/54 ~12 wk 30/19║ - 614
normal therapy
Rodgers, 2003 123 (62/61) All types <10/<10 d Enhance upper limb 74/75 6 wk Mean: 52 vs 38 420
therapy time vs
interdisciplinary
treatment program
Fang, 2003 156 (78/78) All types <7 d Early intensive PT vs 65/62 4 wk 45 - 900
routine therapy without
early PT
GAPS, 2004 70 (35/35) All types 22/25 d Augmented vs standard 68/67 ~10 wk 40/25 - 720
PT to improve mobility
Total 2686 (1515/1171) 48.6/ 22.9/ Weighted

23.3 min 10.9 min mean:
956
ADL indicates activities of daily living; APT, assistant-physiotherapist; d, day(s); wk, weeks; y, year(s); ?, unknown; E/C, experimental vs control group; ICH, intracerebral hemorrhage;
MCA, middle cerebral artery; min, minutes; mo, month(s); N, number of patients in each group; OT, occupational therapist; PNF, proprioceptive neuromuscular facilitation;
PT, physiotherapist; QPT, qualified-physiotherapist; SAH, subdural arachnoid hemorrhage; TEI, thromboembolic infarctions.
*, Only median figures given;
†, Only period of different rehabilitation intensities recorded; average of calculated minutes for every working day during intervention;
§, Average age of experimental and control group together
‡, Findings of the experimental (N=10) and early conventional (N=8) are combined and compared with the control group (N=9);
¶, Randomised crossover design (only first phase of the trial is considered);
║, OT incorporated.
75
Chapter 3
Table 2 shows the main characteristics of the 20 eligible studies included
in the meta‐analysis. Fourteen of these reported statistically significant
effects for functional outcomes in favour of the group with augmented
therapy time. In 6 studies, additional exercise therapy did not result in a
significant difference in efficacy. In total, 2686 patients with stroke were
involved. The start of therapy ranged from within the first week post
stroke9,31,42 to >1 year after stroke onset.11,33,36 Seventeen of the 20 studies
investigated the effects of intensity within the first 6 months following
stroke, whereas in 3 studies the research protocol was initiated >6 months
post stroke.11,33,36
On average the experimental group received twice as much
physiotherapy (48.6 minutes; SD, 30.8) and occupational therapy (22.9
minutes; SD, 23.6) daily as the control group (23.3 minutes; SD, 18.0 and 10.9
minutes; SD, 16.8, respectively; Table 2). The additional time that exercise
therapy was provided to the experimental group ranged from 132 minutes11
to 6816 minutes,30 with a weighted average of 956 minutes or about 16 hours
additional therapy time per patient.

The results of the methodological quality scoring of the 20 RCTs are
presented in Table 3. Initially there was disagreement between the 2
independent reviewers on 21 of the 266 criteria scored. Cohen kappa for
agreement was 0.84. The methodological quality score ranged from 228,31 to
11 points.43
Ten studies used a randomisation procedure with concealed
allocation.4,5,7,9‐11,31,37,40,43 In 16 studies, the observers were blinded to treatment
allocation.4‐11,32‐34,36,37,41,43,44 However, none of the RCTs reported blinded
statistical analysis or adjunct (medical) interventions for each group,
separately. With the exception of Stern et al,28 all studies described drop‐outs
for the experimental and control groups, separately. In 14 studies, the
patients in the 2 groups had had a first stroke and were comparable for age,
ADL index, and type of stroke.4‐7,9‐11,32‐34,36,41,43,44 In 12 studies the originally
scheduled exercise therapy time was reported,4‐10,28,34,36,41,43, and in 11 trials the
actual exercise therapy time was provided.5‐7,9,11,30,32,34,41,43,44
76

Table 3 Application of methodological criteria to studies investigating the effects of intensity of exercise therapy
Item of methodological score
Author, y 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total Co- Reported

score intervention outcome
Stern, 1970 0 0 0 0 0 0 0 1 0 0 0 0 1 0 2 No No effect
Smith, 1981 1 1 0 0 1 0 0 1 1 0 0 0 0 1 6 No Positive
Sivenius, 1985 1 0 0 0 1 0 0 0 0 0 0 0 0 0 2 Yes Positive
Sunderland, 1992 0 1 0 0 1 0 0 1 1 0 0 1 0 1 6 No Positive
Wade, 1992 0 1 0 0 1 0 0 1 1 0 0 1 0 0 5 No Positive
Richards, 1993 0 1 0 0 1 0 0 1 1 0 0 1 1 1 7 No Positive
Werner, 1996 0 1 0 0 1 0 0 1 1 1 0 0 1 0 6 No Positive
Logan, 1997 1 1 0 0 1 0 1 1 1 0 0 1 0 0 7 No Positive
Feys, 1998 0 1 0 0 1 0 0 1 1 1 0 0 1 0 6 No Positive
Kwakkel, 1999 1 1 0 0 1 0 1 1 1 1 0 1 1 1 10 No Positive
Lincoln, 1999 1 1 0 0 1 0 0 1 1 1 0 1 1 1 9 No No effect
Walker, 1999 1 1 0 0 1 0 0 1 1 0 0 1 0 1 7 No Positive
Partridge, 2000 1 1 0 0 1 0 0 0 0 1 0 1 1 0 6 No No effect
Gilbertson, 2000 1 1 0 0 1 0 1 1 1 0 0 1 1 0 8 No Positive
Parker, 2001 0 1 0 0 1 0 1 1 1 1 0 1 1 1 9 No No effect
Green, 2002 1 1 0 0 1 0 1 1 1 1 0 1 0 1 9 No Positive
Slade, 2002 0 1 0 1 1 0 1 1 1 0 0 1 1 1 9 No Positive
Rodgers, 2003 1 1 0 0 1 0 1 1 1 0 0 1 1 1 9 No No effect
Fang, 2003 1 1 0 0 0 0 0 0 0 1 0 0 1 0 4 No Positive
GAPS, 2004 1 1 0 0 1 1 1 1 1 1 0 1 1 1 11 No No effect
Sum score 12 18 0 1 18 1 8 17 16 9 0 14 13 11
77
Chapter 3
Meta‐analysis: ADL
Pooling the effects was only possible for those studies assessing ADL as an
outcome. Fifteen studies evaluated outcome with the Barthel Index (BI), 1
study used the Functional Independence Measure motor (FIM)35, and 4
studies used other measures that assess ADL.4,28,30,31
After intervention a small but statistically significant heterogeneous SES
(χ =37.65, p<0.05) was found in favour of augmented exercise therapy (SES
2
[random] 0.13 SDU; CI, 0.03 to 0.23; Z=2.49, p<0.007) (Figure 1 and Table 4).
The SES obtained was almost the same for the 9 studies (N=1570) that also
measured IADL (0.23 SDU [fixed]; CI, 0.13 to 0.33; Z=4.40, p<0.001) (Figure
2).5‐7,9,10,33,37,43,44

Figure 1. Meta‐analysis for trials on outcome of ADL at the end of the intervention

ADL (mean and 95% CI)
Stern N=62 0.14 [-0.36 - 0.64]
Smith (1) N=68 0.49 [-0.02 - 1.01]
Smith (2) N=65 0.35 [-0.16 - 0.87]
Sivenius N=95 0.75 [0.33 - 1.16]
Sunderland N=132 0.10 [-0.25 - 0.44]
Wade N=94 0.07 [-0.33 - 0.47]
Richards N=27 -0.38 [-1.18 - 0.44]
Werner N=40 0.32 [-0.36 - 1.00]
Logan N=111 0.00 [-0.37 - 0.37]
Feys N=100 - 0.03 [-0.42 - 0.36]
Kwakkel (1) N=49 0.42 [-0.17 - 1.01]
Kwakkel (2) N=52 0.44 [- 0.13 -1.09]
Lincoln (1) N=140 0.00 [-0.35 - 0.35]
Lincoln (2) N=142 0.00 [-0.35 - 0.35]
Walker N=185 0.33 [0.04 - 0.63]
Partridge N=114 0.17 [-0.20 - 0.54]
Gilbertson N=138 0.50 [ 0.16 - 0.84]
Parker (1) N=235 0.00 [- 0.27 - 0.27]
Parker (2) N=231 0.00 [-0.27 - 0.27]
Green N=170 0.00 [-0.30 - 0.30]
Slade N=87 -0.07 [-0.43 - 0.41]

Rodgers N=123 -0.33 [-0.69 - 0.02]
Fang N=156 0.32 [0.16 - 0.64]
GAPS N=70 -0.31 [-0.78 - 0.16]
S.E.S. N=2686 0.13 [0.03 - 0.23]

(random effects model)
-2 -1 0 1 2
Intensive therapy worse Intensive therapy better

78

Figure 2. Meta‐analysis of intensity trials measuring outcome of instrumental ADLs

IADL (mean and 95% CI)
Wade N=94 0.06 [-0.35 - 0.46]
Logan N=111 0.33 [-0.05 - 0.71]
Kwakkel (1) N=49 0.46 [-0.13 - 1.04]
Kwakkel (2) N=52 0.13 [-0.43 - 0.70]
Lincoln (1) N=140 0.61 [0.25 - 0.97]
Lincoln (2) N=142 0.34 [-0.01 - 0.69]
Walker N=185 0.50 [0.21 - 0.79]
Gilbertson N=138 0.49 [0.15 - 0.83]
Parker (1) N=235 0.10 [-0.17 - 0.38]
Parker (2) N=231 0.01 [-0.26 - 0.29]
Rodgers N=123 0.00 [-0.35 - 0.35]
GAPS N=70 -0.21 [-0.68 - 0.26]
S.E.S. N=1570 0.23 [0.13 - 0.33]

(fixed effects model)
-2 -1 0 1 2

A homogeneous non‐significant SES were found (χ2 =0.72, p=0.70) for
studies in which therapeutic intervention was initiated after 6 months post
stroke (0.07 SDU [fixed]; CI, ‐0.17 to 0.28; Z=0.49), whereas the homogeneous
(χ2 =28.61, p=0.10; I2 =33.6%) SES was significant (0.15 SDU [fixed]; CI, 0.06
to 0.23; Z=3.24, p<0.001) in which therapy when applied within the first 6
months.
A positive association was found between the additional number of
minutes of therapy provided in the experimental group as compared with
the control group with an unbiased effect size (r=0.393; p<0.058).
Methodological quality, however, was negatively associated with effect size
(rs= ‐ 0.438; p<0.053).
A cumulative meta‐analysis, adjusted for differences in treatment contrast
across all 20 studies, showed a gradual shift from no significant effect in
studies with a low treatment contrast (0 SDU: CI, 0.30 to 0.30; Z=0.0 p=1.0) to
statistically significant overall effect sizes when studies with a high
treatment contrast were added (0.13 SDU; CI, 0.03 to 0.23; Z=2.49; p=0.007).
(Figure 3). Sensitivity analysis revealed significant homogeneous (χ2 =7.07,
79
Chapter 3
p=0.60) SES for those studies that applied 15 hours or more (0.22 SDU; CI,
0.07 to 0.37; Z=2.95; p=0.005) when compared to studies with a lower
treatment contrast (0.08 SDU; CI, 0.06 to 0.22; Z=1.10; p=0.136).

Figure 3. Cumulative meta‐analysis of intensity trials measuring outcome of ADL
adjusted for treatment contrast

INTENSITY: ADL (mean and 95% CI)
Cumulative
number of Cumulative
effect size cumulative contrast
patients
N=170 Green 0.00 [-0.44 - 0.44] 132 min
N=281 Logan 0.00 [-0.23 - 0.23] 146 min
N=466 Walker 0.12 [-0.10 - 0.35] 208 min
N=604 Gilbertson 0.21 [-0.03 - 0.45] 247 min
N=727 Rodgers 0.11 [-0.17 - 0.38] 276 min
N=869 Lincoln (2) 0.09 [-0.14 - 0.32] 301 min
N=1104 Parker (1) 0.08 [-0.12 - 0.27] 331 min
N=1198 Wade 0.08 [ -0.09 - 0.25] 344 min
N=1429 Parker (2) 0.07 [ -0.08 - 0.21] 370 min
N=1569 Lincoln (1) 0.06 [-0.07 - 0.19] 388 min
N=1656 Slade 0.06 [-0.07 - 0.18] 400 min
N=1751 Sivenius 0.10 [-0.02 - 0.23] 413 min
N=1821 GAPS 0.08 [-0.07 - 0.23] 425 min
N=1935 Partridge 0.17 [-0.20 - 0.54] 453 min
N=2091 Fang 0.12 [0.00 - 0.24] 487 min

N=2191 Feys 0.10 [-0.02 - 0.21] 508 min
N=2323 Sunderland 0.10 [-0.02 - 0.21] 544 min
N=2350 Richards 0.09 [-0.03 - 0.20] 560 min
N=2412 Stern 0.07 [-0.04 - 0.19] 600 min

N=2464 Kwakkel (2) 0.09 [-0.02 - 0.20] 639 min
N=2513 Kwakkel (1) 0.10 [-0.00 - 0.20] 678 min
N=2578 Smith (2) 0.10 [0.00 - 0.21] 744 min
N=2618 Werner 0.12 [0.00 - 0.21] 804 min
N=2686 Smith (1) 0.13 [0.03 - 0.23] 956 min
S.E.S. N = 2686 0.13 [0.03 - 0.23] [mean 956 min]

-1 -0.5 0 0.5 1

Comfortable walking speed and dexterity
Six (N=524) of 20 studies measured the effects of augmented therapy on
walking speed.4,9,11,33,34,43 Pooling individual effect sizes revealed a significant
homogeneous SES of 0.19 (SDU); CI, 0.01 to 0.36; Z=2.12; p=0.017) (Table 4).
80
Another 5 studies (N=420) measured the effects of augmented therapy for
upper extremity function using the Action Research Arm test (ARAT).5,7‐9,43
Pooling these studies using this outcome showed no significant SES in
favour of augmented exercise therapy (0.03 SDU; CI, ‐0.13 to 0.19; Z=0.352,
p=0.637) (Table 5).

Table 4 – Summary effect sizes for comfortable walking speed at the end of the intervention
(N=524)
Trial Outcome Duration of NE /NC SDE /SDC ∆E - ∆C ES gU 95% CI
intervention
Wade, 1992
10 m walk 3 months 49 / 45 0.36 / 0.27 0.03 –(–0.03) = 0.06 0.12 –0.28 – 0.53
Richards, 1993
4 m walk 6 weeks 18 / 9 19.8 / 18.7 0.31 –0.30 = 0.01 0.07 –0.74 – 0.87
D
Kwakkel,1999
10 m walk 20 weeks 31 / 18 0.45/0.37B 0.65 – 0.37 = 0.28 A 0.65 0.06 – 1.25
Partridge, 2000
5 m walk 6 weeks 54 / 60 0.15 / 0.16 0.10 – 0.12 = –0.02 –0.13 –0.50 – 0.24
Green, 2002
10 m walk 13 weeks 85 / 85 0.17 / 0.21 0.05 – 0.01 = 0.04 0.16 –0.14 – 0.46
GAPS, 2004
10 m walk ~10 weeks 35 / 35 0.12 / 0.12 0.05 C 0.41 –0.06 – 0.89
SES Weighted mean (m/s)
(fixed model) 272 / 252 ~0.06 0.19 0.01– 0.36
Table 5 – Summary effect sizes for dexterity at the end of the intervention (N=627)
Trial Outcome Duration of NE /NC SDE /SDC ∆E - ∆C ES gU 95% CI

intervention
Feys, 1998
ARAT 6 weeks 50 / 50 7.86/7.98A 9.28 – 8.06 = 1.22A 0.15 –0.24 – 0.54
Kwakkel, 1999 D B
ARAT 20 weeks 33 / 19 16.4/15.4 10.40 – 2.39 = 8.01C 0.49 –0.08 – 1.07
Lincoln, 1999 G C
ARAT 5 weeks 93 / 47 9/9 –1 –0.11 –0.46 – 0.24
Lincoln, 1999 H
ARAT 5 weeks 94 / 48 9/9 -1 C –0.11 –0.46 – 0.23
Rodgers, 2003
ARAT 6 weeks 62 / 61 14 / 15 11.5 – 11.0 = 0.5 0.04 –0.32 – 0.39
GAPS, 2004
ARAT ~10 weeks 35 / 35 6/6D 0.35 F 0.06 –0.41 – 0.53
SES Weighted mean (pnts)
(fixed model) 367/260 ~0.55 0.03 –0.13 – 0.19

A Data from correspondence with author
B Standard deviations at 6 weeks in stead of baseline
C Calculated from p‐value (Table 3, in GAPS, 2004)
D Leg training group vs control group (immobilisation of paretic arm and leg by means of an inflatable pressure splint)
E Arm training group vs control group (immobilisation of paretic arm and leg by means of an inflatable pressure splint)
F Calculated from p‐value (data from correspondence with author)
G Assistant‐physiotherapist group vs routine physiotherapy group
H Qualified‐physiotherapist group vs routine physiotherapy group
ARAT indicates Action Research Arm Test; C, control group; CI, confidence interval; E, experimental group; ES gu, effect size
(Hedges’g); m, metre; N, number of patients; pnts, number of points on ARAT (range 0‐57); SD, standard deviation; SES,
summary effect size.
81
Chapter 3
Table 6 – Summary effect sizes for ADL at the end of the intervention (N=2686)
Trial ADL Duration of NE /NC SDE /SDC ∆E - ∆C ES gU 95% CI

outcome intervention
Stern, 1970 KIR scale Until dischar- 31 / 31 10 / 10 9.7 – 8.3 = 1.4 0.14 -0.36 – 0.64
ge 92 / 88.7d
Smith, 1981 F Mod ADL P 3 mo 46 / 22 14.1 / 13.7 6.99 0.49 -0.02 – 1.01
G P
Smith, 1981 Mod ADL 3 mo 43 / 22 14.1 / 13.8 5.02 0.35 –0.16 – 0.87
Sivenius, 1985 Lehman ADL 3 mo 50 / 45 9.4 / 11.3 10.5 – 2.7 = 7.8 0.75 0.33 – 1.16
B
●Sunderland, 1992 BI 6 mo 65 / 67 6.0 / 5.19 0.54 0.10 –0.25 – 0.44
Wade, 1992 BI 3 mo 49 / 45 3 / 2.8 –0.1–(–0.3) = 0.2 0.07 –0.33 – 0.47
Richards, 1993 BI 6 wk 18 / 9 4.2 / 4.2 22.5 – 24.1 = –1.6D – 0.38 –1.18 – 0.44
ambulation
Werner, 1996 FIM-MM 12 wk 28 / 12 14 / 19 6.6 – 1.5 = 5.1 0.32 –0.36 – 1.00
Logan, 1997 BI 6 mo 53 / 58 6/6 16 – 16 = 0 0.00 –0.37 – 0.37

A A
●Feys, 1998 BI 6 wk 50 / 50 19.8 / 18 22.8 – 23.4 = –0.6 – 0.03 –0.42 – 0.36
Kwakkel, 1999 H BI 20 wk 31 / 18 3.49/3.88A 10.3 – 8.75 = 1.55A 0.42 –0.17 – 1.01

J A A
●Kwakkel, 1999 BI 20 wk 33 / 19 3.86/3.88 10.43 – 8.75 = 1.68 0.44 –0.13 – 1.09
K
●Lincoln, 1999 BI 5 wk 93 / 47 5/6 6–6=0 0.00 –0.35 – 0.35
L
●Lincoln, 1999 BI 5 wk 94 / 48 4/6 6–6=0 0.00 –0.35 – 0.35
Walker, 1999 BI 6 mo 94 / 91 3/3 1R 0.33 0.04 – 0.63
Partridge, 2000 RLOC 6 wk 54 / 60 4.8 / 4.6 0.7 – (–0.1) = 0.8 0.17 –0.20 – 0.54
Gilbertson, 2000 BI 6 wk 67 / 71 2/2 1–0=1 0.50 0.16– 0.84
Parker, 2001 M BI 6 mo 156 / 79 4/3 0–0=0 0.00 –0.27 – 0.27
Parker, 2001 N BI 6 mo 153 / 78 4/3 0–0=0 0.00 –0.27 – 0.27
Green, 2002 BI 13 wk 85 / 85 1.5 / 1.5 0–0=0 0.00 –0.30 – 0.30

Q A A
Slade, 2002 BI ~84.6 d 47 / 40 23.5/26.3 15.53 – 15.6= –0.07 0.00 –0.42 – 0.42
●Rodgers, 2003 BI 6 wk 62 / 61 3/3 4 – 5 = –1 – 0.33 –0.69– 0.02
Fang, 2003 MBI 4 wk 65 / 62 19.56 / 31.04 21.97 – 13.63 = 8.34 0.32 0.16 – 0.64
GAPS, 2004 BI ~10 wk 35 / 35 3.3 / 3.1 4.8 – 5.8 = –1.0 – 0.31 –0.78 – 0.16
SES 1515 / 0.13 0.03 – 0.23

(random model) 1171
A
Data from correspondence with author; BMean of severe and mild groups; DE indicates mean of
experimental and early conventional group and C mean of conventional group (Table 4, in Richards et
al,1993); F Intensive therapy vs no routine rehabilitation; G Conventional therapy vs no routine rehabilitation;
H
Leg training group vs control group (immobilisation of paretic arm and leg by means of an inflatable
pressure splint); JArm training group vs control group (immobilisation of paretic arm and leg by means of an
inflatable pressure splint); KAssistant‐physiotherapist group vs routine physiotherapy group; LQualified‐
physiotherapist group vs routine physiotherapy group; MADL‐therapy group vs control group; NLeisure‐
therapy group vs control group; PModification of the ADL index: 17 items on a 3‐point scale; a person with a
score of 17 points requiring no help; 51 points means inability to make any contribution on any item; QUntil
discharge; RMean difference is given in Table 2, in Walker et al, 1999.
BI indicates Barthel Index; C, control group; ●, exercise therapy time focused on upper limb only; CI,
confidence interval; d, day; E, experimental group; ES gu, effect size (Hedges’g); FIM‐MM, functional
independence measure – motor measure; KIR, Kenny Institute of Rehabilitation; mo, month(s); N, number of
patients; RLOC, recovery locus of control scale; SD, standard deviation; SES, summary effect size; wk, week
82
Discussion:

From the present systematic review, it may be concluded that augmented
exercise therapy time spent in exercise training in the first 6 months after
stroke results in small improvements in ADL. Pooling reported differences
in ADL, by applying a fixed and random effects model showed small, but
significant SES. The effects were mainly restricted to therapies focused on
the lower limb and ADL in general, as well as to those studies conducted
within the first 6 months of stroke.
The SES in the cumulative meta‐analysis denotes an overall change of
about 4% to 5% in favour of more therapy time when a minimum of at least
about 16 hours additional exercise therapy time is provided. We must
acknowledge, however, that the findings do not allow us to be precise about
optimal treatment contrast. Another important point of discussion is the
clinical significance of such a small finding reflecting only a 1‐point change
(5%) in outcome for the Barthel Index in favour of augmented therapy.
Acknowledging that >80% receive exercise therapy, one may argue from an
epidemiological perspective that even this small change in ADL score is
likely to have a disproportionately large impact for health care polices.1
The benefits of augmented therapy time were mainly related to studies
that focused the extra time on the lower limb or general ADL and not to the
5 RCTs that provided additional therapy time to the upper limb. It is
important to note, however, that an ADL outcome, such as the Barthel Index,
is more sensitive to lower limb improvement than to that in the upper limb.9
Moreover, improvements in mobility are more easily obtained than
improvements in dexterity. We also know that functional outcome of the
upper limb at 6 months after stroke is closely related to the level of recovery
achieved in the first month, at least in patients with a primary middle
cerebral artery stroke.45 In addition, there are indications that gains in the
upper limb may require more intense repetitive practice and may be limited
to those with less severe upper extremity deficits.32,45,46 This finding also
suggests that for patients who are expected to achieve at least some
dexterity, every opportunity should be given to regain function in the
affected upper limb. In contrast, those patients for whom a poor motor
recovery without return of dexterity is anticipated should have treatment
focused on achieving and maintaining a comfortable mobile arm and hand.
Compensation strategies with the nonparetic arm should be fostered.47
Lastly, the findings of our meta‐analysis showed that augmented therapy
also may lead to improvements of about 5% in IADL such as household and
83
Chapter 3
leisure activities. It should be noted, however, that the number of such
studies (n=9) is limited.
Although, in the present study, the intensive rehabilitation groups
received about 16 hours more exercise therapy than the control group,
considerable differences in the total amount of additional therapy provided,
as well as in the timing and the focus of interventions, were observed. The
augmented time of exercise therapy ranged from a minimum of 13211 to a
maximum of 6816 minutes.30 Cumulative meta‐analysis of studies showed a
positive trend in favour of those studies that applied a larger treatment
contrast between experimental and control therapies. This suggests that the
treatment contrast should exceed 16 hours to promote significant differences
in ADL and that this more intensive therapy should be provided in the first
6 months post stroke. Interestingly, no ceiling effect for therapeutic intensity,
beyond which no further response is observed, was found in the present
study. This finding is consistent with a recent RCT on the effects of
additional rehabilitation intensity after brain injury.48 Increasing the number
of hours of therapy per week given to adults recovering from brain injury
accelerated the rate of recovery of personal independence. In agreement
with this finding, Chen et al24 found in a retrospective analysis of 554 records
of patients with stroke that gains on Functional Independence Measure were
weakly, but significantly, related to therapy intensity and rehabilitation
duration after controlling for other variables. Future studies should focus on
the effects of larger treatment contrasts in stroke, either by increasing the
intensity of exercise time in the experimental group and/or by restricting the
therapy in the control group. However, this latter suggestion may cause
ethical concerns about depriving control subjects of the usual and expected
amount of treatment.9
The present meta‐analysis has several limitations. First, we defined
intensity and treatment contrast on the basis of differences in time that
therapy was provided to the experimental and control groups. This is, of
course, a crude estimate of the actual effort and energy that is spent in
performing exercises.2,3 Other aspects, such as patients’ motivation, attention
paid by the therapist and time spent on home exercises, may have
confounded the reported outcomes. Second, although all included studies
investigated the effects of additional exercise therapy, the content of therapy
differed between studies, with regard to goals set and the type of reference
treatment (or condition) applied. Finally, we may have missed relevant
studies not published in scientific journals or published in languages other
than English, German, or Dutch.
84
It should also be noted that a number of other factors may have
influenced the present findings, including different intervention goals,
treatment content in the experimental group and control groups, patient
selection criteria and outcome measures. For example, most studies
investigated the additional effects of a particular method of treatment such
as the neurodevelopmental approach,4‐6 facilitation exercise techniques,28 or
task‐specific exercise programs.9,34 In all but 1 study, the control group
received some form of therapeutic intervention. In the RCT by Kwakkel et
al,9 the affected limbs were immobilised applying an inflatable pressure
splint. The increased treatment contrast between the intervention and
control groups obtained by preventing these patients from an active motor
learning process may have contributed to a relatively larger effect size for
leg training compared to other studies. Finally, when considering the impact
of intensity of rehabilitation on stroke outcome, it should be realised that the
intensity of rehabilitation programs is often limited.49,50 For example, in
stroke units the usual direct contact time may be as little as 4% of the total
waking time. Ten hours of therapy per week (2 h daily) represents only 9%
of the waking time.51 It should also be acknowledged that >2 hours of
therapy each day is not feasible for every patient or clinical setting due to
inability to tolerate the extra therapy sessions or to limited personnel.
Several studies have shown, however, that augmentation of functional
oriented therapy may be achieved by applying ‘constraints’ to the less
affected arm forcing the affected limb to be used during ADL for 6 hours a
day during 2 weeks (ie, augmentation of 60 hours).52 From these studies, it
may be hypothesised that high dose of task‐specific exercise training should
be applied over a shorter period of time. Recent studies have also shown
that the efficiency of limited therapeutic resources can be increased by using
circuit training programs in which a group of patients is allowed to practice
at different workstations simultaneously under the supervision of a
therapist.46,53
Future studies should focus on the most cost‐effective intensity of
therapy in stroke rehabilitation and the identification of patients who should
benefit most from early and intensive exercise therapy. Differences were
found between studies comparing the effects of intensity in the chronic stage
of stroke to those comparing effects within 6 months of stroke onset. It
should be noted, however, that the absence of SESs for the 3 studies that
started augmented exercise therapy time in the chronic phase may be caused
by insufficient statistical power. Future studies should indicate if the effects
of enhanced exercise programs are transient, suggesting an increased speed
of functional recovery or sustained in the chronic phase if therapy is
85
Chapter 3
continued.39,51 Thus far, findings from trials using constraint‐induced

movement therapy in patients with an incomplete upper limb deficit suggest
that intensive, task‐specific exercising in the chronic stage after stroke may
result in improved dexterity.52 Therefore, research on subjects likely to
benefit from higher intensities of stroke rehabilitation should be part of the
future research agenda. This review has demonstrated the lack of data to
define the treatment contrast needed to optimise effects of rehabilitation. At
least it suggests that treatment contrasts between control and experimental
groups should be extended in future high‐quality RCTs.


This part is a research project supported by a grant from the Royal Dutch
Society of Physical Therapy (KNGF; grant reference number
IKPZ/KNGF/05/2000). Chest, Heart & Stroke Scotland provided funding for
Ian Wellwood and the PINTAS study. In addition, it is supported by a grant
of ZonMw in the Netherlands (1435.0017). We like to thank JCK (Hans) Ket
from the VU Medical Library for his independent literature search.

Referenties

Stroke 2001; 32: 268‐274.
2. Langhorne P, Wagenaar R, Partridge C. Physiotherapy after stroke: more is better?
Physiotherapy Research International 1996; 1: 75‐88.
3. Kwakkel G, Wagenaar R, Koelman T et al. Effects of intensity of stroke rehabilitation: a
research synthesis. Stroke 1997; 28: 1550‐1556.
4. Partridge C, Mackenzie M, Edwards S et al. Is dosage of physiotherapy a critical factor in
deciding patterns of recovery from stroke: a pragmatic randomized controlled trial.
5. Lincoln N, Parry R, Vass C. Randomized, controlled trial to evaluate increased intensity of
physiotherapy treatment of arm function after stroke. Stroke 1999; 30: 573‐579.
6. Parker C, Gladman J, Drummond A et al. A multicentre randomized controlled trial of
leisure therapy and conventional occupational therapy after stroke. TOTAL Study Group.
Trial of Occupational Therapy and Leisure. Clin Rehabil 2001; 15: 42‐52.
7. Rodgers H, Mackintosh J, Price C et al. Does an early increased‐intensity interdisciplinary
upper limb therapy programme following acute stroke improve outcome? Clin Rehabil
2003; 17: 579‐589.
86
8. Feys H, deWeerdt W, Selz B et al. Effect of a therapeutic intervention for the hemiplegic
upper limb in the acute phase after stroke: a single‐blind, randomized, controlled
multicenter trial. Stroke 1998; 29: 785‐792.
9. Kwakkel G, Wagenaar R, Twisk J et al. Intensity of leg and arm training after primary
middle‐cerebral‐artery stroke: a randomised trial. Lancet 1999; 354: 191‐96.
10. Gilbertson L, Langhorne P, Walker A et al. Domiciliary occupational therapy for patients
with stroke discharged from hospital: randomised controlled trial. BMJ 2000; 320: 603‐606.
11. Green J, Forster A, Bogle S et al. Physiotherapy for patients with mobility problems more
than 1 year after stroke: a randomized controlled trial. Lancet 2002; 359: 199‐203.
12. Stroke‐1989. Recommendations on stroke prevention, diagnosis, and therapy. Report of the
WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke 1989; 20: 1407‐31.
13. Cambach W, Wagenaar RC, Koelman TW et al. The long‐term effects of pulmonary
rehabilitation in patients with asthma and chronic obstructive pulmonary disease: a
research synthesis. Arch Phys Med Rehabil 1999; 80: 103‐111.
14. Hedges L, Olkin I. Statistical methods for meta‐analysis. Orlanda FL: Academic Press, 1985.
15. Shadish W Haddock K. Combining estimates of effect size. In: Cooper H. and Hedges LV
(eds.): The handbook of research synthesis. Russell Sage Foundation, New York, 1994; 18:
261‐282.
16. Hedges L. Fixed effects models. in Cooper H. and Hedges LV (eds.): The handbook of
research synthesis. Russell Sage Foundation, New York, 1994; 19: 285‐300.
17. Higgins JPT, Thomposon SG, Deeks JJ et al. Measuring inconsistency in meta‐analyses.
BMJ 2003; 327: 557‐560.
18. DerSimonian R. and Laird N. Meta‐analysis in clinical trials. (1986). Controlled Clinical
Trials 1986; 7: 177‐188.
19. Raudenbush S. Random Effects model. In: Cooper H. and Hedges LV (eds.): The handbook
of research synthesis. Russell Sage Foundation, New York, 1994; 20: 301‐323.
20. Brocklehurst J, Andrews K, Richards B et al. How much physical therapy for patients with
stroke? BMJ 1978; 1: 1307‐1310.
21. Wade D, Skilbeck C, Hewer R et al. Therapy after stroke: amounts, determinants and
effects. Int Rehabil Med 1984; 6: 105‐10.
22. Nugent J, Schurr K, Adams R. A dose‐response relationship between amount of weight‐
bearing exercise and walking outcome following cerebrovascular accident. Arch Phys Med
Rehabil 1994; 75: 399‐402.
23. Ballinger C, Ashburn A, Low J et al. Unpacking the black box of therapy ‐ a pilot study to
describe occupational therapy and physiotherapy interventions for people with stroke.
Clin Rehabil. 1999; 13: 301‐309.
24. Chen C, Heinemann A, Granger C et al. Functional gains and therapy intensity during
subacute rehabilitation: a study of 20 facilities. Arch Phys Med Rehabil 2002; 83: 1514‐23.
25. Keith R, Wilson DB, Gutierrez P. Acute and subacute rehabilitation for stroke: a
comparison. Arch Phys Med Rehabil 1995; 76: 495‐500.
87
Chapter 3
26. Rapoport J, Judd‐Van Eerd M. Impact of physical therapy weekend coverage on length of
stay in an acute care community hospital. Phys Ther 1989; 69: 32‐37.
27. Ruff R, Yarnell S, Marinos J. Are stroke patients discharged sooner if in‐patient
rehabilitation services are provided seven v six days per week? Am J Phys Med Rehabil
1999; 78: 143‐146.
28. Stern P, McDowell F, Miller J et al. Effects of facilitation exercise techniques in stroke
29. Peacock P, Riley C, Lampton T et al. The Birmingham Stroke Epidemiology and
Rehabilitation Study. In: Steward GT, editor. Trends in Epidemiology. Springfield, I 11:
Charles C Thomas. 1972: 231‐345.
30. Smith, D, Goldenberg E, Ashburn, A et al. Remedial therapy after stroke: a randomised
controlled trial. BMJ 1981; 282: 517‐520.
31. Sivenius J, Pyorala K, Heinonen O et al. The significance of intensity of rehabilitation of
stroke. A controlled trial. Stroke 1985; 16: 928‐931.
32. Sunderland A, Tinson D, Bradley L et al. Enhanced physical therapy improves recovery of
arm function after stroke. A randomised controlled trial. J Neurol Neurosurg Psychiat
1992; 55: 530‐535.
33. Wade T, Collen M, Robb F, Warlow P. Physiotherapy intervention late after stroke and
mobility. BMJ 1992; 304: 609‐613.
34. Richards C., Malouin F, Wood‐Dauphinee S et al. Task‐specific physical therapy for
optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil 1993; 74:
612‐620.
35. Sunderland A, Fletcher D, Bradley L et al. Enhanced physical therapy for arm function
after stroke: A one year following up study. J Neurol Neurosurg Psychiat 1994; 57: 856‐
858.
36. Werner R, Kessler S. Effectiveness of an intensive outpatient rehabilitation program for
postacute stroke patients. Am J Phys Med Rehabil 1996; 75: 114‐120.
37. Logan P, Ahern J, Gladman J et al. A randomized controlled trial of enhanced Social
Service occupational therapy for stroke patients. Clin Rehabil 1997; 11: 107‐113.
38. Kwakkel G, Kollen B, Wagenaar R. Long term effects of intensity of upper and lower limb
training after stroke: a randomised trial. J Neurol Neurosurg Psychiat 2002; 72: 473‐79.
39. Kwakkel G, Wagenaar R. Effect of duration of upper‐ and lower‐extremity rehabilitation
Ther 2002; 82: 432‐448.
40. Parry R, Lincoln N, Vass C. Effect of severity of arm impairment on the response to
additional physiotherapy early after stroke. Clin Rehabil 1999; 13: 187‐198.
41. Slade A, Tennant A, Chamberlain M. A randomised controlled trial to determine the effect
of intensity of therapy upon length of stay in a neurological rehabilitation setting. J Rehabil
Med 2002; 34: 260‐266.
42. Fang Y, Chen X, Lin J et al. A study on additonal early physiotherapy after stroke and
factors affecting functional recovery. Clin Rehabil 2003; 17: 608‐617.
88
43. Wellwood I, Langhorne P. Glasgow Augmented Physiotherapy after Stroke (GAPS) study.
Can augmented physiotherapy input enhance recovery of mobility after stroke? Clinical
Rehabilitation 2004; 18: 1‐9.
44. Walker M, Gladman J, Lincoln N et al. Occupational therapy for stroke patients not
admitted to hospital: a randomised controlled trial. Lancet 1999; 354: 278‐280.
45. Kwakkel G, Kollen B, van der Grond J et al. Probability of regaining dexterity in the flaccid
upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke 2003;
34: 2181‐2186.
46. Duncan PM, Studenski S, Richards L et al. Randomized clinical trial of therapeutic exercise
in subacute stroke. Stroke 2003; 34: 2173‐2180.
47. Barreca S, Wolf SL, Fasoli S et al. Treatment interventions for the paretic upper limb of
stroke survivors: a critical review. Neurorehabil Neural Repair 2003; 17: 220‐226.
48. Shiel A, Burn J, Clark D et al. The effects of increased rehabilitation therapy after brain
injury: results of a prospective controlled trial. Clin Rehabil 2001; 15: 501‐514.
49. Tinson D. How stroke patients spend their days. International Disabilities Studies 1989; 11:
45‐49.
50. De Weerdt, W, Nuyens G, Feys H et al. Group physiotherapy improves time use by
patients with stroke in rehabilitation. Australian Journal of Physiotherapy 2001; 47: 53‐61.
51. Wade D. Rehabilitation research – time for a change of focus. The Lancet (Neurology) 2002;
1: 209.
52. Van der Lee J, Constraint‐induced therapy for stroke: more of the same or something
completely different? Curr Opin Neurol 2001; 14: 741‐744.
53. Dean C, Richards C, Malouin F. Task related circuit training improves performance of
locomotor tasks in chronic stroke: a randomized controlled pilot trial. Arch Phys Med
Rehabil 2000; 81: 409‐17.
89
Chapter 3
90
CHAPTER

Effects of visual feedback therapy on postural
control in bilateral standing after stroke:
A systematic review
Michiel Kortsmit
Eline Lindeman
Gert Kwakkel
Journal of Rehabilitation Medicine 2006; 38(1): 3‐9
Chapter 4
Abstract

Objective: To establish whether bilateral standing after stroke with visual
feedback therapy improves postural control compared with conventional
therapy and to evaluate the generalisation of the effects of visual feedback
therapy on gait and gait‐related activities.
Design: A systematic review
Methods: A computer‐aided literature search was performed. Randomised
controlled trials and controlled clinical trials, comparing visual feedback
therapy with conventional balance treatments were included up to April
2005. The methodological quality of each study was assessed with the
Physiotherapy Evidence Database scale. Depending on existing
heterogeneity, studies with a common variable of outcome were pooled by
calculating the summary effect sizes using fixed or random effects models.
Results: Eight out of 78 studies, presenting 214 subjects, were included for
qualitative and quantitative analysis. The methodological quality ranged
from 3 to 6 points. The meta‐analysis demonstrated non‐significant
summary effect sizes in favour of visual feedback therapy for weight
distribution and postural sway, as well as balance and gait performance, and
gait speed.
Conclusions: The additional value of visual feedback therapy in bilateral
standing compared with conventional therapy shows no statistically
significant effects on symmetry of weight distribution between paretic and
non paretic leg, postural sway in bilateral standing, gait and gait‐related
activities. Visual feedback therapy should not be favoured over conventional
therapy. The question remains as to exactly how asymmetry in weight
distribution while standing is related to balance control in patients with
stroke.

Key words: cerebrovascular disorders, visual feedback, force plate, postural
control, rehabilitation, meta‐analysis

92
Effects of VFT on postural control in bilateral standing
Introduction

The rate in which stroke occurs in developed countries is approximately
2400 per 1 million persons per year.1 Stroke is one of the leading causes of
impairment and disability in the Western world.2 Many patients with stroke
suffer from significant motor and cognitive impairments, such as visual
spatial impairments, aphasia, hemi‐neglect, dyspraxia, gait disorders and
poor sitting and standing balance control.3,4 In particular, recovery of
postural control is found to be a prerequisite for regaining independence in
activities of daily living (ADL).5
Unfortunately, there is no generally accepted definition of the term
‘postural control’; however, the definition of Pollock and colleagues6 is
frequently used. They described postural control as ‘the act of maintaining,
achieving or restoring a state of balance during any posture or activity’. In
hemiplegic patients the postural control is characterised by an increased
postural sway,7,8 and asymmetrical weight distribution with a shift in the
average position of the body’s centre of pressure towards the unaffected
side.9,10 Current research concerning balance deficits in hemiplegic patients
focuses on differential components such as postural sway and symmetry of
weight distribution. The use of force plate feedback in stroke rehabilitation
has been examined in a number of these studies. This type of therapy
provides visual or auditory feedback of patient’s postural sway or weight
distribution between the paretic and non paretic lower limb.11,12 The interest
in force plate feedback as a rehabilitation instrument was positively
influenced by the development of the Balance Master™ (NeuroCom
International). This computerised force plate provides continuous visual
feedback on the position of the centre of gravity (COG), giving a new tool for
training: the visual feedback therapy (VFT). Despite the number of
publications dedicated to feedback therapy, only one recent review has
systematically evaluated the effectiveness of this therapy on promoting the
recovery of postural control after stroke.13 Barclay‐Goddard et al13 concluded
after systematic reviewing 7 randomised controlled trials (RCT), that force
plate feedback (visual or auditory) improved stance symmetry after stroke,
but they could not establish effects on postural sway or measures related to
gait and independency in ADLs.
The purpose of the present systematic review was to examine the
effects of the additional VFT on postural control in bilateral standing in
subjects suffering from stroke. The primary aim of this review was to
establish whether VFT reduces postural sway and improves symmetry of
weight distribution in bilateral standing after stroke compared with
93
Chapter 4
conventional treatment. In addition, the effects of VFT on parameters of gait
and gait‐related activities including ADL were evaluated.
Methods

Search strategy for study identification
A computer‐aided literature search was performed in the following
electronic databases; PubMed (MEDLINE), Cochrane Central register of
Controlled Trials, CINAHL, Physiotherapy Evidence Database (PEDro) and
DOC‐online. Only articles published in the period up to April 2005 and
written in English, German or Dutch were included. All references
presented in relevant studies were also examined. The following MeSH and
keywords were used: cerebrovascular accident, cerebrovascular disorders,
hemiplegia, paresis or stroke (patient type), rehabilitation, posture,
symmetry, balance, postural control, musculoskeletal equilibrium or weight‐
bearing (intervention type), force plates, force platforms or feedback (device
type) and randomised controlled trial, controlled clinical trial, comparative
study or trial (publication type). The complete study identification was
performed by 2 independent reviewers (RPSvP, MK). The databases were
searched using a study identification strategy that was formulated in
PubMed and adapted to the other databases. The full search strategy is
available on request from the first author.
The abstracts of the publications, retrieved from the computer‐aided
literature search, were selected on basis of the following 3 inclusion criteria:
• The studies involved adult subjects suffering from stroke. The
participants were diagnosed as patients with stroke following the
definition of the World Health Organization. Stroke is defined as ‘a focal
(at times global) neurological impairment of sudden onset, and lasting
more than 24 hours (or leading to dead) and of presumed vascular
origin’.14
• Effects of VFT on postural control in bilateral standing were evaluated.
The feedback had to provide visual representations of the individual’s
centre of gravity or weight distribution between the paretic and non
paretic leg. In the present review feedback is defined as a ‘process by
which a person uses biofeedback information to gain voluntary control
over processes or functions that are primarily under autonomic
control’.15
• The studies were RCTs or controlled clinical trials (CCT).16
94
Methodological quality assessment
The methodological quality of the selected RCTs and CCTs was rated using
the PEDro scale17,18 by 2 independent reviewers (RPSvP, MK). Reviewers
were not blinded to author(s), institution(s) or journal. The PEDro scale
contains 11 items. The first item assesses external validity and the other 10
items assess the internal and statistical validity of the studies.17,18 These 10
items were used to calculate the PEDro score. All items were scored binary
(i.e., yes=1/no=0), which could result in a maximum score of 10 points.
Agreement regarding each item was evaluated by calculating a Kappa
statistic. Disagreements regarding items were solved by discussion between
the reviewers. If disagreement persisted, a third reviewer (GK) made the
final decision.

Analysis of the results was performed separately for each study. When the
interventions, patient characteristics and outcome measures were
comparable, statistical pooling was performed. The data were re‐analysed
by pooling the individual effect sizes (gi) using Hedges’ g model.19,20 In this
model the difference between mean changes in the experimental group and
in the control group during the therapy period were calculated and divided
by the average population standard deviation (SDi).
Subsequently, unbiased effect sizes (gu) were calculated for each
study after adjusting for the number of degrees of freedom. The impact of
sample size was addressed by calculating a weighting factor (wi) for each
study, and assigning larger effect‐weights to studies with larger samples.
Subsequently, gu’s of individual studies were averaged, resulting in
a weighted summary effect size (SES), whereas the weights of each study
were combined to estimate the variance of the SES.21 The fixed effects model
was used to decide whether a SES was statistically significant (SES [fixed]). If
significant between‐study variation existed a random effects model was
applied (SES [random]).22 Post hoc sensitivity analysis for study design was
performed if significant heterogeneity was found between individual effect
sizes. For all outcome variables, the critical value for rejecting H0 (i.e., there
is no evidence for VFT) was set two‐tailed at 0.05.

95
Table 1 Characteristics of the included studies
96
Reference Objective study Design N Mean Time Equipment Training Outcome Outcome Conclusions Methodo-
(year ) (E/C) age (d) period (Gait & gait- (author) logical
(E/C) since (weeks) (Bilateral related quality**
Chapter 4
To investigate: stroke standing)¹ activities)¹

(E/C)
Shumway-Cook the effect of RCT 16 66/64 36/37 Standing 2 Total Sway – VFT is more effective Ext. val#:
et al. (1988) additional VFT (8/8) Feedback area (EO), than CT in reducing yes
compared with CT Trainer Lateral lateral sway and increa- 4 points**
in re-establishing Sway (EO) sing load on the affected Failure at
stance stability in leg, however, no signify- questions
post-acute stroke cant post-treatment 3,4,5,6,7,
patients effects were found. 9
#
Winstein et al. the effect of CCT 42 52/54 54/44 Standing 3-4 Sway (EO), Gait speed Significant improvement Ext. val :
(1989) additional VFT (21/21) Feedback Weight of static standing sym- yes
compared with CT Trainer, Distribution metry was found in VFT- 3 points**
for balance re- group. No additional Failure at
training in post- Stride effects of VFT on gait questions
acute stroke analyser speed, cadence, stride 2,3,5,6,7,
patients with a system length and cycle time 8,9
standing feedback were observed.
trainer
Sackley et al. the effectiveness RCT 26 61/68 141/ Nottingham 4 Sway (EO), Nottingham Significant better Ext. val#:
(1997) of additional VFT (13/13) 132 Balance Weight 10 Points performance VFT on yes
vs placebo VFT in Platform Distribution ADL Scale, stance symmetry and 6 points**
improving stance Rivermead sway and motor and Failure at
symmetry and Motor ADL function. Between questions
functional ability in Function group differences 3,5,6,9
post-acute stroke Assess- disappeared at 3
patients ment months post stroke.
Walker et al. the effect of RCT 32## 65/62 41/35 Balance 3-8 Sway (EO) BBS, No between-group Ext. val#:
(2000) additional VFT (16/16) MasterTM Sway (EC) TUG, differences in any of the yes
compared with Gait speed outcome measures were 4 points**
balance training on found Failure at
CoG position in questions
post-acute stroke 3,5,6,7,8,
patients 9
Grant et al. the beneficial RCT 16 65/65 33* Balance 3-8 Sway (EO), BBS, No between-group diffe- Ext. val#:
(1997) effect of VFT com- (8/8) MasterTM Sway (EC), TUG, rences on any outcome yes
pared with CT for Weight Gait speed measure were found, 5 points**
balance re-training Distribution although the CT group Failure at
in post-acute tended to perform better questions
stroke patients on tasks involving gait. 3,5,6,7,9

Reference Objective study Design N Mean Time Equipment Training Outcome Outcome Conclusions Methodo-
(year) (E/C) age (d) period (Gait & gait- (author) logical
(E/C) since (weeks) (Bilateral related quality**
To investigate: stroke standing)¹ activities)¹
(E/C)
Geiger et al. the effects of RCT 13 62/59 100/ Balance 4 – BBS, No additional effects of Ext.val#:
(2001) additional VFT (7/6) 134 MasterTM TUG VFT was found yes
compared with CT compared with the CT 5 points**
on balance and group Failure at
mobility in post- questions
acute stroke 3,5,6,7,9
patients
#
Chen et al. the delayed effects RCT 41 59/55 90/ Balance 2 Sway (EO), Brunnstrom No significant between- Ext. val :
(2002) of additional VFT (23/18) 113 MasterTM Sway (EC), stages; group differences were yes
compared with CT Static FIM found with respect to 5 points**
on balance Stability, static balance and loco- Failure at
retraining in post- Dynamic motion and mobility questions
acute hemiplegic Stability scoring of FIM. Signifi- 3,5,6,7,9
patients cant improvements were
observed for dynamic
balance function and
outcome of ADL in
favour of VFT.
Cheng et al. the effects of CCT 52 61/61 96/99 Balance 3 Static Fall No between-group Ext. val#:
(2004) additional VFT (28/24) MasterTM Stability, occurrence difference for any static yes
compared with CT Dynamic stability outcome was 4 points**
on the occurrence Stability found. The post-training Failure at
of falls in posttest showed significantly questions
acute hemiplegic better dynamic balance 3,5,6,7,8,
patients performance in favour of 9
VFT. The occurrence of
falls decreased,
although not statistical
significant in favour of
the VFT group.
¹ Only outcomes relevant for this systematic analysis are presented; * Average time since stroke of both groups;
**Quality assessment of RCT’s is measured by counting the number of checklist criteria (2-11) of the PEDro-scale that are satisfied in the trial report (sumscore 0-10) of the items 2-11).
#
The first item of the PEDro-scale has a yes/no-score. Yes means that the external validity is satisfied.
##
The VFT group is compared to the conventional group (the data of the 3th group –control group- are not used in this meta-analysis
BBS indicates Berg Balance Scale; C, control group; CCT, controlled clinical trial; CoG, center-of-gravity; CT, conventional balance therapy; E, experimental group; EC, eyes closed;
EO. eyes open; FIM, functional independence measure; N, number of patients; PEDro, physiotherapy evidence database; RCT, randomised controlled trial; TUG , timed up & go test;
97
VFT, visual feedback therapy

Chapter 4
Results

Study identification
After screening 78 identified studies, 9 studies were found to be relevant for
further analysis.8,11,12,23‐28 The study of Engardt et al25 was excluded, because
the patients in this study received postural control therapy with auditory
instead of visual feedback. A total of 8 studies, involving 214 patients, met
all the inclusion criteria.8,11,12,23,24,26‐28 The patients included in the study of
Grant et al (N=16),26 however, showed to be a subset of the study of Walker
and colleagues.12 Therefore the study of Grant was only used for outcomes
not investigated by the study of Walker and colleagues.12 Six studies (N=128)
were classified as RCTs8,11,12,23,26,27 and 2 as CCTs (N=86)24,28 Table I shows the
main characteristics of the 8 eligible studies included in the systematic
review. All studies were performed within the first 6 months post stroke,
ranging from 5 weeks8,26 to 20 weeks7 after stroke onset.

Methodological quality assessment
The methodological quality of the 8 included studies is presented in
Table I.8,11,12,23,24,26‐28 Therefore 80 quality items (10 per study) were scored.
Initially, the 2 reviewers disagreed on 5 of the 80 (6.3%) quality items. This
resulted in an average Cohenʹs Kappa score for all items of 0.88. The median
PEDro score was 4, ranging from 3 to 6 points.
Eight studies did not use a randomisation procedure with concealed
allocation and did not describe an intention‐to‐treat analysis.8,11,12,23,24,26‐28 In
one study the observers were blinded to treatment allocation.27

Pooling of outcomes was possible for (a) weight distribution and postural
sway while bilateral standing; (b) Berg Balance Scale (BBS)29,30; (c) Timed Up
& Go test (TUG)31 and (d) gait speed.

Weight distribution while bilateral standing
For purpose of the present meta‐analysis all weight distribution data were
put in comparable datasets. A homogeneous non‐significant SES was found
for 3 studies (N=75), 2 RCTs26,27 and 1 CCT28 evaluating weight distribution
with VFT in bilateral standing compared with conventional treatment (SES
[fixed] 0.40; CI ‐0.06 to 0.86) (26‐28) (Figure 1). Winstein et al28 presented the
weight distribution in percentage body weight on the paretic side. Grant et
al26 and Sackley et al27 depicted the weight distribution data as a ratio of the
paretic vs the non paretic limb. A post hoc sensitivity analysis for study
98
design was performed. Subsequently, when the CCT of Winstein et al28 was
excluded from the analysis the post hoc analysis resulted in a non‐significant
SES between VFT in bilateral standing and conventional therapy (SES [fixed]
0.51; CI: ‐0.11 to 1.14).26,27

Figure 1. Meta‐analysis of visual feedback therapy (VFT) trials measuring outcomes
of weight distribution and postural sway performance while bilateral standing

Weight Distribution
Winstein 1989 N=34 0.26 [ 0.03 - 0.49]

Grant 1997 N=16 0.24 [-0.24 - 0.74]
Sackley 1997 N=25 0.70 [ 0.37 - 1.02]
SES weight distribution N=75 0.40 [-0.06 - 0.86]

Postural Sway with eyes open (EO)
Shumway-Cook 1988 N=16 0.47 [-0.03 - 0.97]

Winstein 1989 N=34 0.50 [ 0.27 - 0.74]
Sackley 1997 N=25 -0.33 [-0.64 -(-0.01)]
Walker 2000 N=32 -0.05 [-0.29 - 0.20]
Chen 2002 N=41 0.38 [ 0.19 - 0.58]
SES postural sway (EO) N=148 0.20 [-0.12 - 0.53]

Postural Sway with eyes closed (EC)
Walker 2000 N=32 0.36 [ 0.11 - 0.61]

Chen 2002 N=41 0.22 [ 0.03 - 0.42]
SES postural sway (EC) N=73 0.28 [-0.18 - 0.75]

-2 -1 0 1 2
Favours conventional therapy Favours VF therapy

Meta‐analysis of weight distribution between paretic and non paretic lower limb, postural sway
with eyes open (EO) and postural sway with eyes closed (EC) in VFT vs conventional therapy.
Effect sizes are based on Hedges’ g (and 95% confidence intervals). The middle of each bar
represents the mean effect size, whereas the length of the bar reflects the 95% confidence
interval. Bars to the right of the vertical line denote a positive effect for the VFT and vice versa.
When the bar of an individual study crosses the vertical line at zero, no definite conclusions can
be drawn in favour of the VF or conventional group. The summary effect sizes (SES) value
represents the summarised effect size of all included studies.
99
Chapter 4
Postural sway while bilateral standing
Postural sway was measured in two conditions: with eyes open and with
eyes closed. Five studies (N=148), 4 RCTs8,12,23,27 and 1 CCT28, investigated the
effects of VFT on postural sway in bilateral standing with eyes open. Two of
these studies12,23 presented the postural sway (eyes open) in percentage (%)
of the theoretic limits of stability and 2 studies27,28 presented this outcome in
displacement values. Despite the differences regarding postural sway
measurement, all data were included in the present meta‐analysis. After
intervention a non‐significant heterogeneous SES was found for postural
sway (eyes open) (SES [random] 0.20; CI: ‐0.12 to 0.53)8,12,23,27,28 (Figure 1). The
data in the RCT of Shumway‐Cook and colleagues were presented in
interquartile ranges and standard error measurements (SEM).8 The means of
the pre‐ and post‐treatment data were analysed and SEM was converted to
standard deviations (SD).16 Excluding the CCT of Winstein et al28 a post hoc
sensitivity analysis for study design resulted in a non‐significant SES
between VFT and conventional therapy (SES [fixed] 0.26; CI: ‐0.11 to
0.63).8,12,23,27
Two RCTs (N=73) measured the effects of VFT on postural sway
with eyes closed in bilateral standing.12,23 In both studies the postural sway
data were presented in percentage limits of stability. The meta‐analysis
resulted in a non‐significant homogeneous SES for postural sway (eyes
closed) in bilateral standing comparing VFT and conventional therapy (SES
[fixed] 0.28; CI: ‐0.18 to 0.75)12,23 (Figure 1).

Berg Balance Scale
Two RCTs (N=45) evaluated the effects of VFT while bilateral standing on
balance, measured with the BBS.11,12 A non‐significant homogeneous SES
was found for BBS (SES [fixed] ‐0.20; CI: ‐0.79 to 0.39)11,12 (Figure 2).

Timed Up & Go test
The TUG is evaluated in 2 RCTs (N=44).11,12 The effects of VFT in bilateral
standing on the outcome measure TUG are presented in Figure 2.
A non‐significant homogeneous SES was found for TUG, when comparing
VFT with conventional therapy (SES [fixed] ‐0.14; CI: ‐0.73 to 0.45).11,12

Gait speed
Two studies (N=44), 1 RCT12 and 1 CCT28, evaluated the effects of VFT while
bilateral standing on gait speed. A non‐significant heterogeneous SES was
found for gait speed when comparing VFT with conventional therapy (SES
[random] 0.08; CI: ‐0.97 to 1.14)12,28 (Figure 2).
100
The balance and gait performance tests (BBS, TUG and gait speed) tended to
favour the conventional treatment instead of the VFT, but without statistical
significance.

Figure 2. Meta‐analysis of visual feedback therapy (VFT) trials measuring outcomes
of gait and gait‐related activities

Berg Balance Scale
Walker 2000 N=32 -0.12 [-0.37 - 0.12]

Geiger 2001 N=13 -0.39 [-1.01 - 0.22]
SES berg balance scale N=45 -0.20 [-0.79 - 0.39]

Timed Up & Go test
Walker 2000 N=32 -0.12 [-0.36 - 0.13]

Geiger 2001 N=12 -0.19 [-0.85 - 0.46]
SES timed up & go test N=44 -0.14 [-0.73- 0.45]

Gait Speed
Winstein 1989 N=40 0.61 [ 0.41 - 0.81]

Walker 2000 N=32 -0.46 [-0.71 -(-0.22)]
SES gait speed N=72 0.08 [-0.97 - 1.14]

-2 -1 0 1 2
Favours conventional therapy Favours VF therapy

Meta‐analysis of the Berg Balance Scale, the Timed Up & Go test and gait speed in VFT vs
conventional therapy. Effect sizes are based on Hedges’ g (and 95% confidence intervals(CI)).
The middle of each bar represents the mean effect size, whereas the length of the bar reflects the
95% CI. Bars to the right of the vertical line denote a positive effect for the VFT and vice versa.
When the bar of an individual study crosses the vertical line at zero, no definite conclusions can
be drawn in favour of the VF or conventional group. The summary effect sizes (SES) value
represents the summarised effect size of all included studies.

101
Chapter 4
Discussion:

The present systematic review aims to estimate the effects of the additional
value of VFT while bilateral standing on postural control, gait performance
and gait‐related activities after stroke. This review shows, however, no
significant effects in favour of VFT for (left‐right) symmetry of weight
distribution in bilateral standing, postural sway, balance control measured
with BBS, transfers and walking ability measured with TUG or gait speed.
Despite differences between inclusion criteria and number of included
studies, the findings presented in this systematic review correspond to a
large extent with those of Barclay‐Goddard et al13 who reviewed studies that
also included non‐stroke victims.
Improving symmetry of weight distribution while bilateral standing,
is one of the main treatment goals in the rehabilitation of patients with
stroke, acknowledging that the degree of asymmetric weight distribution
during quiet standing is negatively associated with motor function and
independence.7 Furthermore, the transfer of weight distribution is seen as an
indicator for walking performance.9,32 It has been documented that patients
with stroke shift 60% to 90% of the body weight to the non paretic limb.27,33,34
However, the question is how this asymmetry in weight distribution while
standing is related to balance control and with that to the safety not to fall.
For example, Kirker et al35 found that patients with stroke are more stable,
while standing when they keep their postural control, as soon as the center
of pressure is successfully shifted above the unaffected limb.35 This finding
suggests that the asymmetrical stance of people with hemiparesis may be a
compensatory strategy to overcome muscle weakness,36,37 delayed muscle
activation,35,38 synergistic‐dependent activation patterns of muscles39 and
existing perceptual deficits.40‐42 This assumption is also supported by
Sackley,7 who noted that asymmetrical weight transfer does not necessarily
imply that the subjects are more unstable and less able to control their
balance in order to prevent falling. In other words, asymmetry does not
necessarily imply a decreased postural control and higher risks for
falling.43,44 Unfortunately, almost none of the studies, except Cheng et al, did
measure the impact of VFT on the incidence of falling or near falling after
stroke.24
The lack of evidence on postural control may also reflect the absence
of valid outcome measures that represents more appropriate the strategy to
obtain postural control while bilateral standing on two force plates. For
example, De Haart et al45 stated that the speed (i.e., number of weight shifts)
and imprecision (normalised average lateral displacement) by asking
102
patients well‐controlled weight shifts in the frontal plane, could provide
additional information about their improvement in balance control after
stroke compared with the traditional measures of outcome. In addition, it
might be hypothesised that in stroke patients different strategies are used for
maintaining upright position during quiet bilateral standing.46 For example,
stabilogram analysis revealed that delaying time intervals of open‐loop
control mechanisms as well as inappropriate timing of descending
commands to postural muscles, may be important factors that contribute to
inappropriate displacements of the centre of pressure beyond the limits of
safety.47 A further understanding of these changes, as well as the adaptive
mechanisms underlying the functional (re)organisation of postural control is
needed to conceptualise the effects of hemiplegia on postural instability in
patients with stroke. Subsequently, new treatment programs need to be
developed aiming to improve postural control in stroke in stead of restoring
symmetry alone.
The present review also suggests that VFT failed to generalise to a
better balance control while performing gait and gait‐related activities.
These results are of great clinical value indicating that training of postural
control should preferably be applied while performing the gait‐related tasks
itself. It should be noted, however, that the Berg Balance Scale is sensitive to
ceilings effects48 and may have prevented to find significant effects, for
example in the study of Walker et al.12 Future studies are needed to
investigate the relationship of patients preferred asymmetrical standing
position on performance of gait and to establish how recovery of (left‐right)
symmetry in standing balance is related to improvements of gait and gait‐
related activities.
Unfortunately, in the present review not all outcomes could be
pooled. For example, the ADL outcomes of Sackley & Lincoln27 and Chen et
al (23) were too diverse to be pooled. The studies reported significant effects
on the Nottingham 10 points ADL scale27 and FIMTM 23 that favoured VFT.
One should notice that these positive effects are in contrast to the findings of
the present meta‐analysis. However, only limited evidence could be
attributed to the individual results of these studies. Additionally, the data of
the Balance Master™ outcome ‘dynamic stability’ were not defined in the
individual studies.23,24 As a consequence, it was unclear how to interpret
these outcomes in terms of improvement in postural control.
The present review has a number of shortcomings. We may have
missed relevant studies not published in scientific journals or published in
other languages than English, German or Dutch. These shortcomings
103
Chapter 4
emphasise the need for more high‐quality and larger RCTs in stroke
rehabilitation studies in the future.


We thank Hans (J.C.F.) Ket from the VU Medical Library for providing
support for the literature search.

Referenties

1. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs,
and effects on individuals and populations. Lancet 1999; 354:1457‐1463.
2. Rijken PM, Dekker J. Clinical experience of rehabilitation therapists with chronic disease: a
quantitative approach. Clin Rehabil 1998; 12:143‐150.
3. Tatemichi TK, Desmond DW, Stern Y et al. Cognitive impairment after stroke: frequency,
patterns, and relationship to functional abilities. J Neurol Neurosurg Psychiatry 1994;
57:202‐207.
4. Yamamoto L, Magalong E. Outcome measures in stroke. Crit Care Nurs Q 2003; 26:283‐293.
5. Fong KN, Chan CC, Au DK. Relationship of motor and cognitive abilities to functional
performance in stroke rehabilitation. Brain Inj 2001; 15:443‐453.
6. Pollock AS, Durward BR, Rowe PJ et al. What is balance? Clin Rehabil 2000; 14:402‐406.
7. Sackley CM. Falls, sway, and symmetry of weight‐bearing after stroke. Int Disabil Stud
1991; 13:1‐4.
8. Shumway‐Cook A, Anson D, Haller S. Postural sway biofeedback: its effect on
reestablishing stance stability in hemiplegic patients. Arch Phys Med Rehabil 1988; 69:395‐
400.
9. Goldie PA, Matyas TA, Evans OM et al. Maximum voluntary weight‐bearing by the
affected and unaffected legs in standing following stroke. Clin Biomech (Bristol , Avon )
1996; 11:333‐342.
10. Nichols DS. Balance retraining after stroke using force platform biofeedback. Phys Ther
1997; 77:553‐558.
11. Geiger RA, Allen JB, OʹKeefe J et al. Balance and mobility following stroke: effects of
physical therapy interventions with and without biofeedback/forceplate training. Phys
Ther 2001; 81:995‐1005.
12. Walker C, Brouwer BJ, Culham EG. Use of visual feedback in retraining balance following
acute stroke. Phys Ther 2000; 80:886‐895.
13. Barclay‐Goddard R, Stevenson T, Poluha W et al. Force platform feedback for standing
balance training after stroke. Cochrane Database Syst Rev 2004:CD004129.
104
1989; 20:1407‐1431.
15. Walker A. Thesaurus of Psychological Index Terms. 8th ed. American Psychological
Association, 1997.
16. Alderson P, Green S, Higgins JPT. Cochrane Reviewersʹ Handbook 4.2.2. Available from:
http://www.cochrane.org/resources/handbook/hbook.htm. [Cited 2004 18th of November].
17. PEDro. The Physiotherapy Evidence Database (PEDro). Available from:

http://www.pedro.fhs.usyd.edu.au/ . [Cited 2004 18th of November].
18. Sherrington C, Herbert RD, Maher CG et al. PEDro. A database of randomized trials and
systematic reviews in physiotherapy. Man Ther 2000; 5:223‐226.
19. Hedges LV, Olkin I. Statistical methods for research synthesis. Orlando, Fla: Academic
Press, Inc, 1985.
20. Hedges LV. Fixed effects models. In: Cooper LV, Hedges LV, editors. The handbook of
research synthesis. New York: Russell Sage Foundation, 1994: 285‐300.
261‐282.
22. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Control Clin Trials 1986; 7:177‐188.
23. Chen IC, Cheng PT, Chen CL et al. Effects of balance training on hemiplegic stroke
patients. Chang Gung Med J 2002; 25:583‐590.
24. Cheng PT, Wang CM, Chung CY et al. Effects of visual feedback rhythmic weight‐shift
training on hemiplegic stroke patients. Clin Rehabil 2004; 18:747‐753.
25. Engardt M, Ribbe T, Olsson E. Vertical ground reaction force feedback to enhance stroke
patientsʹ symmetrical body‐weight distribution while rising/sitting down. Scand J Rehabil
Med 1993; 25:41‐48.
26. Grant T, Brouwer BJ, Culham EG et al. Balance retraining following acute stroke: a
comparison of two methods. Canadian Journal of Rehabilitation 1997; 11:69‐73.
27. Sackley CM, Lincoln NB. Single blind randomized controlled trial of visual feedback after
stroke: effects on stance symmetry and function. Disabil Rehabil 1997; 19:536‐546.
28. Winstein CJ, Gardner ER, McNeal DR et al. Standing balance training: effect on balance
and locomotion in hemiparetic adults. Arch Phys Med Rehabil 1989; 70:755‐762.
29. Berg K, Wood‐Dauphinee S, Williams JI et al. Measuring balance in the elderly:
preliminary development of an instrument. Physiother Can 1989; 41:304‐311.
30. Berg K, Wood‐Dauphinee S, Williams JI. The Balance Scale: reliability assessment with
elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995; 27:27‐36.
31. Podsiadlo D, Richardson S. The timed ʺUp & Goʺ: a test of basic functional mobility for
frail elderly persons. J Am Geriatr Soc 1991; 39:142‐148.
32. Cheng PT, Liaw MY, Wong MK et al. The sit‐to‐stand movement in stroke patients and its
correlation with falling. Arch Phys Med Rehabil 1998; 79:1043‐1046.
105
Chapter 4
33. Dickstein R, Nissan M, Pillar T et al. Foot‐ground pressure pattern of standing hemiplegic
patients. Major characteristics and patterns of improvement. Phys Ther 1984; 64:19‐23.
34. Laufer Y, Dickstein R, Resnik S et al. Weight‐bearing shifts of hemiparetic and healthy
adults upon stepping on stairs of various heights. Clin Rehabil 2000; 14:125‐129.
35. Kirker SG, Jenner JR, Simpson DS et al. Changing patterns of postural hip muscle activity
during recovery from stroke. Clin Rehabil 2000; 14:618‐626.
36. Dickstein R, Shefi S, Marcovitz E et al. Anticipatory postural adjustment in selected trunk
muscles in post stroke hemiparetic patients. Arch Phys Med Rehabil 2004; 85:261‐267.
37. Hamrin E. II. Early activation in stroke: does it make a difference? Scand J Rehabil Med
1982; 14:101‐109.
38. Diener HC, Bacher M, Guschlbauer B et al. The coordination of posture and voluntary
movement in patients with hemiparesis. J Neurol 1993; 240:161‐167.
39. Di Fabio RP, Badke MB, Duncan PW. Adapting human postural reflexes following
localized cerebrovascular lesion: analysis of bilateral long latency responses. Brain Res
1986; 363:257‐264.
40. Eng JJ, Chu KS. Reliability and comparison of weight‐bearing ability during standing tasks
for individuals with chronic stroke. Arch Phys Med Rehabil 2002; 83:1138‐1144.
41. Garland SJ, Willems DA, Ivanova TD et al. Recovery of standing balance and functional
mobility after stroke. Arch Phys Med Rehabil 2003; 84:1753‐1759.
42. Yelnik AP, Lebreton FO, Bonan IV et al. Perception of verticality after recent cerebral
hemispheric stroke. Stroke 2002; 33:2247‐2253.
43. Geurts AC, Nienhuis B, Mulder TW. Intrasubject variability of selected force‐platform
parameters in the quantification of postural control. Arch Phys Med Rehabil 1993; 74:1144‐
1150.
44. Panzer VP, Bandinelli S, Hallett M. Biomechanical assessment of quiet standing and
changes associated with aging. Arch Phys Med Rehabil 1995; 76:151‐157.
45. de Haart M, Geurts AC, Dault MC et al. Restoration of weight‐shifting capacity in patients
with postacute stroke: a rehabilitation cohort study. Arch Phys Med Rehabil 2005; 86:755‐
762.
46. Collins JJ, De Luca CJ. Open‐loop and closed‐loop control of posture: a random‐walk
analysis of center‐of‐pressure trajectories. Exp Brain Res 1993; 95:308‐318.
47. Collins JJ, De Luca CJ, Pavlik AE et al. The effects of spaceflight on open‐loop and closed‐
loop postural control mechanisms: human neurovestibular studies on SLS‐2. Exp Brain Res
1995; 107:145‐150.
48. Mao HF, Hsueh IP, Tang PF et al. Analysis and comparison of the psychometric properties
of three balance measures for stroke patients. Stroke 2002; 33:1022‐1027
106
CHAPTER
The development of a clinical practice stroke
guideline for physiotherapists in The Netherlands:
A systematic review of available evidence
Erik JM Hendriks
Nico LU Van Meeteren
Paul JM Helders
Gert Kwakkel

Disability and Rehabilitation 2007; 29(10): 767‐783
Chapter 5
Abstract

Purpose: To develop a clinical practice guideline for the physiotherapy
management of patients with stroke, as support for the clinical decision‐
making process, especially with respect to the selection of appropriate
interventions, prognostic factors and outcome measures.
Introduction: Physiotherapists have a high caseload of patients with stroke,
so there is a need to identify effective evidence‐based physiotherapy
procedures. The availability of a guideline that includes information about
prognostic factors, interventions, and outcome measures would facilitate
clinical decision‐making.
Method: A systematic computerised literature search was performed to
identify evidence concerning the use of: 1) prognostic factors related to
functional recovery; 2) physiotherapy interventions in patients with stroke;
and 3) outcome measures to assess patients’ progress in functional health.
Experts, physiotherapists working in the field of stroke rehabilitation, and a
multidisciplinary group of health professionals reviewed the clinical
applicability and feasibility of the recommendations for clinical practice and
their comments were used to compose the definitive guideline.
Results: Of 9482 relevant articles, 322 were selected. These were screened for
methodological quality. Seventy‐two recommendations for clinical practice
were retrieved from these articles and included in the guideline: 6
recommendations concerned the prediction of functional recovery of
activities of daily living (ADL), including walking ability and hand/arm use;
65 recommendations concerned the choice of physiotherapy interventions;
and 1 recommendation concerned the choice of outcome instruments to use.
A core set of seven reliable, responsive, and valid outcome measures was
established, to determine impairments and activity limitations in patients
with stroke.
Conclusions: The guideline provides physiotherapists with an evidence‐
based instrument to assist them in their clinical decision making regarding
patients with stroke. As most of the recommendations included in the
guideline came from studies of patients in the post acute and chronic phase
of stroke, and in general involved patients with less severe and
uncomplicated stroke, more needs to be learned about the more complex
cases.

Key Words: clinical practice guideline, physiotherapy, rehabilitation, stroke,
prognostic factors, interventions, outcome measures

108
Clinical practice stroke guideline for physiotherapists
Introduction

Stroke is a major health problem with high societal costs due to its increasing
prevalence and the long‐term disability it causes. In the Netherlands, the
incidence of cerebrovascular disorders is estimated at 34,500 (~2.2/1000/year)
and the prevalence at 190,000 (~1.2% of Dutch population), and nowadays
more patients are admitted to hospital (admission for stroke has increased
from 22,717 in 1980 to 32,623 in 2003).1 It is intrinsic to health care to
continuously look for evidence‐based rehabilitation services. Recently, the
‘best evidence’ for stroke management, derived from methodologically
sound clinical research, has been collected in systematic reviews and
converted into several multidisciplinary stroke guidelines.2‐6 However,
physiotherapists would probably prefer to have more detailed information
about making a valid functional prognosis, designing the most effective
intervention program, and selecting the most appropriate measures to
evaluate outcome, to facilitate clinical decision making in each individual
patient in line with his or her specific functional health status.7 As yet, there
are no specific guidelines for physiotherapy in the management of stroke,
even though physiotherapy accounts for a substantial proportion of the total
therapy time provided by stroke rehabilitation services.8,9
The aim of the present article was to describe the available evidence
to guide the clinical decision‐making process of physiotherapists dealing
with the rehabilitation of patients with stroke regarding: 1) the best
determinants of the ultimate functional recovery of patients diagnosed with
stroke; b) the effectiveness of applicable physiotherapy interventions; and c)
a core set of reliable, valid, and responsive outcome measures to assess
patients’ progress in functional health at fixed moments after stroke. This
evidence is presented as the Clinical Practice Guideline on Physiotherapy
management of patients with Stroke (CPGPS) in the Netherlands.10

Method

Development of guideline
A systematic literature search was conducted to determine evidence (i.e., the
‘state of the art’) for three aspects of the physiotherapy management of
patients with stroke: 1) prognostics; 2) interventions; and 3) outcomes.
Subsequently, the methodological quality of the included studies was
investigated. Levels of evidence were determined on the basis of the ‘best
evidence’ from systematic reviews, randomised controlled trials (RCTs),
controlled clinical trials (CCTs), and pre‐experimental studies. The best
109
Chapter 5
evidence was then converted into graded recommendations for clinical

practice.

Figure 1 Flow chart concerning the selection and grading of the available evidence of
each therapeutic intervention in the CPGPS
Clinical Practice
Guideline
Physiotherapy Stroke
(CPGPS)
Description of Systematic Analysis of Quantitative Levels

physiotherapy literature- methodological analysis of of
-related search quality effect evidence
intervention
1-generic priciples of rehabilitation Physiotherapy Summarised

2-w alking & mobility-realed activities Evidence Database effect sizes
3-hand and arm use -PEDro- -Hedges' g-
4-generic Activities of Daily Living
Systematic 1 RCT or Pre-

reviews or > 2 controlled experimental
> 2 RCTs clinical trials (CCTs) studies
Level A1+A2 Level B Level C
Recommendations for everyday clinical practice
Grade 1 Grade 2 Grade 3
Advice to evaluate the applied intervention with

specific outcome measures
Figure 1 shows how the recommendations for physiotherapy‐related

interventions were developed. Recommendations for each intervention were
based on: 1) description of the intervention; 2) systematic literature search; 3)
analysis of methodological quality of the studies, according to the PEDro
scale11; 4) quantitative analysis of the effects of the individual studies, and, if
the studies were comparable with respect to type of intervention and
measurement of outcome (for methods see Chapter 2)12; 5) levels of evidence
based on evidence from the literature; 6) formulation of recommendations
for using the described intervention in clinical practice; and 7) advice
regarding the use of valid, reliable, and responsive outcome measures to
110
describe the functional health status of patients with stroke and to evaluate
the effects of a physiotherapy intervention. The interventions are described
in terms of general principles of rehabilitation, walking and mobility‐related
activities, hand and arm use, and activities of daily living (ADL).

Participants in development process of CPGPS
Seven groups of participants contributed to the development of the
guidelines during the development period March 2002 to March 2004:
1) The board of the Royal Dutch Society for Physical Therapy (Koninklijk
Nederlands Genootschap voor Fysiotherapie: KNGF), which initiated the
development of the guideline and approved the definitive version.
2) The Department of Physical Therapy of the VU University Medical Center
(VUmc) in Amsterdam, the Netherlands, which developed the guideline and
formed a steering committee and task group.
3) A steering committee (N=5), which planned and coordinated the activities
of the task group.
4) A task group (GK and RPSvP), which developed the format of the
guideline; wrote the draft versions; invited the expert group,
multiprofessional group, and pilot group to comment on these draft versions
of the guideline; and wrote the definitive version of the CPGPS.
5) An expert group (N=8), consisting of clinical experts, especially on stroke,
who commented on the guideline or parts of it during its development,
assessed the draft versions of the guideline and its applicability in daily
physiotherapy practice. The experts were all physiotherapists experienced in
stroke rehabilitation, representative for Dutch institutions treating stroke
patients.
6) A pilot group, consisting of randomly selected physiotherapists (N=169),
who tested and commented on the draft version of the outcome measures
and their applicability. Their comments, together with information on the
clinical utility and overlap of the outcome measures, were used to develop
the final version of the outcome measures.
7) A multiprofessional group (N=9), consisting of clinicians from various
specialties providing care in this setting (neurologist, rehabilitation
physician, general practitioner, nursing home doctor, geriatrician,
psychologist, (district) nurse, occupational therapist, and speech therapist)
and a patient representative of the Dutch Stroke Association, assessed the
quality of the final draft version, and its applicability to everyday clinical
practice. They also determined whether the physiotherapy guideline
conflicted with the recommendations of their own disciplinary guidelines.2,3

111
Chapter 5
Definitions
Stroke was defined according to the World Health Organization as ‘a clinical
syndrome typified by rapidly developing signs of focal or global disturbance
of cerebral functions, lasting more than 24 hours or leading to death, with no
apparent causes other than of vascular origin’.13 Three phases of stroke were
identified, namely, acute/sub‐acute, post acute, and chronic phase. The acute
phase of stroke was considered to be the first week after stroke onset, the
sub‐acute phase from the 2nd to the 4th week after stroke, and the post acute
phase from the 2nd to 6th month after stroke. The chronic phase started 6
months after stroke.12 Physiotherapy was defined as the skilled use of
physical interventions (in contrast to medical or surgical treatments) to
restore physical functioning and to improve activity and participation in
daily‐life situations after injury or disease.4 Physiotherapy interventions for
patients with stroke commonly include exercise therapy, neuromuscular
electrical stimulation, mechanical devices, such as balance trainers and
treadmills, as well as assistive devices (canes and walkers) along with
instructions for their proper use.

Literature Search
An extensive computerised search of the Dutch, English, or German
literature included in the MEDLINE (1966 through January 2004), CINAHL
(1982 through January 2004), and EMBASE databases (1988 through January
2004), Cochrane Central Register of Controlled Trials, Cochrane Database of
Systematic Reviews (The Cochrane Library, Issue 4, 2003), DocOnline
(Database of the Dutch Institute of Allied Health Care) (1987 through
January 2004) and PEDro (January 2004) was conducted, using the keywords
‘cerebrovascular disorders’, ‘cerebrovascular accident’, ‘stroke’,
‘hemiplegia’, and ‘rehabilitation’. Two researchers (GK and RPSvP)
independently searched these electronic databases for relevant articles. The
bibliographies of review articles and narrative reviews, and the abstracts of
conferences were also screened. In addition, the references of the retrieved
studies were reviewed. Inclusion of articles was based on agreement
between the two independent reviewers. This search strategy was the core
search which served as the basis for further refinement according to the
three topics: prognostic factors, physiotherapy‐related interventions and
outcome measures.

Prognostic factors
To determine prognostic factors, the following keywords were used:
’prognostic factors’, ‘prognosis’, ‘prediction’, ‘functional outcome’, ‘outcome
112
assessment’, and ‘follow‐up’. Factors were included if they fulfilled the
following three selection criteria: (1) the prognostic factors were described to
affect the functional outcome of patients with stroke; (2) the prognostic
factors were correlated with walking ability, hand and arm use, or ADL;
and (3) the study was a systematic review or meta‐analysis. Quality
assessment of studies of prognostic factors was based on 11 criteria for
methodological quality for prognostic research.14,15 (Table 1)

Table 1 – Criteria used to assign levels of evidence to studies on prognostic factors.14,15
Level of scientific evidence for studies on prognostic factors

I Studies that satisfy all items for internal and statistical validity (> 8 points)
II Studies that satisfy all items for internal validity (> 5 points)
III Studies that do not satisfy all items for internal validity
Level of scientific evidence of the systematic reviews on prognostic factors

Systematic reviews (meta-analyses) that include at least 5 studies at quality level I,
A
which investigate the same prognostic factor
Systematic reviews (meta-analyses) that include at least 3 studies at quality level I,

B
which investigate the same prognostic factor
Systematic reviews (meta-analyses) that include at least 2 studies at quality level I, II,
C
or III, which investigate the same prognostic factor
Grades of recommendation of the studies on prognostic factors

1 Supported by research at level A
2 Supported by research at level B
3 Supported by research at level C

Physiotherapy‐related interventions
The following keywords and MeSH were used to identify the interventions:
‘physiotherapy’, ‘physical therapy’, ‘exercise therapy’, ‘electrotherapy’, and
‘occupational therapy’. Systematic reviews (SR), randomised and controlled
clinical trials (RCTs and CCTs), and (non‐controlled) pre‐experimental
studies were included for review. Studies that investigated robotics or the
effects of physiotherapy in combination with acupuncture or drug therapies
were excluded.
Articles were considered relevant and selected if the study
population included adults of 18 years or older, diagnosed with stroke, and
113
Chapter 5
the study evaluated the effectiveness of physiotherapy‐related interventions.
The quality of the studies was assessed with the PEDro criteria11 for
methodological quality and the levels of evidence were based on the criteria
of Sackett et al.7 (Table 2)
Table 2 – Criteria used to assign levels of evidence to intervention studies.7
Level of scientific evidence to intervention studies

Systematic reviews (meta-analyses) that include at least 2 or more RCTs at quality level
A1
A2, which show consistent results between studies
At least 2 RCTs of a good methodological quality (PEDro-score > 4 points) with
A2
sufficient power and consistency
At least 2 RCTs of a moderate methodological quality (PEDro-score < 3 points) or with
B
insufficient power, or at least 2 CCTs, or one RCT with PEDro-score > 4 points
C Pre-experimental studies
D Expert opinion*
Grades of recommendation to intervention studies
Supported by one systematic review al level A1 or at least 2 independent trials at level

1
A2
4 Not supported by research; based on expert opinion*
CCT indicates controlled clinical trial; PEDro, physiotherapy evidence database;

RCT, randomised controlled trial
* In contrast to other guidelines, no recommendations of grade 4 were entered in the CPGPS. The grade 4
3
recommendations were recently established in the Dutch multidisciplinary guidelines for stroke rehabilitation.

Outcome measures
The following keywords were used to identify outcome measures:
’measurement’, ‘measure’, ‘assessment’, ‘instrument’, ‘scale’, ‘test’,
‘questionnaire’, ‘classification’, ‘evaluation’, and ‘outcome’. The following
keywords were used to determine the quality of the outcome measures:
‘reliability’, ‘validity’, and ‘responsiveness’.
For inclusion in the analysis, the outcome measures needed to be
consistent with the International Classification of Functioning, Disability and
Health (ICF)16; to show high‐level psychometric properties, i.e., reliability
(inter‐ and intra rater), validity and responsiveness17 in studies with adult
114
stroke patients, and to have good clinical utility (easy and quick to
administer) (Table 3); to minimally overlap each other; and to be consistent
with current physiotherapy practice. Excluded were outcome measures that
evaluated the cognitive impairments of stroke patients. Quality assessment
of outcome measures was based on the criteria for outcome measures
formulated by Bot et al.18 (Table 3)

Table 3 – Criteria used to assign levels of evidence to outcome measures.18
Level of scientific evidence for outcome measures
A 6 criteria:
- Validated in a stroke patient population:
0 = no; 1 = yes
- Test-retest reliability:
0 = ICC < 0.69; 1 = ICC > 0.70
- Concurrent validity, Spearman rho (rs) or Pearson correlationcoefficient:
0 = r < 0.69; 1 = r > 0.70
- Responsiveness:
0 = low; 1 = high
- Clinical use:
0 = time to administer > 16 minutes, and
1 = time to administer < 15 minutes
- Test-protocol:
0 = test-protocol not available; 1 = test-protocol available
B Meets 5 of the level A criteria
C Meets 3 or 4 of the level A criteria
D Meets 1 or 2 of the level A criteria
Grades of recommendation for outcome measures
1 Supported by research at level A
4 Supported by research at level D
ICC indicates intra class correlation coefficient; SDD, smallest detectable difference
115
Chapter 5
Results

Evidence to be included in the guideline
In total 322 articles (out of 9482 citations) were used to establish the content
of the guideline: Six studies14,15,19‐22 to establish prognostic factors to predict
functional recovery in patients with stroke; 284 studies to establish
physiotherapy interventions for stroke rehabilitation (for references: see10);
and 32 studies23‐54 to establish outcome measures to assess patient progress.
In total, 72 possible guideline elements were identified: 6 relevant to
prognostic factors, 65 relevant to physiotherapy interventions, and 1
relevant to outcome measures (Table 4).
Table 4 Summary of 72 recommendations of the CPGPS:

Type of intervention and corresponding grade of recommendation
nr. Type of intervention Grade# nr. Type of intervention Grade#
Prognostic factors
Functional electro stimulation 1*
(grades of recommendation refer to 36
(paretic leg)
criteria in Table 1)
3 Biofeedback to the paretic lower 1*

1 Prognosis walking ability 37
limb
Prognosis dexterity paretic arm in 3 2

2 38 Applying Ankle-Foot-Orthosis
first 4 weeks after onset stroke
3 Prognostic factor arm: paretic leg 3 39 Using walking aids 3*
4 Prognostic factor arm: Barthel index 3* 40 Limb loading 2*
5 Prognosis ADL 3 41 External auditory rhythms 2
Prognosis recovery of sequence in 3 Therapeutic positioning paretic 2

6 42
ADL arm
Physiotherapy-related interventions
Stretching paretic wrist and 2
(grades of recommendation refer to 43
fingers
criteria in Table 2)
Treatment in stroke teams (stroke 1 Immobilisation techniques 2
7 44
unit) (arm/hand)
Incorporating stroke unit in stroke 3 Sensory training paretic arm and 3
8 45
service hand
Adherence to evidence-based 3 2
9 46 Using air-splints
guidelines
10 Intensity of exercise therapy 1 47 Wrapping paretic arm 3
11 Task-specific training 1 48 Exercise training the paretic arm 1*
1 Bilateral training cyclic arm 3

12 Context-specific training 49
movements
1* Constraint-induced movement 1
13 Neurological treatment approaches 50
therapy: dexterity
Treating with basic principles of the 3** Constraint-induced movement 1

14 51
NDT-concept therapy: somatosensory deficits
NMS of the paretic forearm

Motor learning (variation and 3 3
15 52 without EMG-triggering: muscle
repetition-without-repetition)
strength and ROM
116

nr. Type of intervention Grade# nr. Type of intervention Grade#
NMS of the paretic forearm:

Early start of rehabilitation (within 72 3 2*
16 53 dexterity (absence of active wrist
hours after onset stroke)
and finger extension)
NMS of the paretic forearm:
17 Positioning paretic site in bed 3* 54 dexterity (with active wrist and 2
finger extension)
3 NMS of the paretic forearm with 2

18 Prevention decubitus 55
EMG-triggering
3 Biofeedback to the paretic upper 1*

19 Prevention of broncho-pneumonia 56
limb
20 Pulmonal ventilation 3 57 TENS paretic arm 1
21 (Assistive) active movements 3 58 NMS for GHS and HSP 1
22 Prevention deep venous thrombosis 3 59 Exercises for reducing HSP 1*
3 Shoulder exercises with pulleys in 3**

23 Informing partner of patient 60
HSP
Treatment of hand oedema:
24 Training sitting balance 1 61 intermittent pneumatic 2*
compression
Asymmetric wheelchair self- 2* Treatment of hand oedema: other 3*
25 62
propelling treatments
Using paretic hand during 3 2
26 63 Mirror therapy paretic arm
wheelchair propelling
Training transfers from sit-to-stand 1 Slings and supportive devices for 3
27 64
and visa versa reducing GHS and HSP
Preventing falls during standing up 2 Strapping techniques for reducing 3
28 65
and sitting down GHS and HSP
Training standing balance on force 1 2
29 66 Strategy training for apraxia
plates
(Functional) strengthening paretic 1 1*
30 67 Training leisure activities
muscles
Strengthening paretic leg and 2* 1
31 68 Training attention deficits
spasticity
Aerobics (combination of strength- 3 1*
32 69 Training memory deficits
and endurance training)
Body-weight supported treadmill 1 1
33 70 Neglect: visual scanning training
training
Treadmill training without body 1 Visual scanning training: prism 2
34 71
weight support and walking ability glasses
Outcome measures
Treadmill training without body 2
35 (grades of recommendation refer
weight support and gait speed
to criteria in Table 3)
Monitoring outcomes 3
72
(systematically)
* No or insufficient evidence was found for this intervention;
** Negative effect was found for this intervention
ADL indicates activities of daily living; CPGPS, clinical practice guideline on physiotherapy management of patients with stroke;
EMG, electromyogram; HSP, hemiplegic shoulder pain; GHS, glenohumeral subluxation; Grade#, grade of recommendation;
NDT, neurodevelopmental treatment; NMS, neuromuscular stimulation; nr., number of recommendation of CPGPS; ROM, range
of motion; TENS, transcutaneous electrical nerve stimulation.
117
Chapter 5
Prognostic factors of functional recovery
The identification of prognostic factors was based on six systematic
reviews.14,15,19‐22

Walking ability
A number of factors to predict walking ability (defined in the guideline as
regaining a Functional Ambulation Categories score > 4) at 6 months after
stroke were identified. The best explanatory factors were initial walking
ability in the first 2 weeks after stroke, degree of motor paresis of the paretic
leg, homonymous hemianopia, sitting balance, urinary incontinence, high
age, initial functioning (activities of daily living; ADL) in first 2 weeks after
stroke14 (Grade 3 evidence). These factors were generally similar to those
predicting ADL 6 months after stroke.

Activities of Daily Living (ADL)
The best predictor of recovery of independence in ADL at 6 months after
stroke was the Barthel Index score in the first 2 weeks after stroke. Other
predictors were urine incontinence in the first 2 weeks after stroke, level of
consciousness in the first 48 hours after stroke, high age, status following
recurrent stroke, degree of motor paresis, sitting balance in the first 2 weeks
after stroke, orientation in time and place, and level of perceived social
support14,15 (Grade 3 evidence).

Hand and arm use
The dexterity of the hemiplegic arm can best be predicted within 4 weeks
after stroke.55 The best clinical predictor of recovery of dexterity of the
paretic arm 6 months after stroke was severity of arm paresis at 4 weeks
after stroke, as assessed with the Fugl‐Meyer Assessment.55 Other strong
predictors of recovery of dexterity after stroke were severity of the upper
extremity paresis, voluntary grip function of the hemiplegic arm37,56 or
voluntary extension movements of the hemiplegic’s wrist and fingers57
within the first 4 weeks after stroke, and muscle strength of the paretic leg55
(Grade 3 evidence). By using these prognostic factors in an early stage of
rehabilitation, physiotherapists should be able to predict the functional
outcome of their patients 6 months after stroke58 (Grade 3 evidence). An
example of a model to predict the recovery of walking ability after stroke is
given in Box 1.

118
Box 1.
An example of using outcome measures to predict functional recovery after stroke

Kwakkel93 developed a model to predict the degree of walking ability, as measured
with the Functional Ambulation Categories (FAC), 6 months after stroke, using the
initial Barthel Index (BI) score at 2 weeks after stroke in a linear regression model:
FAC = 1.860 + (0.03*(BI*5)) + (1.236*SB), where sitting balance (SB) is defined as
ability to maintain sitting balance for minimally 30 seconds without support (score =
1 indicates maintaining SB is possible; score = 0, maintaining SB is not possible). As
an example, a stroke patient has a BI score of 5 points 2 weeks after stroke, then the
FAC score at 6 months would be calculated as follows:
FAC = 1.860 + (0.03*25) + (1.236*1) = 3.846

Physiotherapy interventions
The choice of physiotherapy interventions to include in the guideline was in
part based on a recent review of the efficacy of physiotherapy interventions
on functional outcome in stroke patients (see Chapter 2).10,12 The literature
search identified 284 relevant studies (25 SR, 16 critical reviews, 153 RCTs,
49 CCTs, and 41 pre‐experimental studies).10 We used PICO search questions
(Patient, Intervention, Comparison, and Outcome)7 to identify 46 relevant
physiotherapy interventions, as outlined in Figure 1.10 An example of a PICO
question is: “What is the evidence for constraint‐induced movement therapy
compared to regular arm/hand therapy on dexterity of the paretic arm in patients
with stroke?” (Table 5). We grouped these interventions as being consistent
with the general principles of rehabilitation, or as influencing walking and
mobility‐related activities, hand and arm use, and generic ADL.
We included 65 recommendations/interventions in the guideline, 24
of grade 1 evidence (Table 5); 18 of grade 2 evidence10, and 23 of grade 3
evidence10. In this way, the guideline recommends task‐oriented and
context‐specific exercise training, in particular when applied intensively and
early after stroke onset (Grade 1 evidence). The
interventions/recommendations (together with the level of evidence) are
given in Table 4.12

119

Table 5 The 24 ‘Grade 1’-recommendations of intervention studies (level A evidence), in detail described in the CPGPS10
120
Chapter 5
PICO Patients Intervention Comparison Outcome
In patients …the effectiveness of… …compared to… …is effective for…

with stroke…
1. Generic principles: …multidisciplinary …conventional ...increasing survival, decreasing length of stay and
Working in stroke teams interventions in stroke- increasing ADL-independency in the (sub)acute
rehabilitation settings…
units… phase after stroke.
2. Generic principles: …augmented exercise …regular time spent in …increasing the rate of recovery of ADL in the
Intensity of exercise training therapy time spent in the rehabilitation… (sub)acute and postacute phase after stroke.
first 6 months after stroke…
3. Generic principles: …tasks directly trained …the not-trained …increasing the trained task in the (sub)acute,
Task- specific training (such as training balance in tasks… postacute and chronic phase after stroke;
standing position)… generalisability to other trained tasks is hardly found.
4. Generic principles: …training in a well-known …training in a not-well …increasing the effectiveness of task-learning in the
Context- specific training context… known context… (sub)acute, postacute and chronic phase after
stroke.
5. Generic principles: …one specific neurological …another specific …is not effective on outcomes at activity-level.
Neurological treatment approaches treatment approach (such neurological treatment
as NDT, PNF, MRP, approach (such as NDT,
Brunnstrom etcetera)… PNF, MRP, Brunnstrom
etcetera)…
6. Walking and mobility-related activities: …reaching with the paretic – …increasing the sitting balance.
Sitting balance arm, while sitting, with the
arm reaching outside the
bearing surface…
7. Walking and mobility-related activities: …training symmetrically – …increasing the symmetric weight-bearing during
Standing up and sitting down standing up and sitting standing-up and sitting-down between the 2 legs,
down… and the speed of these transfers in the postacute
and chronic phase after stroke.
8. Walking and mobility-related activities: …additional training of …conventional standing …increasing symmetrical weight-bearing between
Standing balance on force plates standing balance on force balance training… both legs while bilateral standing in the postacute
plates with visual feedback phase after stroke. Unclear if effects will generalise
while bilateral standing… to better walking ability.


with stroke…
9. Walking and mobility-related activities: …(functional) strength – …increasing muscle strength of the paretic leg and
Strength training paretic leg training of the paretic leg increasing gait speed in the postacute and chronic
(using fitness-apparatus of phase after stroke.
functional training), 2 to 3
times a week…
10. Walking and mobility-related activities: …BWSTT (< 40% body- – …increasing endurance.
BWSTT weight support) in stroke
patients who cannot walk in
the first 6 weeks after
stroke and decreased
physical condition…
11. Walking and mobility-related activities: …intensive treadmill – …increasing walking ability in the postacute phase
Treadmill training without body-weight training without body-weight after stroke.
support support in patients with a
decreased walking ability…
12. Walking and mobility-related activities: …FES on the paretic leg…. – …is not effective in on gait speed and walking
FES (paretic leg) ability.
13. Walking and mobility-related activities: …biofeedback to the – …is not effective on ROM of the dorsiflexion of the
Biofeedback to the paretic lower limb dorsiflexion muscles of the paretic ankle and gait speed.
paretic lower limb during
gait…
14. Hand and arm use: …exercise training of the … another specific …is not effective for faster recovery of the dexterity
Exercise training the paretic arm paretic upper limb based on neurological treatment the paretic arm.
a specific neurological approach…
treatment approach…
15. Hand and arm use: …constraint-induced – …increasing dexterity of the paretic arm. The effect
CIMT movement therapy (= can be increased on behalf of the increasing
forced use) in combination trainings intensity of CIMT.
with an intensive functional
training program in patients
with active wrist extension
121
(20 degrees) and finger
extension (10 degrees)…

122
Chapter 5

with stroke…
16. Hand and arm use: …constraint-induced – …is more effective in patients with somatosensory
CIMT movement therapy (= deficits.
forced use)…
17. Hand and arm use: …biofeedback to the – …is not effective on active ROM and muscle
Biofeedback to the paretic upper limb muscles of paretic arm… strength of the paretic arm.
18. Hand and arm use: …transcutaneous nerve – …decreasing spasticity in the postacute phase after
TENS stimulation of the paretic stroke, but the effects will not generalise to better
arm… dexterity.
19. Hand and arm use: … neuromuscular – …increasing passive ROM of lateral rotation of the
NMS with GHS and HSP stimulation in patients with paretic shoulder (13 degrees) and reducing the
glenohumeral subluxation glenohumeral subluxation (5 mm) in the (sub)acute
of the paretic shoulder and and postacute phase after stroke. However these
hemiplegic shoulder pain… effects are temporary. NMS doesn’t result in a
reduction of the hemiplegic shoulder pain.
20. Hand and arm use: …passive of assisted active – …is not more effective to other physiotherapy
NMS with GHS and HSP shoulder exercises with the interventions aimed at reducing hemiplegic shoulder
paretic arm… pain.
21. ADL: …home-based therapy – …increasing ADL-independency, participation in

Training leisure activities aimed at increasing leisure leisure activities, and mood of the patient.
activities (such as regaining
gardening or painting)…
22. ADL: …attention training… – …increasing alertness and sustained attention in the
Training attention deficits postacute phase after stroke. The effects will not
result in improving ADL.
23. ADL: …memory training… – …is not effective to reduce memory problems in the
Training memory deficits postacute phase after stroke.
24. ADL: …treating neglect, daily 30 – …increasing the negligible body side, measured
Neglect: visual scanning training to 60 minutes during a few with visual scanning tests. The effects will not result
weeks in patients with right in improvement of scanning in daily live.
hemispherical stroke…
ADL indicates activities of daily living; BWSTT, body-weight supported treadmill training; CIMT, constraint-induced movement therapy; FES, functional electrical stimulation;
GHS, glenohumeral subluxation; HSP, hemiplegic shoulder pain; MRP, motor relearning programme; NDT, neurodevelopment treatment; NMS, neuromuscular stimulation;
PNF, proprioceptive neuromuscular facilitation; ROM, range of motion; TENS, transcutaneous electrical nerve stimulation
Outcome measures
The recent emphasis on ‘evidence‐based practice’ means that extra attention
should be paid to the validity of outcome measures.59 Thirty‐three studies23‐54
of outcome measures were identified, yielding 32 potential outcome
measures. An independent sample of 169 physiotherapists not involved in
guideline development were asked to measure outcome according to the
three ICF domains (functions, activities, and participation)16, and to indicate
which of the33 outcome measures they would prefer to use to assess
treatment outcome in patients who had had a stroke. The definitive test
battery (25 outcome measures) was established in consensus meetings with
the experts and task group. These outcome measures were considered to
reflect the three ICF activity categories, namely, walking and mobility‐
related activities; hand and arm use; and ADL. The outcome measures were
divided into two sections. The first section, consisting of the core set of
outcome measures, should be applied to all stroke patients, since these
measures were considered to evaluate whether physiotherapy care was
adequate in all phases after stroke. These core outcome measures had
minimal overlap and were 1) the Motricity Index (MI)29,33 (Grade 2 evidence),
2) Trunk Control Test (TCT)29,35 (Grade 2 evidence), 3) Berg Balance Scale
(BBS)23 (Grade 1 evidence), 4) Functional Ambulation Categories (FAC)40,41
(Grade 2 evidence), 5) comfortable Ten Metre Walk (TMW)54 (Grade 1
evidence), 6) Frenchay Arm Test (FAT)34,37,54 (Grade 2 evidence), and 7)
Barthel Index (BI)28 (Grade 2 evidence). The psychometric properties and
level of evidence of these selected measures of outcome are summarised in
Table 6.

Optional outcome measures
The second section consisted of 18 optional outcome measures, to be used to
evaluate a specific function or activity in individual patients with stroke. For
instance, if the hand of the paretic arm becomes edematous, it would be
desirable to measure the volume of the hand. This is not necessary if the
hand is not edematous. The optional outcome measures are: Modified
Rankin Scale52, Neutral‐0‐Method (Range of Motion)49, Numeric Pain Rating
Scale42, Nottingham Sensory Assessment30,44, Modified Ashworth Scale24,60,
testing the cranial nerves32, Brunnstrom Fugl‐Meyer assessment36, Hand
volumeter47, Trunk Impairment Scale53, Action Research Arm Test45, Nine
Hole Peg Test37, Timed Balance Test25,43, Rivermead Mobility Index27, Falls
Efficacy Scale for Stroke38,39, Timed Up&Go Test48, Six Minutes Walk26,
Nottingham Extended ADL‐index46,54, and Frenchay Activities Index31,50.

123
Table 6 Characteristics of the primary set of outcome measures included in the CPGPS (for explanation of the used criteria see Table 3)
124
Outcome Brief description Validated Concurrent Test-Retest Respon- Clinical Number Level of
measure in stroke validity: Reliability: siveness: Use of criteria evidence
Chapter 5
patient max 6
criteria,
population see Table 2
Motricity Index Evaluates voluntary motor activity or Demeurisse MI-leg vs FM- rs (inter) = 0.91** Low TPA: yes 5 2
maximal isometric muscle strength of 1980 leg: rs (intra) = 0.98** SDD (MI-arm) = TTA: 10-15
(paretic) arm as well as (paretic) leg Collin & Wade rs = 0.69** (Koolstra 2004) 12 points min.
muscles. Reliable, valid, and quick to 1990 MI-arm vs FM- SDD (MI-leg) =
perform, and poor responsiveness. arm: 13 points
Six items scored on an ordinal rating rs = 0.71** (Koolstra 2004)
scale (sum score 0-200 points) (Koolstra 2004)
Trunk Control Evaluates the stability of the trunk. Collin & Wade TCT vs MI-leg: rs (inter) = 0.96** Low TPA: yes 5 2
Test Reliable, valid, simple to administer, 1990 rs = 0.71** r (intra) = 0.87** SDD = 25 points TTA: 5-10
and poor responsiveness. Franchignoni TCT vs FAC: (Koolstra 2004) (Koolstra 2004) min.
A 3-point ordinal rating scale (0, 12, 1997 rs = 0.69**
or 25 points for each item) is used to (Koolstra 2004)
score four axial movements (sum
score: 0-100 points)
Berg Balance Evaluates static and dynamic Berg 1995 BBS vs TUG: ICC (inter) = High TPA: yes 6 1
Scale balance in a functional way. The rs = -0.70** 0.96** SDD = 6 points TTA: 15
scale is valid, reliable, and BBS vs FRT: ICC (intra) = (Stevenson et al min.
responsive, and takes about 15 rs = 0.88** 0.98** ‘01)
minutes to administer. The BBS (Koolstra 2004) (Koolstra 2004)
consists of 14 items, scored on 5-
point ordinal rating scale (0-4 points).
The sum score varies between 0 and
56 points
Functional Evaluates the degree of dependence Holden 1984 FAC vs rs (inter) = 0.79** Low TPA: yes 5 2
Ambulation in walking ability. The FAC is a valid, Holden 1986 TMWcomf.: ICC (intra) = SDD = 1 point TTA: 1
Categories reliable assessment tool, easy to rs = 0.79** 0.96** (Koolstra 2004) min.
administer, and poor responsiveness. FAC vs BI: (Koolstra 2004)
It contains 6 items, scored on a 2- r = 0.89**
point ordinal scale (sum score, 0-5 (Koolstra 2004)
points)

Outcome Brief description Validated Concurrent Test-Retest Respon- Clinical Number Level of
measure in stroke validity: Reliability: siveness: Use of criteria evidence
patient max 6
criteria,
population see Table 2
Ten Metre Walk Gives a valid and reliable indication Wade 1992 TMWcomf. vs rp (inter) = 0.97** High TPA: yes 6 1
of the comfortable walking speed. It FAC : ICC (intra) = SDD = 0.16 m/s TTA: 5-10
is responsive and simple to rs =0.79** 0.97** (Koolstra 2004) min.
administer, and can be tested in (Koolstra 2004)
patients with a FAC score of 3 or
more points. The mean of 3 walking
trials is recorded. Patients can be
tested wearing orthotics or using
walking aids
Frenchay Arm Evaluates the use of paretic hand Wade 1992 FAT vs UAT.: ICC = 0.90** Low TPA: yes 5 2
Test and arm. The FAT is a reliable and DeSouza rp = 0.93** (Hoogstraat SDD = 1.3 points TTA: 5-10
valid tool with poor responsiveness. 1980 (Koolstra 2004) unpubl.) (Hoogstraat min.
Items scored on a 2-point ordinal unpubl.)
rating scale (0-1 point), with a total
score of 0 to 5 points
Barthel Index Evaluates the degree of dependence Collin 1988 BI vs FAC: rs (inter) = 0.95** Low TPA: yes 5 2
in ADL. The BI is a valid, reliable rs = 0.89** rs (intra) = 0.95** SDD = 4 points TTA: 3-
assessment tool, and is easy to BI vs ARAT: (Koolstra 2004) (Koolstra 2004) 5min.
administer with poor responsiveness. rs = 0.46*
There are several different versions (Koolstra 2004)
of the test; we chose the 20-point
Collin version.28 This version
contains 10 items, some of which are
scored on a 2-point (0-1 point) and
others on a 4-point ordinal rating
scale (0-3 points)
** p<0.001
* p<0.01
ARAT indicates action research arm test; BBS, berg balance scale; BI, barthel index; FAC, functional ambulation categories; FAT, frenchay arm test; FM, fugl-meyer assessment;
FRT, functional reach test; ICC, intraclass correlation coefficient; MI, motricity index; rp , pearsons correlation coefficient; rs ,spearman correlation coefficient; SDD, smallest detectable difference;
TCT, trunk control test; TMW, ten metre walk; TPA, test protocol available; TTA, time to administer; TUG, timed up&go test; UAT, utrecht arm test; vs = versus
125
Chapter 5
Moments of assessment after stroke
The task group and expert group reached agreement on when the core
outcome variables should be measured. Since the information acquired can
assist physiotherapists in their clinical reasoning and decision making, it is
important to measure these variables at the start and end of a course of
treatment, before each (multidisciplinary) stroke team meeting (actual
information about patients’ status and progress), and at 3 and 6 months after
stroke (to use in future prognostic research).

Discussion

In general, the use of evidence‐based guidelines improves patient care.7,61
The same is true regarding clinical decision‐making in physiotherapy.9,62 To
improve physiotherapy care for patients with stroke in the Netherlands, we
developed a clinical practice guideline on physiotherapy for patients with
stroke (CPGPS). We first performed a literature review, identifying 322
relevant articles that covered three aspects of the physiotherapy
management of stroke patients, namely, prognostics, interventions, and
outcomes. The methodological quality of these studies was assessed, as was
the content of the interventions used. Seventy‐two recommendations for
clinical practice for physiotherapists were distilled from these articles: Six
recommendations concerned the prediction of functional recovery of generic
ADL, including specific ADLs such as walking ability and hand/arm use
(grade 3 evidence); 65 recommendations concerned physiotherapy
interventions (24 of grade 1 evidence; 18 of grade 2 evidence; and 23 of grade
3 evidence); and 1 recommendation concerned when to assess functional
outcome, using reliable, responsive, and valid outcome measures. According
to the guideline, physiotherapists should assess each stroke patient with the
core set of 7 high‐quality outcome measures (grade 1 or 2). Most (6 of 7) of
these outcome measures assessed activities of the ICF framework.59,63,64 As
such, the guideline should be used by physiotherapists in clinical decision‐
making.65
The guideline was constructed according to international
standards.66‐68 The main electronic databases were searched and the
methodological quality of the included studies was analysed.7,11,14,15,18
Although sometimes arbitrary choices were made when scoring the
methodological quality of the studies,69 our choices seem to have been
justified, according to recent stroke rehabilitation literature.70 Furthermore,
where possible, we analysed the effects of the interventions (and if possible
126
statistical pooling of comparable interventions).10,12 Most of the intervention
studies included were small and hence had a low statistical power to reveal
statistically significant effects.12 The differences in methodological quality
resulted in an almost significant negative trend between the calculated effect
sizes in 123 of the included RCTs and the quality rating according to the
PEDro scale.12 In addition, the generalisability of the results of studies of
prognostic factors is often limited due to methodological flaws and the often
arbitrary timing of predicting outcome after stroke.14 Recently, a new
longitudinal regression model was developed in which the longitudinal
relationship of observed changes in body functions, such as strength and
synergism, is related with observed improvements in activities such as gait.71
The advantage of such longitudinal regression models is that time is used as
a covariate that independently determines the accuracy of outcome.71 In
addition, most regression models have not been cross‐validated in an
independent group of stroke patients, which makes the generalisability of
the derived model questionable. There is a need for long‐term studies of the
chronic phase in order to identify those patients who are susceptible for
functional decline, for example in gait performance.72
Each step in the clinical decision‐making process should incorporate the
patient’s wishes and be based on the patient’s functional prognosis.
However, physiotherapists should use their clinical experience to critically
appraise treatment goals and evaluative measurements in term of activities
and participation.65,73,74 In other words, when treating patients, there is
always a compromise between existing evidence on the one hand, and the
patients’ clinical state and circumstances, the patients’ preferences, including
cultural and ethical factors, and constraints, such as time available to apply
the guideline and available equipment and expertise,65,73 on the other.
Consequently, clinical practice guidelines cannot be seen as a simple
cookbook in which steps are taken automatically. Moreover, such guidelines
do not always cover all the aspect or events that occur in “real life”.
While many of the physiotherapy interventions included in the guideline
were restricted to exercises,10 in practice physiotherapists often use
combined interventions or interventions which, to our knowledge, have
never been investigated in well‐designed studies.10,12 For example, there are
few RCTs of the effect of physiotherapy on stair climbing, of the use of
walking aids, of training transfers (bed to chair), or of instructions for fall
prevention.10,12 In addition, a discussion is warranted on which research
design is most appropriate for generating evidence to improve everyday
physiotherapy practice.75‐77 It might be useful to consider non‐linear
127
Chapter 5
dynamics,78,79 and psychological constructs in physiotherapy research and

stroke rehabilitation, such as control perceptions.80
Recently, a number of multidisciplinary stroke guidelines have been
developed in the UK6, Scotland4, USA81, Canada82, New Zealand83, and the
Netherlands2,3. To date, to our knowledge, beside our guideline10, no
physiotherapy‐specific stroke guideline has been published, except extracts
of the physiotherapy elements of the UK stroke guideline.84 However, the
development of a monodisciplinary stroke guideline has been criticised
recently,85 because stroke rehabilitation is a team activity and therefore
cannot be split up into the effects of specific professional therapies.85 We
consider monodisciplinary guidelines an extension of existing
multidisciplinary guidelines, offering more detailed information related to a
certain discipline.86
We are aware, however, that the applications of CPGPS are not
restricted to the discipline ‘physiotherapy’ alone. Moreover, it should be
emphasised that the content of physiotherapy differs in each institutional
setting and heavily depends on the available expertise in each
multidisciplinary team as well as the context of health care system in
general. Therefore, the present CPGPS should not be seen as an attribution
of certain interventions to a certain discipline but rather as a collection of
available knowledge about the effectiveness of interventions applicable by
physiotherapists working in the Dutch health care system.
Posthoc analyses of the content of the guideline demonstrated that
almost 90% of the recommendations were based on the results of
intervention studies involving patients in the post acute and chronic phase
of stroke, and patients who had experienced a less severe or uncomplicated
stroke. We have to conclude that evidence‐based interventions are based on
only a minority of patients, given the complexity of stroke. In fact, it could
be queried whether individual stroke patients will benefit from this
guideline and evidence‐based interventions in everyday physiotherapy
practice. To our knowledge, this gap between evidence‐based knowledge
and the real world has not been investigated.
We are also aware that developing CPGPS does not automatically
result into a changed behaviour of physiotherapists in their daily practice by
lack of knowledge about the factors impeding successful implementation.
For example, the present CPGPS showed moderate evidence for a reduced
length of stay in favour of Motor Relearning Programme (MRP) or
traditional care, compared to a rather impairment focused neuromuscular
treatment approach such as neurodevelopmental treatment (NDT). No
evidence was found for applying a specific neurological treatment program
128
in terms of muscle strength, synergism, muscle tone, walking ability,
dexterity or ADL.12 Achieved consensus of the dubious role of strictly
applying NDT concept after stroke has resulted in an implementation
research program for 2 years paid by the Dutch Government.87 In this
implementation project NDT teachers are educated how to apply the
evidence‐based guidelines into practice, how to measure change and how to
estimate prognosis in patients with stroke. Since recently, all NDT teachers
in the Netherlands accepted to participate in this implementation project of
the CPGPS and endorsed to change their name into ‘Neurorehabilitation‐
CVA’.
The conceptual evidence‐based model for clinical decision‐making
composed by Haynes et al.65 emphasises the central role of clinical expertise
in this process. Clinical expertise has three components, namely, research
evidence, patients’ clinical state and circumstances, and patients’ preferences
and actions. In developing the guideline, we concentrated on one
component, research evidence, and paid less attention to the other two
components.65 To improve the guidelines, we suggest that in the future a)
patients with stroke should be stratified into different functional profiles
according to their prognosis in their recovery of functional health
status71,88,89; b) clinical decision rules for each stratum or group should be
developed90; and c) concepts concerning clinimetric monitoring of functional
health status of patients with stroke should be developed.91 In addition, we
need to know more about the time dependence of functional recovery after
stroke,71,88 about the mechanisms underlying therapy‐induced functional
improvement, and the time dependence of predictors of functional
outcome.71,88,89 The recent shift in physiotherapy toward task‐oriented and
context‐specific training means that outcome measures may need to be
developed in order to evaluate patients with stroke in their real‐life
activities.64,92 These improvements can be integrated in an update of the
CPGPS. The board of the Royal Dutch Society for Physical Therapy
stipulated that the guideline should be revised every 5 years. As one of the
aims of developing this guideline was to improve everyday physiotherapy
practice, in the future attention should be paid to factors that hinder the
implementation of the guideline.

Acknowledgement

We would like to thank the members of the expert group: BC Harmeling‐van
der Wel; BJ Kollen; JSM Hobbelen; JH Buurke; J Halfens; L Wagenborg; MJ
129
Chapter 5
Vogel; and M Berns and the steering committee: J Dekker; PhJ Van der Wees;
M Heldoorn; and R Van Klaveren, and also JCF Ket (VU Medical Library)
and the representatives of the multi‐professional groups. This project is
supported by a grant from the KNGF, grant reference number:
IKPZ/KNGF/05/2000.

References

LATM, Koek HL, Van Trijp MJCA, Van Dis SJ, Peters RJG, Bots ML et al., editors. Hart‐en
vaatziekten in Nederland 2005, cijfers over risicofactoren, ziekte, behandeling en sterfte
[dutch]. Den Haag: Nederlandse Hartstichting, 2005: 6‐12.

national clinical guideline (no: 64). 64. 2002. Edinburgh, SIGN.
7. Sackett DL, Straus SE, Richardson WS et al. Evidence‐Based Medicine. How to practice and
teach EBM. 2nd ed. Edinburgh: Churchill Livingstone, 2000.
8. De Wit L, Putman K, Dejaeger E al. Use of time by stroke patients: a comparison of four
9. Jette DU, Latham NK, Smout RJ et al. Physical therapy interventions for patients with
stroke in inpatient rehabilitation facilities. Phys Ther 2005; 85:238‐248.
10. Van Peppen RPS, Kwakkel G, Harmeling BC et al. Clinical practice guideline on
Physiotherapy‐management of patients with Stroke [in dutch: KNGF‐richtlijn Beroerte].
Ned Tijdschr v Fysioth 2004; 114 (5:supplement):1‐78.
11. PEDro. The Physiotherapy Evidence Database (PEDro). 2004.

http://www.pedro.fhs.usyd.edu.au/
12. Van Peppen RP, Kwakkel G, Wood‐Dauphinee S et al. The impact of physical therapy on
functional outcomes after stroke: whatʹs the evidence? Clin Rehabil 2004; 18:833‐862.
130
1989; 20:1407‐1431.
14. Kwakkel G, Wagenaar RC, Kollen BJ et al. Predicting disability in stroke‐‐a critical review
of the literature. Age Ageing 1996; 25:479‐489.
15. Meijer R, Ihnenfeldt DS, de Groot IJ et al. Prognostic factors for ambulation and activities of
daily living in the subacute phase after stroke. A systematic review of the literature. Clin
Rehabil 2003; 17:119‐129.
Health. http://www.who.int/classification/icf/intros/ICF‐Eng‐Intro.pdf . 2001. Geneve.
17. Streiner DL, Norman GR. Health measurement scales, a practical guide to their
development and use. second ed. New York: Oxford University Press, 2003.
18. Bot SD, Terwee CB, van der Windt DA et al. Clinimetric evaluation of shoulder disability
questionnaires: a systematic review of the literature. Ann Rheum Dis 2004; 63:335‐341.
19. Counsell C, Dennis M. Systematic review of prognostic models in patients with acute
stroke. Cerebrovasc Dis 2001; 12:159‐170.
20. Dombovy ML, Sandok BA, Basford JR. Rehabilitation for stroke: a review. Stroke 1986;
17:363‐369.
21. Jongbloed L. Prediction of function after stroke: a critical review. Stroke 1986; 17(4):765‐776.
22. Meijer R, Ihnenfeldt DS, van Limbeek J, Vermeulen M, de Haan RJ. Prognostic factors in
the subacute phase after stroke for the future residence after six months to one year. A
systematic review of the literature. Clin Rehabil 2003; 17:512‐520.
24. Blackburn M, van Vliet P, Mockett SP. Reliability of measurements obtained with the
modified Ashworth scale in the lower extremities of people with stroke. Phys Ther 2002;
82:25‐34.
25. Bohannon RW, Larkin PA, Cook AC, Gear J, Singer J. Decrease in timed balance test scores
with aging. Phys Ther 1984; 64(7):1067‐1070.
26. Butland RJ, Pang J, Gross ER et al. Two‐, six‐, and 12‐minute walking tests in respiratory
disease. Br Med J (Clin Res Ed) 1982; 284:1607‐1608.
27. Collen FM, Wade DT, Robb GF et al. The Rivermead Mobility Index: a further
development of the Rivermead Motor Assessment. Int Disabil Stud 1991; 13:50‐54.
28. Collin C, Wade DT, Davies S et al. The Barthel ADL Index: a reliability study. Int Disabil
Stud 1988; 10:61‐63.
29. Collin C, Wade D. Assessing motor impairment after stroke: a pilot reliability study. J
Neurol Neurosurg Psychiatry 1990; 53:576‐579.
30. Crow JL, Harmeling BC. Development of a consensus and evidence‐based standardised
clinical assessment and record form for neurological inpatients: the Neuro Dataset.
Physiotherapy 2002; 88:33‐46.
131
Chapter 5
31. De Haan RJ. Clinimetrics in stroke. Dept. Clin. Epidemiology & Biostatistics, Academic
Medical Centre, Amsterdam, 1994.
32. De Weerdt W. Patiënten met neurologische aandoeningen. Deel 1: handleiding voor het
functioneel onderzoek. Leuven (België): Acco, 2001.
33. Demeurisse G, Demol O, Robaye E. Motor evaluation in vascular hemiplegia. Eur Neurol
1980; 19:382‐389.
34. DeSouza LH, Langton‐Hewer R, Miller S. Assessment of recovery of arm control in
hemiplegic stroke patients. Arm function test. Int Rehabil Med 1980; 2:3‐9.
35. Franchignoni FP, Tesio L, Ricupero C et al. Trunk control test as an early predictor of
stroke rehabilitation outcome. Stroke 1997; 28:1382‐1385.
36. Fugl‐Meyer AR, Jaasko L, Leyman I et al. The post‐stroke hemiplegic patient. 1: a method
for evaluation of physical performance. Scand J Rehabil Med 1975; 7:13‐31.
37. Heller A, Wade DT, Wood VA et al. Arm function after stroke: measurement and recovery
over the first three months. J Neurol Neurosurg Psychiatry 1987; 50:714‐719.
38. Hellstrom K, Lindmark B. Fear of falling in patients with stroke: a reliability study. Clin
Rehabil 1999; 13:509‐517.
39. Hellstrom K, Lindmark B, Fugl‐Meyer A. The Falls‐Efficacy Scale, Swedish version: does it
reflect clinically meaningful changes after stroke? Disabil Rehabil 2002; 24:471‐481.
40. Holden MK, Gill KM, Magliozzi MR et al. Clinical gait assessment in the neurologically
impaired. Reliability and meaningfulness. Phys Ther 1984; 64:35‐40.
41. Holden MK, Gill KM, Magliozzi MR. Gait assessment for neurologically impaired patints.
Sandards for outcome assessment. Phys Ther 1986; 66:1530‐1539.
42. Joos E, Peretz A, Beguin S et al. Reliability and reproducibility of visual analogue scale and
numeric rating scale for therapeutic evaluation of pain in rheumatic patients. J Rheumatol
1991; 18:1269‐1270.
43. Kwakkel G, Wagenaar RC, Twisk JW et al. Intensity of leg and arm training after primary
middle‐cerebral‐artery stroke: a randomised trial. Lancet 1999; 354:191‐196.
44. Lincoln NB, Jackson JM, Adams SA. Reliability and revision of the Nottingham sensory
assessment for stroke patients. Physiotherapy 1998; 84:358‐365.
45. Lyle RC. A performance test for assessment of upper limb function in physical
rehabilitation treatment and research. Int J Rehabil Res 1981; 4:483‐492.
46. Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clin
Rehabil 1987; 1:301‐305.
47. Oerlemans HM, Goris RJ, Oostendorp RA. Impairment level sumscore in reflex
sympathetic dystrophy of one upper extremity. Arch Phys Med Rehabil 1998; 79:979‐990.
48. Podsiadlo D, Richardson S. The timed ʺUp & Goʺ: a test of basic functional mobility for
frail elderly persons. J Am Geriatr Soc 1991; 39:142‐148.
49. Ryf C, Weymann A. Range of Motion ‐ AO Neutral‐0‐Method; measurement and
documentation. Stutgart: Thieme, 1999.
132
50. Schuling J, de Haan R, Limburg M et al. The Frenchay Activities Index. Assessment of
functional status in stroke patients. Stroke 1993; 24:1173‐1177.
51. Stevenson TJ. Detecting change in patients with stroke using the Berg Balance Scale. Aust J
Physiother 2001; 47:29‐38.
52. Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, Van Gijn J. Interobserver
agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604‐607.
53. Verheyden G, Nieuwboer A, Mertin J et al. The Trunk Impairment Scale: a new tool to
measure motor impairment of the trunk after stroke. Clin Rehabil 2004; 18:326‐334.
54. Wade DT. Measurements in neurological rehabilitation. Oxford: Oxford University Press,

1992.
55. Kwakkel G, Kollen BJ, Van der Grond J, et al. Probability of regaining dexterity in the
flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke
2003; 34:2181‐2186.
56. Sunderland A, Tinson D, Bradley L et al. Arm function after stroke. An evaluation of grip
strength as a measure of recovery and a prognostic indicator. J Neurol Neurosurg
Psychiatry 1989; 52:1267‐1272.
57. Wade DT, Langton‐Hewer R, Wood VA et al. The hemiplegic arm after stroke:
measurement and recovery. J Neurol Neurosurg Psychiatry 1983; 46:521‐524.
58. Kwakkel G, van Dijk GM, Wagenaar RC. Accuracy of physical and occupational therapistsʹ
early predictions of recovery after severe middle cerebral artery stroke. Clin Rehabil 2000;
14:28‐41.
rehabilitation: ICF activity. Disabil Rehabil 2005; 27:315‐340.
60. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle
spasticity. Phys Ther 1987; 67:206‐207.
61. Duncan PW, Zorowitz R, Bates B et al. Management of Adult Stroke Rehabilitation Care: a
clinical practice guideline. Stroke 2005; 36:e100‐e143.
62. Jette DU, Bacon K, Batty C et al. Evidence‐based practice: beliefs, attitudes, knowledge, and
behaviors of physical therapists. Phys Ther 2003; 83:786‐805.
outcome measures. 2003:
64. Jette AM. Assessing disability in studies on physical activity. Am J Prev Med 2003; 25 (3
Suppl 2):122‐128.
133
Chapter 5
67. Shaneyfelt TM, Mayo‐Smith MF, Rothwangl J. Are guidelines following guidelines? The
methodological quality of clinical practice guidelines in the peer‐reviewed medical
literature. JAMA 1999; 281:1900‐1905.
68. The AGREE Collaboration. Appraisal of Guidelines Research & Evaluation (AGREE);
Instrument voor beoordeling van richtlijnen. 2001.
69. Juni P, Witschi A, Bloch R et al. The hazards of scoring the quality of clinical trials for meta‐
analysis. JAMA 1999; 282:1054‐1060.
70. Bhogal SK, Teasell RW, Foley NC et al. The PEDro scale provides a more comprehensive
measure of methodological quality than the Jadad scale in stroke rehabilitation literature. J
Clin Epidemiol 2005; 58:668‐673.
72. Van de Port I, Kwakkel G, van Wijk I et al. Susceptibility to deterioration of mobility long‐
term after stroke: a prospective cohort study. Stroke 2006; 37:167‐171.
Sinai J Med 1999; 66:75‐83.
74. Grol R, Wensing M, Eccles M. Improvement patient care. The implementation of change in
75. Devereaux PJ, Bhandari M, Clarke M et al. Need for expertise based randomised controlled
trials. BMJ 2005; 330:88.
76. Hotopf M. The pragmatic randomised controlled trial. Advances in Psychiatric Treatment
2002; 8:326‐333.
77. Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical
research for decision making in clinical and health policy. JAMA 2003; 290:1624‐1632.
78. Kwakkel G, Wagenaar RC. Effect of duration of upper‐ and lower‐extremity rehabilitation
Ther 2002; 82:432‐448.
79. Scholz JP. Dynamic pattern theory‐‐some implications for therapeutics. Phys Ther 1990;
70:827‐843.
80. Johnston M, Pollard B, Morrison V et al. Functional limitations and survival following
stroke: psychological and clinical predictors of 3‐year outcome. Int J Behav Med 2004;
11:187‐196.
81. Gresham GE, Duncan PW, Statson WB. Priorities for future research: clinical practice
guidelines, number 16. US Dept Health and Human Services ‐ Agency for Health Care
Policy and Research, editor. AHCPR publication no. 95‐0662. 1995. Rockville.
82. Teasell RW, Foley NC, Bhogal SK et al. An evidence‐based review of stroke rehabilitation.
Top Stroke Rehabil 2003; 10:29‐58.
83. Hanger HC, Wilkinson T, Keeling S et al. New Zealand guideline for management of
stroke. N Z Med J 2004; 117:U863.
134
84. Hammond R, Lennon S, Walker MF et al. Changing occupational therapy and
physiotherapy practice through guidelines and audit in the United Kingdom. Clin Rehabil
2005; 19:365‐371.
85. Wade D. Investigating the effectiveness of rehabilitation professions‐‐a misguided
enterprise? Clin Rehabil 2005; 19:1‐3.
86. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ
2004; 328:343‐345.
87. Geurts AC, Halfens JHC, Buurke JH et al. Implementatie van nieuwe klinische inzichten in
studies over herstel van loopvaardigheid na een CVA. Grant ZonMW, projectnr: 1435.0047.
2006.
89. Vlaeyen JW, Morley S. Cognitive‐behavioral treatments for chronic pain: what works for
whom? Clin J Pain 2005; 21:1‐8.
90. Craik RL. Thirty‐Sixth Mary McMillan Lecture: Never satisfied. Phys Ther 2005; 85:1224‐
1237.
330:644‐648.
92. Jette AM. Outcomes research: shifting the dominant research paradigm in physical
therapy. Phys Ther 1995; 75:965‐970.
93. Kwakkel G. Dynamics in functional recovery after stroke. Wageningen, The Netherlands,
1998.
135
Chapter 5
136
CHAPTER
Outcome measures in physiotherapy management of
patients with stroke: a survey into self‐reported use,
and barriers to and facilitators for use
Francois JF Maissan
Frank R Van Genderen
Rob van Dolder

Submitted
Chapter 6
Abstract

Objective: To investigate physiotherapists’ self‐reported use of outcome
measures as recommended in the Dutch clinical practice guideline for the
management of patients with stroke (CPGPS), and to assess perceived
barriers to and facilitators for the use of outcome measures in everyday
practice.
Method: A 41‐item survey, including the Barriers and Facilitators
Questionnaire (BFQ), was sent by post to 400 physiotherapists in each of the
following settings in the Netherlands: acute care hospitals (ACH; N=100),
rehabilitation centres (RC; N=100), nursing homes (NH; N=100) and private
physiotherapy practices (PPP; N=100).
Results: One hundred and eighty‐nine physiotherapists returned the survey
(47%; ACH, N=57; RC, N=67; NH, N=26 and PPP, N=39); the surveys of 167
physiotherapists involved in stroke settings were analysed. These
physiotherapists reported regularly using three (median; range 0‐7) of the
seven recommended measurement instruments, with those working in RC
or ACH reporting a significantly higher use than their colleagues in PPP (4
vs. 0 and 3 vs. 0; p<0.001 and p=0.02 respectively). The BFQ revealed that
there were setting‐specific facilitators, such as ‘a positive attitude towards
outcome measures’ (as mentioned by 93% of the physiotherapists) and
‘acquaintance with outcome measures’ (90%), and barriers such as ‘changing
routines’ (32%), ‘time investment’ (29%), and ‘financial compensation’ (21%).
Conclusion: Despite an almost uniformly positive attitude, physiotherapists
infrequently use the outcome measures recommended in the CPGPS. Robust
setting‐specific tailored implementation strategies based on the reported
barriers and facilitators are needed.

Key Words: physiotherapy, cerebrovascular disorders, outcome measures,
guideline, implementation, survey

138
Outcome measures in physiotherapy stroke management
Introduction

The judicious use of outcome measures to monitor the health status of
patients is considered an aspect of good clinical practice in physiotherapy.1‐4
Their use leads to improved patient care, because professionals have
feedback on the effect of an intervention, and to improved communication,
both with patients and members of an interdisciplinary team.5 While
physiotherapists are encouraged to use outcome measures as a part of their
daily practice,6,7 recent surveys indicate they do not regularly do so.2,4,8‐12
In September 2004 a Clinical Practice Guideline on the Physiotherapy
management of patients with Stroke (CPGPS) was published in the
Netherlands.7,13 One part of the CPGPS recommends the use of a core set of
seven valid, reliable and responsive measurement instruments to assess the
functional health status of patients who have had a stroke.7 This evidence‐
based core set aims to monitor specific aspects in the ‘Activities’ domain of
the International Classification of Functioning, Disability and Health (ICF)14‐
16, as advocated by Geyh and colleagues.17
It will be difficult to study the adherence of physiotherapists to the entire
CPGPS at once. The use of outcome measures by professionals can be seen
as a useful indicator of guideline adherence.4 Consequently, in the present
survey we focused on the CPGPS recommendations concerning the use of a
core set of outcome measures. A crucial element for the successful
implementation of evidence‐based therapy in daily practice is an initial
analysis of the patients and professionals involved and their institutional
context.18 This study analysed the current use of outcome measures by
physiotherapists involved in the care of patients with stroke. Such
knowledge makes it possible to tailor future implementation strategies. To
date, little is known about the use of outcome measures by physiotherapists
who provide care for patients with stroke in the Netherlands.
We therefore carried out a survey among physiotherapists in different
Dutch stroke settings, to investigate the self‐reported use of outcome
measures as recommended in the CPGPS, 2 months after publication of the
CPGPS, and to identify perceived barriers to and facilitators for the use of
these outcome measures (Barriers and Facilitators Questionnaire). This
information may prove helpful in tailoring strategies to promote the
implementation of the CPGPS recommendations.
139
Chapter 6
Methods

A questionnaire was sent to a proportionally stratified sample19 of
physiotherapists in the Netherlands to assess the self‐reported use of
measurement instruments as recommended in the CPGPS. Physiotherapists
were also asked to provide information about apparent barriers to and
facilitators for the use of the recommended outcome measures. In this
survey, outcome measures included the objectification, quantification,
interpretation and registration of patients’ outcomes and were based on the
‘clinimetrics’ definition by Feinstein “the domain concerned with indexes, rating
scales, and other expressions that are used to describe or measure symptoms,
physical signs, and other distinctly clinical phenomena in clinical medicine”.20

CPGPS
The seven measurement instruments recommended in the CPGPS are the
Motricity Index (MI)21, Trunk Control Test (TCT)22, Berg Balance Scale
(BBS)23, Functional Ambulation Categories (FAC)24, Ten Metre Walk
(TMW)25, Frenchay Arm Test (FAT)26 and Barthel Index (BI)27. The guideline
recommends that physiotherapists assess patients’ functional status at least
five times at fixed time points during treatment, namely, (a) at the start, (b)
at the end of a course of treatment in any location; (c) before each
multidisciplinary stroke team meeting (information about patients’ current
status and progress); (d) at 3 months, and (e) at 6 months after the stroke.7
The CPGPS also recommends that appropriate outcome data are sent to
colleagues if patients are transferred from one clinical setting to another,7 to
safeguard the continuity of physiotherapy care during rehabilitation, which
is usually started in an acute care hospital (e.g. stroke‐unit of a local or
university hospital) and continued in a rehabilitation centre, a nursing home
or the community (private physiotherapy practice).28

Questionnaire design
A 41‐item questionnaire on the self‐reported use of outcome measures in the
physiotherapy management of patients with stroke was used. This
questionnaire comprised three sections:
Section I consisted of seven multiple choice questions about relevant
personal, demographic and professional characteristics of the
physiotherapists, such as age, professional experience and number of stroke
patients treated weekly.
Section II included 14 questions concerning (a) the routine use of
measurement instruments on a nominal scale (yes / no), (b) the self‐reported
140
use of the recommended core measurement instruments (e.g. Berg Balance
Scale), and (c) time points of assessment (e.g. at admission and discharge)
and registration (e.g. sending discharge letters).
Section III contained 20 statements concerning potential barriers to and
facilitators for the use of outcome measures in everyday practice in
physiotherapy stroke management, such as ‘Reluctance to adhere to
guidelines’ or ‘Experience with outcome measures’, etc. This ‘Barriers and
Facilitators Questionnaire’ (BFQ) was based on a validated questionnaire for
perceived barriers to professional change.29,30 The original 27 statement
questionnaire was adapted for the purpose of this study. Eleven statements
concerning ‘prevention’ were not applicable and therefore removed. Four
statements with regard to patients’ view about outcomes and
physiotherapists’ training and experience with outcome measures were
added. The final 20 statements were tested for content‐validity by five
experts. Physiotherapists rated each statement on a 5‐point Likert scale,
ranging from ‘fully disagree’ (1 point) to ‘fully agree’ (5 points).

Sample
The survey was performed in November 2004, 2 months after the
publication of the CPGPS in the Netherlands. The survey was sent by post to
a proportionally stratified sample of physiotherapists (N=4x100), randomly
selected from the database of the Royal Dutch Society for Physical Therapy
and equally distributed over the four main settings of physiotherapy stroke
management: acute care hospitals (ACH), rehabilitation centres (RC),
nursing homes (NH), and private physiotherapy practices (PPP).28 Non‐
responders were sent a reminder in February 2005. The data supplied by
physiotherapists who reported treating patients with stroke were analysed.

Data analysis
SPSS 12.0 statistical software was used for data analysis (SPSS Inc, Chicago,
Illinois, USA), using a significance level of p<0.05. Descriptive statistics were
used to describe the physiotherapists and their responses, and to examine
the frequency of the self‐reported use of the recommended measurement
instruments.31 Sum scores were calculated for all self‐reported outcome
measures, ranging from 0 (no use of any of the outcome measures) to 7
(regular use of all recommended outcome measures). The association
between sum scores of self‐reported use of recommended core instruments
and the number of stroke patients treated weekly and the age of the
physiotherapists was assessed using Spearmans rho. The strength of the
associations was worded as recommended by Learner and Goodman, who
141
Chapter 6
suggested that a correlation coefficient ≥ 0.7 is indicative of a strong

association.32 To assess perceived barriers to and facilitators for the use of
outcome measures in the four settings, cross tables and (cumulative)
frequencies were used: the 5‐point Likert scale was recoded into a 3‐point
scale (fully disagree/disagree, do not agree nor disagree, and agree/fully
agree) to simplify data interpretation. Rank scores were used to determine
the barriers and facilitators most frequently mentioned.
A principal component analysis (PCA) with Varimax rotation was used
to uncover underlying dimensions of the BFQ in this specific professional
area.31,33 Subsequently, the internal consistency of the total BFQ and of each
of the identified factors was assessed using Cronbachʹs α. Finally, sum
scores were calculated for each identified factor by adding up the individual
item scores assigned to that specific factor. To assess differences between
statements regarding perceived barriers and facilitators in the four settings,
a one‐way analysis of variance (ANOVA) was performed with post hoc
multiple setting comparison using Bonferroni post‐hoc test.31 All analyses
were assessed at a significance level of p< 0.05.

Figure 1. Physiotherapists (N) per setting

Questionnaires
ACH RC NH PPP
Sent
100 100 100 100
Response 1 23 Total Response 1

37 10 18
22% (N=88)
Reminder
Total Response 1+2

Response 1+2 57 67 26 39
47% (N=189)
DataAnalysis Total Included

57 63 25 22 42% (N=167)
Results

Of the 400 questionnaires sent, 2 were undeliverable and 189 were returned
(of which 88 within 2 months; the remainder were returned after a reminder
was sent), representing an overall response rate of 47%. Twenty‐two
142
questionnaires were excluded from analysis because the physiotherapists

concerned were not involved in the care of patients with stroke. Seventeen
out of these 22 excluded physiotherapists worked in a PPP, four in
rehabilitation centres and 1 in a nursing home. The remaining 167
questionnaires were included in the analyses, representing an effective
response rate of 42% (Figure 1 and Table 1).

Table 1 – Characteristics of included physiotherapists
Acute Care Rehabilitation Nursing Private PT Total % (N)
Hospitals Centres Homes Practices
100%
(N=57) (N=63) (N=25) (N=22) (N=167)
Gender
male 35% 32% 20% 59% 35%
female 65% 68% 80% 41% 65%
Age
< 30 years 14% 25% 36% 14% 22%
30-34 years 19% 14% 20% 9% 16%
35-39 years 13% 13% 16% 4% 12%
40-44 years 7% 11% 20% 14% 11%
45-49 years 21% 18% 4% 18% 17%
> 50 years 26% 19% 4% 41% 22%
Number of stroke
patients
treated weekly
1 14% 5% 4% 41% 13%
2-3 32% 11% 16% 45% 23%
4-6 28% 32% 32% 14% 28%
7-10 10% 17% 16% 0% 13%
> 10 16% 35% 32% 0% 23%
Cooperate in stroke
service?
yes 93% 94% 72% 9% 79%
no 7% 6% 28% 91% 21%
In possession of
CPGPS?*
yes 96% 94% 92% 91% 94%
no 4% 6% 4% 5% 5%
Informed about
content of CPGPS?*
yes 79% 83% 60% 36% 72%
no 11% 13% 28% 18% 15%
Using recommended
core set of outcome
measures?*
yes 53% 73% 36% 9% 52%
no 26% 16% 40% 32% 25%
* = The remaining percentage in each table cell reflects missing data

CPGPS indicates Clinical Practice Guideline on Physiotherapy management of patients with Stroke;
N, number of physiotherapists; PT, physiotherapy
143
Chapter 6
Section I: characteristics of the effective response
Of the 167 physiotherapists whose information was analysed, 63 worked in
RC, 57 in ACH, 25 in NH, and 22 in PPP. Most of these physiotherapists
worked in an institutional or interinstitutional stroke service (N=132; 79%),
had a copy of the CPGPS (94%), were knowledgeable about the content of
the CPGPS (72%) and reported using at least some of the recommended
measurement instruments of the CPGPS (52%). Most of the physiotherapists
who worked in PPP had a copy of the CPGPS (N=20; 91%) and did not work
in a stroke service (91%). Of these physiotherapists in PPP, 46% and 69% did
not provide information about the content of the CPGPS and their use of the
core set of recommended outcome measures.

Section 2: self‐reported use of recommended outcome measures
The 167 physiotherapists reported using three of the seven recommended
outcome measures. The most widely used measurement instrument was the
FAC (N=82; 49%); the least used was the FAT (N=11; 7%).
Specified per setting, the highest reported use of the seven measurement
instruments was among physiotherapists working in RC (median=4 /
modus=4), followed by physiotherapists working in ACH (3 / 3), in NH (2 /
0) and in PPP (0 / 0). Physiotherapists working in RC or ACH made
significantly greater use of outcome measures than their colleagues working
in PPP (4 versus 0 and 3 versus 0; p<0.001 and p=0.02 respectively).
Physiotherapists working in PPP reported the most infrequent use of the
recommended measurement instruments: reported use was lower than 10%
for six of the seven measures. The highest reported use of outcome measures
was by physiotherapists working in RC, ranging from 79% for the BBS
(N=50) to 11% for the FAT; and the lowest was by physiotherapists working
in PPP, ranging from 23% for the TMW (N=5) to 5% for the BI (Table 2).
Overall, outcome monitoring of the patient’s health status at fixed time
points as recommended by the CPGPS varied from 69% (N=115) in the week
of admission to 16% at 6 months after stroke (Table 3). Compared to
physiotherapists working in the other settings, physiotherapists working in
PPP followed the guideline recommendations the least in this respect,
ranging from 18% (N=4) at 6 months after stroke to 5% at discharge or at the
end of a treatment period. The number of missing values for these
physiotherapists was relatively high (≥ 45%).
Most physiotherapists (93%) reported sending a discharge letter to the
professional responsible for the further treatment of the patient (proportion
of physiotherapists by setting: ACH=96%; RC=93%; NH=83% and
144
PPP=100%), whereas only 42% of them stated receiving such discharges
letter (RC=60% NH=54%; PPP=42%; and ACH=12%).
The association between the sum scores of self‐reported use of core
outcome measures and the number of stroke patients treated weekly was
only significant (though weak) for physiotherapists working in ACH
(rho=0.35; p=0.009). For the other settings, no significant relation was found
(RC, rho=0.18, p=0.17; NH, rho=‐0.16, p=0.46; and PPP, rho=0.15, p=0.64).
Physiotherapists’ age was negatively, but not significantly, associated with
their compliance with the core set of measurements (ACH, rho=‐0.13, p=0.97;
RC, rho=‐0.25, p=0.07; NH, rho=‐0.08, p=0.70; and PPP, rho=‐0.14, p=0.27).

Table 2 – Self-reported use of recommended core outcome measures by physiotherapists
Hospitals Centres Homes Practices
100%
(N=57) (N=63) (N=25) (N=22) (N=167)
Motricity Index*
yes 47% 49% 28% 5% 40%
no 42% 44% 64% 55% 48%
Trunk Control Test*
yes 60% 40% 40% 9% 43%
no 32% 52% 52% 50% 45%
Berg Balance Scale*
yes 33% 79% 40% 5% 48%
no 49% 17% 52% 55% 38%
Functional Ambulation
Categories*
yes 49% 67% 44% 5% 49%
no 39% 24% 48% 55% 37%
Ten Metre Walk*
yes 19% 73% 40% 23% 44%
no 65% 22% 52% 36% 44%
Frenchay Arm Test*
yes 4% 11% 4% 5% 7%
no 79% 79% 88% 55% 79%
Barthel Index*
yes 39% 19% 36% 5% 26%
no 47% 76% 60% 50% 62%

N indicates number of physiotherapists; PT, physiotherapy

Section 3: Barriers and facilitators questionnaire (BFQ)
A: Psychometrics of BFQ
All data of the BFQ were normally distributed. The internal consistency of
the complete BFQ was good (Cronbachʹs α=0.86). Factor analysis identified
six factors that together explained 65% of the variance in the use of outcome
145
Chapter 6
measures (Table 4). These were: (1) ‘personal environment’ (explained 15.4% of
variance, Cronbach’s α=0.86); (2) ‘practitioner’ (12.1%, α=0.77); (3) ‘patient’
(10.5%, α=0.61); (4) ‘professional attitude’ (9.6%, α=0.58); (5) ‘economic
environment’ (9.5%, α=0.62); and (6) ‘administrative environment’ (7.0%,
α=0.34).

Table 3 – Self-reported use of assessment time points by physiotherapists
According to Hospitals Centres Homes Practices
recommendations in 100%
CPGPS:7 (N=57) (N=63) (N=25) (N=22) (N=167)
In week of admission*
yes 84% 81% 56% 9% 69%
no 11% 14% 40% 32% 19%
In week of discharge*
yes 77% 60% 48% 5% 57%
no 16% 29% 40% 41% 28%
In week of
multidisciplinary
meeting*
yes 33% 67% 36% 5% 43%
no 49% 22% 52% 36% 38%
3 months after onset
of stroke*
yes 4% 21% 44% 14% 17%
no 70% 65% 48% 41% 61%
6 months after onset
of stroke*
yes 4% 14% 44% 18% 16%
no 70% 70% 48% 32% 62%

N indicates number of physiotherapists; PT, physiotherapy

B: Outcomes of BFQ
Four major facilitators and three barriers to the use of outcome measures
were identified (Table 4). Facilitators were ‘a positive attitude towards
outcome measures’ (mentioned by 156 physiotherapists = 93%), ‘familiarity
with outcome measures’ (90%), ‘ability to make a comparative clinical
assessment’ (90%), and ‘cooperation of colleagues in applying outcome
measures’ (83%). The barriers that were mentioned the most were ‘changing
routines’ (N=52; 32%), ‘time investment’ (29%), and ‘financial compensation’
(21%). Physiotherapists working in different settings mentioned different
barriers and facilitators (see Table 4). The most marked differences
concerned the factors ‘personal environment’ (PPP‐RC (p=0.02) and PPP‐ACH
(p=0.02)), ‘practitioner’ (PPP‐RC (p<0.001); PPP‐ACH (p<0.001); PPP‐NH
(p=0.014) and RC‐NH (p=0.02)) and ‘economic environment’ (PPP‐RC (p=0.03)).
The other three factors were not significantly different between settings.
146
Table 4 – Barriers to and facilitators for the use of the recommended outcome measures, as reported
by physiotherapists
Factor:
% Fully disagree or disagree* % Agree or fully agree*
‘Personal environment’ ACH RC NH PPP Tot ACH RC NH PPP Tot
1. Familiarity with outcome measures 0.0 1.9 7.1 16.7 2.5 88.9 92.4 85.8 83.3 89.8
2. Experience with outcome measures 11.1 5.7 28.6 66.7 13.5 77.8 88.6 57.1 16.7 77.1
3. Knowing much about outcome measures 6.7 7.5 14.3 14.3 8.4 73.3 75.5 64.3 57.1 72.2
4. Trained to use outcome measures correctly 4.4 5.8 7.1 14.3 5.9 64.5 75.0 64.3 57.1 68.7
‘Practitioner’ ACH RC NH PPP Tot ACH RC NH PPP Tot
5. Cooperation of fellow physiotherapists in 0.0 1.9 7.1 33.3 3.4 88.9 92.4 64.3 33.4 83.1
applying outcome measures
6. Cooperation of managers in applying 11.6 5.7 7.7 50.0 9.0 57.5 81.1 53.8 0.0 71.2
outcome measures
7. No need for extra accommodation to apply 6.8 2.0 7.1 0.0 4.3 65.9 92.1 64.3 50.0 76.6
outcome measures**
8. Outcome measures fit in with my daily 8.8 3.8 7.1 14.3 6.7 73.3 83.0 64.3 57.1 75.6
practice routine
‘Patient’ ACH RC NH PPP Tot ACH RC NH PPP Tot
9. Outcome measures give patients insight into 20.0 5.7 0.0 14.3 10.9 37.8 66.0 78.6 28.6 54.6
their physical functioning
10. Outcome measures leave enough room for 6.7 7.7 7.1 16.7 7.7 53.3 63.5 50.0 83.3 59.9
individual patients’ preferences
11. Lay-out of measurement part of CPGPS 13.3 11.5 0.0 0.0 10.2 35.6 61.6 66.7 16.7 50.0
makes it easy to use
‘Professional attitude’ ACH RC NH PPP Tot ACH RC NH PPP Tot
12. No general reluctance to adhere to 4.4 7.5 0.0 0.0 5.1 82.2 73.6 92.9 42.9 77.3
guidelines**
13. Positive attitude towards the use of 0.0 0.0 0.0 0.0 0.0 95.5 94.3 92.9 71.4 93.3
outcome measures
14. Outcome measures allow me to make a 0.0 2.0 6.7 0.0 1.7 88.6 90.2 86.7 100 89.7
balanced clinical assessment
15. No problems with changing routines** 22.2 37.7 50.0 14.3 31.8 51.1 34.0 35.7 57.1 42.1
‘Economic environment’ ACH RC NH PPP Tot ACH RC NH PPP Tot
16. Use of outcome measures does not 31.8 7.5 20.0 66.7 21.1 27.3 66.1 66.6 0.0 48.3
require financial compensation**
17. Patients do not find the use of outcome 6.6 5.7 0.0 0.0 5.1 62.2 60.3 35.7 33.3 56.8
measures too time-consuming**
18. Use of outcome measures is not too time- 26.6 26.4 28.5 57.1 28.6 31.1 56.6 42.8 28.6 43.7
consuming**
‘Administrative environment’ ACH RC NH PPP Tot ACH RC NH PPP Tot
19. No risk that use of outcome measures will

be abused for disciplinary action against 6.8 4.1 0.0 16.7 5.3 38.6 38.8 40.0 33.3 38.6
physiotherapists**
20. Description of outcome measures is 15.9 17.7 20.0 33.3 18.1 47.7 35.3 40.0 16.7 39.7
mainly correct
ACH indicates acute care hospitals; NH, nursing homes; RC, rehabilitation centres; PPP, private physiotherapy
practices; CPGPS, Clinical Practice Guideline on the Physiotherapy management of patients with Stroke.
*The remaining percentages correspondent to ‘do not agree nor disagree’ answers.
** The original statements of the BFQ were reformulated for the purpose of data analysis
147
Chapter 6
Discussion
The outcome measures recommended by the CPGPS appear to be used
modestly in physiotherapy practice (Table 2 and 3) leaving ample room for
improvement in this respect among physiotherapists working in stroke
management in the Netherlands. While most physiotherapists were positive
about using such clinical outcome measures (Table 4, item 13), only half of
them actually claimed to use these instruments (Table 2), with the highest
use being reported by physiotherapists who either reported to be familiar
with the content of the guideline or were involved in institutional stroke
management with a relatively high case load or both (Table 1). Almost half
of the therapists reported using measurement instruments for mobility‐
related activities (40% MI, 43% TCT and 48% BBS) and walking (44% TMW
and 49% FAC). Instruments broadly quantifying ADL (BI) and hand and
arm use (FAT) were reported to be used far less, by 26% and 7% of the
physiotherapists, respectively (see Table 2). The frequency with which
therapists claim to assess patients decreased if patients were situated in (or
perhaps transferred to) the acute care setting (ACH), the long stay in RC and
NH, or were treated in PPP (Table 3). Physiotherapists working in PPP in
particular reported poor adherence to the CPGPS recommendations (Table 2
and 3). This might be attributable more to the phase of rehabilitation of the
patients than to the setting per se, as these data are in line with those of
Lennon (2% of senior physiotherapists in UK stroke care reassess patients at
6 months after stroke).34 Alternatively, this might be a consequence of the
relatively low case load (Table 1) and barriers, such as physiotherapists’
opinions about financial compensations and competencies, in PPP (Table 4).
While we expected that physiotherapists who regularly treated stroke
patients would make most use of outcome measures, there was only a weak
correlation between the number of patients treated and guideline adherence,
and only for physiotherapists working in ACH (rho=0.35; p<0.01). This weak
correlation also means that physiotherapists who saw few patients (i.e.,
those working in PPP) did not use the guideline to monitor patients’
functional status either.
An adequate sample of physiotherapists according to Field completed the
questionnaire,31 leading to an acceptable response rate,3 comparable to that
in other similar studies.2,8,34 Those physiotherapists who have a special
interest in guidelines were more likely to respond in the present survey,
resulting in selection bias, and in combination with socially preferable
answers this may mean that the use of outcome measures was
overestimated. The use of outcome measures appears to be governed by the
148
physiotherapists’ personal environment, the role of practitioner and the

economic environment (Table 4). Almost a third of the physiotherapists
reported reluctance to change routines as a barrier to the use of outcome
measures (item 15), in parallel with some of the economic environment (item
16 and 18). These distinct barriers have been mentioned by other authors.35,36
In this respect, one should bear in mind the differences in the responses
between settings, which may at the same time reflect the progress of
rehabilitation in consecutive settings. This especially holds true for
physiotherapists working in a PPP. The therapists in PPP differed
significantly more than their colleagues (p<0.05) on items such as reported
experience with outcome measures, cooperation of managers in applying
outcome measures, financial compensation, and time investment (see Table
4, items 2, 6, 16 and 18, respectively). The present response supports the
tailoring of implementation strategies to physiotherapists in general to the
different Dutch stroke settings they are working in. Although Cronbach’s
alpha for the overall BFQ was adequate, not all factors reached the generally
accepted standard of 0.7. Three factors have a moderate internal consistency,
varying from 0.58 to 0.62, and only the ‘administrative environment’ factor did
not reach an acceptable level. All in all, Dutch physiotherapists reported a
positive attitude and a moderate use of outcome measures, with those
working in PPP adhering poorly to the CPGPS recommendations related to
outcomes.
We sampled 100 physiotherapists per setting, whose age and sex were
comparable to those of the general Dutch physiotherapist population.37
Although physiotherapists working in PPP were probably underrepresented
because two‐thirds of practicing physiotherapists in the Netherlands (about
12,000 of 18,650) work in a PPP,37,38 it should be remembered that few
patients with stroke consult such physiotherapists38 (see Table 1). However,
a larger study should investigate not only the reported use but also the
actual use and performance of outcome measures. Such an investigation
should be combined with a study of the origin of explicit barriers to and
facilitators for guideline implementation. Physiotherapists tend to
overestimate their use of such instruments, as can be seen in comparisons of
actual use and self‐reported use (Chapter 7), possibly because of their
tendency to give socially desirable answers. This was probably also the case
in the present study, which all the more suggests that the use of outcome
measures could be improved. Nevertheless, physiotherapists claimed to use
the recommended measurement instruments, with the exception of the FAT,
which was introduced only recently with the publication of the CPGPS in
the Netherlands, and was thus relatively unknown at the time of the survey.
149
Chapter 6
Alternatively, the FAT39 might be used less because physiotherapists do not
expect functional recovery of the paretic arm, and occupational therapists
take over the assessment of the paretic arm. The low reported use of the BI
can be explained, in agreement with the data by Lennon,34 from the fact that
in intramural settings (ACH, RC, and NH), it is usually other members of a
multidisciplinary team (e.g. occupational therapists) who monitor patients’
arm and hand use with the help of this ADL outcome measure. Future
research therefore needs to ask for both the use of the measure itself and the
use of the data produced by an instrument.
With the exception of the FAT the self‐reported use of the other outcome
measures by the Dutch physiotherapists in our sample was between 26%
and 49%, which is comparable with the baseline measures in other studies
investigating the (self‐reported) use of measurement instruments.8,9,12
The decreasing frequency of outcome assessment throughout the
rehabilitation process (Table 3) seems to be associated with the fixed time
points of assessment recommended in the guideline.7 This ‘fixed‐time‐point
strategy’ for the use of outcome measures contrasts with the ‘success‐of‐
treatment‐related strategy’ advocated by Glasziou et al.4 Glasziou recognized
the need for different monitoring intervals for different phases, such as the
phases of a disease for diagnosis, prognosis and therapy evaluation4 In
practice, however, the physiotherapists surveyed may have used the
measurement instruments to monitor the success of treatment rather than to
monitor patient functional recovery per se. The fact remains that the
assessment frequency was low, lower than that reported by others.15,40
Another explanation for the decreasing frequency of use of outcome
measures throughout the rehabilitation process is that physiotherapists in
ACH were unable to use measurement instruments at for instance 6 months
after stroke, because their patients had moved on from the ACH by then.
As yet physiotherapists do not routinely use clinical assessment
instruments in the management of patients with stroke. The use of clinical
outcome measures in different phases of a disease for diagnosis, prognosis
and therapy evaluation to monitor the health status of patients can help
physiotherapists to specify relevant and attainable treatment goals, to get
feedback on the success during the intervention and to optimise the
communication with patients and/or members of an interdisciplinary team.1‐
3 However, physiotherapists seem unable to educate themselves in the use of
clinical measurement tools. If this is indeed so, teaching physiotherapists to
enhance the use of outcome measures has to be integrated in a clinical
reasoning process in the management of patients with stroke. Setting‐
specific strategies are needed to promote the implementation of clinical
150
outcome measures in the physiotherapy management of patients with

stroke,18 based on the barriers and facilitators found in this study. Such
strategies could be based on the implementation model by Lomas et al,41,42
with a focus on education in stroke management. In future guideline
development and dissemination, these tailored implementation strategies
will have to be based on an initial analysis of the patients and professionals
involved and their specific institutional context.

Acknowledgements
We would like to thank the students of the Graduate Programme of
Physiotherapy Science at the University of Utrecht (Ivo Daanen, Hans Herik,
Erwin Huiszoon, Han Kingma, Leny de Ligny, Koert Nederbragt, Eric
Passchier, Peter Viehoff, Judith Weijman, and Elles Zock) for contributing to
this project, and Dr Paul Westers of the Centre for Biostatistics (Utrecht
University) for his valuable suggestions for improving the statistical
analysis. We are grateful to all the physiotherapists who responded to this
survey.

References
2. Haigh R, Tennant A, Biering‐Sorensen F et al. The use of outcome measures in physical
medicine and rehabilitation within Europe. J Rehabil Med 2001; 33:273‐278.
behaviors of physical therapists. Phys Ther 2003; 83:786‐805.
330:644‐648.
5. Hammond R. Evaluation of physiotherapy by measuring outcome. Physiotherapy 2000;
86:170‐172.
6. Partridge CJ. The outcome of physiotherapy and its measurement. Physiotherapy 1982;
68:362‐363.
7. Van Peppen RPS, Hendriks HJM, Van Meeteren NLU et al. The development of a clinical
practice stroke guideline for physiotherapists in The Netherlands: A systematic review of
available evidence. Disabil Rehabil 2007; 29:767‐783.
8. Abrams D, Davidson M, Harrick J et al. Monitoring the change: current trends in outcome
measure usage in physiotherapy. Man Ther 2006; 11:46‐53.
151
Chapter 6
9. Akinpelu AO, Eluchie NC. Familiarity with, knowledge, and utilization of standardized
outcome measures among physiotherapists in Nigeria. Physiother Theory Pract 2006;
22:61‐72.
10. Chesson R, Macleod M, Massie S. Outcome measures used in therapy departments in
Scotland. Physiotherapy 1996; 82:673‐679.
11. Duckworth M. Outcome measurement selection and typology. Physiotherapy 1999; 85:21‐
27.
12. Maher C, Williams M. Factors influencing the use of outcome measures in physiotherapy
management of lung transplant patients in Australia and New Zealand. Physiother Theory
Pract 2005; 21:201‐217.
13. Van Peppen RPS, Kwakkel G, Harmeling BC et al. Clinical practice guideline on
Health. 2001. Geneve. http://www.who.int/classification/icf/intros/ICF‐Eng‐Intro.pdf .
16. Jette AM. Assessing disability in studies on physical activity. Am J Prev Med 2003; 25(3
Suppl 2):122‐128.
17. Geyh S, Cieza A, Schouten J et al. ICF Core Sets for stroke. J Rehabil Med 2004;(44
Suppl):135‐141.
change in patientsʹ care. Lancet 2003; 362:1225‐1230.
19. Portney LG, Watkins MP. Foundations of clinical research, applications to practice. 2nd
edition ed. New Jersey: Prentice‐Hall, 2000.
20. Feinstein JL. Clinimetrics. New Haven ‐ London: Yale University Press, 1987.
21. Demeurisse G, Demol O, Robaye E. Motor evaluation in vascular hemiplegia. Eur Neurol
1980; 19:382‐389.
22. Franchignoni FP, Tesio L, Ricupero C et al. Trunk control test as an early predictor of
stroke rehabilitation outcome. Stroke 1997; 28:1382‐1385.
24. Holden MK, Gill KM, Magliozzi MR. Gait assessment for neurologically impaired patients.
Standards for outcome assessment. Phys Ther 1986; 66:1530‐1539.
25. Wade DT. Measurements in neurological rehabilitation. Oxford: Oxford University Press,

1992.
26. Heller A, Wade DT, Wood VA et al. Ward E. Arm function after stroke: measurement and
recovery over the first three months. J Neurol Neurosurg Psychiatry 1987; 50:714‐719.
152
27. Collin C, Wade DT, Davies S et al. The Barthel ADL Index: a reliability study. Int Disabil
Stud 1988; 10:61‐63.

30. Peters MAJ, Harmsen M, Laurant MGH et al. Room for improvement? Barriers to and
opportunities for improvement of patient care [dutch: Ruimte voor verandering?
Knelpunten en mogelijkheden voor verbeteringen in de patientenzorg]. Centre for Quality
of Care Research (WOK), editor. 2003. Nijmegen, The Netherlands, Radbout University
Medical Centre.
31. Field AP. Discovering Statistics using SPSS. second ed. London: SAGE Publications Ltd,
2005.
32. Learner J, Goodman NW. Descriptions of correlation. Lancet 1996; 348:199‐200.
33. Streiner DL, Norman GR. Health measurement scales, a practical guide to their
development and use. second ed. New York: Oxford University Press, 2003.
34. Lennon S. Physiotherapy practice in stroke rehabilitation: a survey. Disabil Rehabil 2003;
25:455‐461.
35. Pollock AS, Legg L, Langhorne P et al. Barriers to achieving evidence‐based stroke
rehabilitation. Clin Rehabil 2000; 14:611‐617.
36. Turner‐Stokes L, Turner‐Stokes T. The use of standardized outcome measures in
rehabilitation centres in the UK. Clin Rehabil 1997; 11:306‐313.
37. Kenens RJ, Hingstman L. Cijfers uit de registratie van fysiotherapeuten, peiling 1 januari
2005. 2006. Utrecht, NIVEL.
38. Vugts CJ, Van der Velden LFJ, Hingstman L et al. Behoefteraming Fysiotherapeuten 2002‐
2015. 2003. Utrecht, NIVEL/Prismant.
39. Nakayama H, Jorgensen HS, Raaschou HO et al. Recovery of upper extremity function in
stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil 1994; 75:394‐398.
40. Rothstein JM, Echternach JL, Riddle DL. The Hypothesis‐Oriented Algorithm for Clinicians
II (HOAC II): a guide for patient management. Phys Ther 2003; 83:455‐470.
153
Chapter 6
154
CHAPTER
Feasibility and effectiveness of an educational
program to promote the use of outcome measures by
physiotherapists involved in stroke rehabilitation:
An RCT on tutor expertise
Marieke J Schuurmans
Eric C Stutterheim
Eline Lindeman

Submitted
Chapter 7
Abstract

Objective: To determine the feasibility and effectiveness of a tutor‐guided
educational programme for physiotherapists, the Physiotherapists‘
Educational Programme on Clinimetrics in Stroke (PEPCiS), intended to
promote the use of outcome measures in the management of patients with
stroke.
Design: Randomized controlled feasibility trial.
Methods: Thirty voluntarily participating physiotherapists involved in
stroke management were randomized into two groups and participated in 5
tutor‐guided training sessions for physiotherapists (i.e., PEPCiS). Tutors
differed in their clinical experience with outcome measures in stroke.
Feasibility was estimated by physiotherapists’ adherence to PEPCiS,
satisfaction with PEPCiS and their appreciation of the tutoring style of the
allocated tutor; effectiveness was estimated by counting the frequencies with
which outcome measures were mentioned in the records of patients
entrusted to the participating therapists.
Results: The participants’ attendance record was generally good (a median
of 5 of the 5 sessions; range 4‐5) and they were satisfied with PEPCiS (mean:
7.5 on a 0‐10 scale). In the entire group (N=30) the use of outcome measures
increased from 3 per patient before PEPCiS to 5 thereafter (p=0.001).
Between‐group differences were non‐significant for the totals of the
instruments used (median 3 to 6 in the expert tutor group [ETG] vs. 3 to 4 in
the non‐expert tutor group [NETG]; p=0.07). Physiotherapists in the ETG
appreciated the PEPCiS content, their knowledge gain and all tutor style
aspects significantly more than those in the NETG (p<0.05).
Conclusion: The present pilot study suggests that education by PEPCiS
enhances the use of clinical outcome measures by physiotherapists in the
management of patients with stroke.
A future study with sufficient power will investigate the influence of PEPCiS
as well as interfering factors, e.g. tutor expertise and performance, in order
to establish and improve the effectiveness of educational interventions as a
part of implementation strategies for the regular use of outcome measures
by physiotherapists.

Key Words: physiotherapy, cerebrovascular disorders, outcome measures,
implementation, educational programme
156
Feasibility and effectiveness of PEPCiS
Introduction

Like their colleagues in other countries1‐6 physiotherapists in the
Netherlands7 fail to regularly use outcome measures. This was demonstrated
again recently for Dutch physiotherapists involved in stroke management
(Chapter 6), despite the recommendation for regular use of outcome
measures in the relevant professional physiotherapy guideline of the Royal
Dutch Society for Physical Therapy, the Clinical Practice Guideline for
Physiotherapy management of patients with Stroke (CPGPS).8,9 Common
barriers to the proper use of outcome measures include lack of experience
and uncertainty about the use of the instruments.1,5,10‐12 Despite these
barriers, physiotherapists have reported an overall positive attitude towards
the use of outcome measures.1,12 In line with the opinion of several experts in
the field, physiotherapists are aware of the importance of a considered use of
outcome measures to monitor the health status of patients as an essential
aspect of good clinical practice.13,14
In an attempt to facilitate the practical use of outcome measures and
hence to improve the transparency of the clinical decision making process
according to the recommendations in the CPGPS,15 a ‘Physiotherapists’
Educational Programme on Clinimetrics in Stroke’ (PEPCiS) has been
developed. This educational programme was designed to train Dutch
physiotherapists involved in stroke management to use outcome measures
and thereby to increase the use of these measures in their daily practice
routine.
Training is often a precondition for successful behavioural changes of
professionals like using outcome measures on a regular basis.16 In such
contexts, interactive and personal training in small groups has shown to be
more effective than more traditional lectures in large groups.17,18 We tried to
gain further insights into the necessary behavioural change in
physiotherapists and to identify the perceived motivational, organizational
and institutional barriers to and facilitators for this change, using the
theories by Ajzen19 and Grol20 respectively.
Consequently, this pilot study aimed to investigate the feasibility (in
terms of adherence and satisfaction) and effectiveness (in terms of frequency
with which outcome measures were mentioned) of the PEPCiS programme
as regards increasing physiotherapists’ use of outcome measures in stroke
care. Secondary to this aim, the influence of tutor style will be explored.
157
Chapter 7
Method

Design
In this pilot study, 30 voluntarily participating physiotherapists involved in
the management of patients with stroke were stratified based on the setting
in which they work (i.e., acute care hospital, rehabilitation centre, nursing
home or private physiotherapy practice). Within each stratum,
physiotherapists were randomly assigned to group taught by an expert tutor
(expert tutor group: ETG, N=15) or a group taught by a non‐expert tutor
(NETG, N=15). The ETG was taught by a tutor who had extensive experience
with outcome measures in stroke (RvP; > 10 years), whereas the NETG was
taught by a tutor with little experience in this respect (MW; < 1 year). Both
tutors had comparable experience with teaching the programme, which they
had gained in a prior pilot project,21 as well as with process‐oriented tutoring
(> 3 years) from their regular job as lecturers at the University of Applied
Sciences Utrecht. The participating physiotherapists were unaware of the
differences in expertise between the allocated tutors. Physiotherapists in the
ETG and NETG groups received the same educational programme aimed to
implementing and enhancing the use of outcome measures in clinical
practice. The programme is based on several learning strategies and
focusing on the evidence‐based practice, clinical reasoning and outcome
measures recommended in the CPGPS. The educational programme was
presented from March to June 2006.

Subjects
For logistical reasons, a maximum of 30 physiotherapists were recruited
from responders to a ‘call for participation’ in the newsletter of the Utrecht
regional section of the Royal Dutch Society for Physical Therapy. Six weeks
prior to the study, all responders received a hard‐copy of the clinical practice
guideline (CPGPS) and were instructed to read the whole document
thoroughly. In a preparatory meeting, 4 weeks before the start of the
educational programme, all responders were informed about the study. We
tried to blind the participants by deliberately leaving them unaware of the
precise aims of the study, namely the planned patient record analyses and
the contrast between the two tutors. To be included participants had to treat
at least 1 patient with stroke per week on a regular basis.

Intervention
Physiotherapists in both groups attended the same interactive evidence‐
based training course, the Physiotherapists’ Educational Programme on
158
Clinimetrics in Stroke (PEPCiS, see Appendix).15 The two groups of
physiotherapists were taught on different evenings (Tuesdays and
Thursdays respectively) in a fully‐equipped ‘clinimetrics‐classroom’ at the
Institute for Human Movement Studies, Department of Physiotherapy of the
University of Applied Sciences Utrecht, the Netherlands. The classroom
setting included physiotherapy equipment, all materials and forms to record
the outcome measures, and ‘on‐line’ computers for patient data recording.
Both groups were taught in five 2‐hour evening sessions over a 14‐week
period. The 5 training sessions started in week 11 of 2006 (March), and
continued in weeks 13, 15, 20 and 25 (June 2006).

Measurements
The intervention was assessed on variables of feasibility and effectiveness of
the educational programme. Variables of feasibility were (1) the participants’
compliance with study procedures, (2) the participants’ satisfaction with
PEPCiS and (3) the participants’ appreciation of the tutoring style of their
allocated tutor. The variables of effectiveness were the actual use and self‐
reported use of outcome measures by participants in their own practice
routine. The characteristics of the participants, including the psychological
predictors of behaviour, e.g. motivation according to the theory of planned
behaviour,19 and the barriers to and facilitators for the use of outcome
measures, were assessed at baseline (T0), while the feasibility variables were
assessed after the end of the 14‐week intervention (T1). Actual use and self‐
reported use were assessed at T0 and T1.

Compliance with study procedures was assessed as attendance at the
training sessions and drop‐outs rates from the study. Attendance was
recorded by the tutors at each session (ranging from 0 to 5 sessions) in
programme diaries. Participants had to attend at least 4 of the 5 PEPCiS
sessions to get credits for the quality register of the Royal Dutch Society for
Physical Therapy. Drop‐outs were defined as participants who quit the
study and were lost to follow‐up. Compliance with measurement
procedures was assessed measured by counting the number of participants
who (a) delivered their patients’ records (to assess actual use), and (b)
completed the on‐line self‐report questionnaires (to assess self‐reported use),
while recording those who were lost to analysis.

Participant satisfaction was determined after the end of the intervention
(T1) using a 4‐item questionnaire. Each item was given a mark between 0
and 10. Information was obtained on satisfaction with PEPCiS, in terms of
159
Chapter 7
(1) ‘organization’, (2) ‘content’, (3) ‘knowledge gain’, and 4) ‘level of
participation’.

Participants’ appreciation of tutoring style was evaluated after the end
of the PEPCiS programme, using the Tutor Behaviour Questionnaire
(TBQ).22,23 The TBQ consists of 39 items which explore tutoring style in terms
of ‘knowledge of subject matter’ (19 items) and ‘skill in process facilitation’
(19 items), using 5‐point Likert‐scale (range 1 to 5), and ‘overall
effectiveness’, defined as the participants’ perception of how well the tutor
performed in his/her role (1 item; 1‐10 scale).22 Knowledge of subject matter
was assessed using three scales assessing the corresponding sub‐categories
of behaviour: A1) use of expertise (UE), i.e. the degree to which the tutor used
his/her knowledge of the subject matter to help the participants; A2)
cognitive congruence (CC), i.e. the degree to which the tutor understood the
participants’ existing level of knowledge and A3) test orientation (TO), i.e. the
degree to which the tutor focused on summative assessment to direct the
physiotherapists’ learning. The ‘skill in process facilitation’ was assessed by
three subscales: B1) authority (AU), i.e. the degree to which the tutor used
authority to direct participants’ activities within the group; B2) role
congruence (RC), i.e. the degree to which the tutor was able to empathize
with, and relate to, participants’ lives; and B3) cooperation orientation (CO),
i.e. the degree to which the tutor was interested in encouraging cooperation
among members of the group.22

Psychological predictors of behaviour in terms of using the
recommended outcome measures were assessed at baseline (T0) using a
questionnaire based on the Theory of Planned Behaviour (TPB).19 This
questionnaire was developed using operationalisation instructions from the
manual for health service researchers.24 The TPB is a model which is widely
used to predict a wide range of behaviour25 and can also be applied to the
behaviour of health professionals.26 The TPB proposes that ‘intention to
engage in the behaviour’ (INT) and ‘perceived control over the behaviour’
(PBC) are the proximal predictors of (professional) behaviour. We
hypothesized that participants with high INT and high levels of PBC would
be more likely to change their professional behaviour and will use outcome
measures more regularly. INT is defined as the motivation to engage in a
particular behaviour (in this case: using outcome measures) and indicates
the extent to which people are willing to try or how much effort they would
invest to perform the behaviour.19 PBC is defined as ‘a person’s perception of
the ease or difficulty of performing a behaviour’.19 The INT and PBC items
160
were rated on 5‐point Likert scales. Mean scores were calculated for the
items of INT and PBC, with a mean score of 5 meaning very high intention
and perceived behaviour control, respectively.

Perceived barriers and facilitators. The validated Barriers and
Facilitators Questionnaire (BFQ),12 which includes 20 statements (1‐5 scale),
was used at baseline (T0) to identify perceived barriers to and facilitators for
the use of outcome measures in everyday practice in physiotherapy stroke
management. An initial analysis of perceived barriers to and facilitators for
using outcome measures by professionals involved is a crucial condition for
successful implementation20 of the outcome measures recommended in the
CPGPS in daily physiotherapy practice.

Actual use of outcome measures, defined as the number of times their use
was recorded in patient records by physiotherapists involved in stroke
management, was assessed by analyzing patient records (maximum 5 per
physiotherapist) for the frequency with which the participants used the core
outcome measures recommended in the CPGPS (0 to 7). Before the start of
the educational programme, participants had to bring an anonymous copy
of their 5 most recent (stroke) patient records. The actual use of outcome
measures was analysed again at T1 by assessing new patient records
(maximum 5).

Self‐reported use of outcome measures was assessed with a 7‐item
questionnaire relating to the 7 recommended outcome measures. The
questions invited the participants to report their own use of the 7
recommended outcome measures for the 5 most recently treated patients on
a 6‐point Likert scale, e.g., ‘I used the Berg Balance Scale in [1,2,3,4 or 5
patients: select one option] for the 5 patients with stroke I most recently
treated’.

Statistical analysis
Data were analysed by an independent researcher (ES) with SPSS 12.0
statistical software (SPSS Inc, Chicago, Illinois, USA), using a significance
level of p<0.05. Summary descriptive statistics, i.e. central tendencies were
computed for the actual and self‐reported use of recommended outcome
measures.27 Differences in numbers of patient records at T0 and T1 and
actual and self‐reported frequencies of use were converted to percentage
scores to compare physiotherapists’ actual use and self‐reported use of
161
Chapter 7
outcome measures. The BFQ statements (1‐5 points on each statement) were
converted to a sum score (max 100 points).
Baseline differences in group characteristics, adherence, satisfaction and
tutor behaviour were analysed by either independent samples T‐test or Chi‐
square test where appropriate.27,28 Non‐parametric statistical tests were used
to analyze the change scores for the use of outcome measures by the total
group (Wilcoxon). Between‐group comparisons for feasibility variables were
made using the independent T‐test, while comparisons of the effectiveness
variable (effect of training), i.e. the median of change scores for actual use
between T0 and T1, were done with the Mann‐Whitney U‐test.27,28

Results

Physiotherapists
Of the 41 physiotherapists who responded to the original invitation, 35 were
involved in stroke management and were considered eligible after screening
by telephone (Figure 1). However, 5 candidates were unable to fit the
training sessions into their schedule leaving 30 participants.

Figure 1. Flow of participants through the trial
41 responded to newsletter
6 excluded by criteria
35 screened by telephone
5 excluded
30 physiotherapists randomized
15 physiotherapists 15 physiotherapists
Expert Non-Expert
Tutor Group Tutor Group
(n=15) (n=15)
0 withdrew at T1 - 0 withdrew at T1 -
immediately after immediately after
intervention intervention

162

Table 1 – Baseline characteristics of participating physiotherapists
Characteristics ETG NETG Total

(N=15) (N=15) (N=30) Statistics Sig.*
Gender, 0.24C 0.62

female 12 13 25
Setting of practice: 1.45C 0.69

ACH 2 3 5
RC 0 1 1
NH 10 9 19
PPP 3 2 5
Age, -0.64T 0.53

39.0
mean (SD), y 36.5 (9.8) 37.7 (9.9)
(10.2)
range, y 25-53 22-53
22-53
Experience in stroke management, mean -0.60T 0.55

(SD), y 9.5 (8.1) 11.0 (5.6) 10.2 (6.9)
range, y 2-27 2-20 2-27
Number of patients with stroke treated/ wk, -0.54T 0.59

median (mode), n 4 (3) 4 (3) 4 (3)
range 2-12 3-15 2-15
Psychological predictors of behaviour: 0.34T 0.74

- Intention, mean (SD) 4.2 (0.4) 4.1 (0.6) 4.2 (0.5) -1.05T 0.30
- PBC, mean (SD) 3.7 (0.7) 3.9 (0.6) 3.8 (0.6)
Barriers and facilitators to use outcome

measures:
BFQ total score -0.68T 0.50
mean (SD) 60.7 (5.2) 62.0 (4.9) 61.4 (5.0)
ACH indicates acute care hospitals; BFQ, barriers and facilitators questionnaire; N, number of physiotherapists;
NH, nursing homes; RC, rehabilitation centres; PBC, perceived behavioural control; PPP, private physiotherapy
practices; SD, standard deviation; sig., significance (p value); wk, weekly; and y, years.
C
=Chi‐square test; T=T‐test; * sig. at p<0.05

Table 1 shows the baseline characteristics of these 30 participating
physiotherapists. The mean age of the participants was 38 years (SD: 10y).
They had a mean of 10 years experience in stroke rehabilitation (SD: 7y) and
treated about 4 patients with stroke per week. The majority of the
participants in both experimental arms were female (N=25) and worked in
nursing homes (N=19). No statistically significant baseline differences
between the groups were found (p>0.05) in terms of age, median number of
patients treated, experience, intention and perceived behavioural control or
perceived barriers and facilitators (Table 1).
163
Chapter 7
Outcomes

Feasibility (Table 2):
Adherence to study procedures. There were no drop‐outs, and the
participants in both groups attended at a median of 5 of the 5 PEPCiS
sessions. Twelve participants in each group were present at all 5 sessions.
The remaining participants in the ETG (N=3) as well as in the NETG (N=3)
attended 4 sessions. After the end of the PEPCiS programme, no significant
differences were found between the two arms in terms of the number of
anonymous copies of their most recent (stroke) patient records presented by
the participants and completion of the on‐line self‐report questionnaires.
Participants’ satisfaction. All participants in both groups (N=30) answered
the 4 questions about satisfaction with PEPCiS and rated the 4 items at 6.9 to
8.9 points. The mean score for satisfaction with PEPCiS as a whole was 7.5
points, ranging from 8.0 (ETG) to 6.9 (NETG). Physiotherapists in the ETG
rated 2 items significantly higher than those in the NETG, i.e., ‘content’ (8.9
vs 7.8; p=0.02) and ‘ knowledge gain’ (8.6 vs 6.5; p=0.03).
Participants’ appreciation of tutoring style. Compared to participants in the
NETG, those in the ETG reported a significantly higher degree of
‘knowledge of subject matter’ (73 vs 56 points; p<0.001) and ‘skill in process
facilitation’ (71 vs 60; p<0.001) for their tutor. Participants in the ETG also
rated the overall effectiveness of their tutor significantly higher (8.3 vs 6.2;
p<0.001).

Effectiveness (Table 3):
Use of outcome measures. For the entire group, the median actual use of the
7 recommended outcome measures, as recorded in the 5 patient records,
increased significantly from 3 to 5, while the self‐reported use increased
from 4 to 6 per patient (p<0.001) (Figure 2).
Except for the FAT and BI, the group as a whole showed a statistically
significant change in the actual use of the recommended outcome measures
(p<0.05) during the intervention, with increases for the other 5 measures
ranging from 37% (for FAC) to 17% (for TMW). Self‐report use of all
outcome measures showed a statistically significant increase between the
baseline and post‐intervention assessments (p<0.05), varying from 43% (for
FAC) to 21% (for FAT) (Figure 3).
Summarizing the use of all 7 recommended outcome measures (by
calculating the sum score of percentages of means divided by the 7 outcome
measures) shows that the actual use increased from 25% to 49%, and the self‐
164
reported use from 30% to 61%, respectively, between the baseline and post‐
intervention assessments (Table 3).

Table 2 – Feasibility of PEPCiS
ETG NETG
Post Post
Outcome variables T-statistics
intervention intervention
(T1)-between
(T1) (T1)
groups- (sign.)
(N=15) (N=15)
1. Compliance with study procedures
- Attendance / Drop-out
number of PTs (N): 15 / 0 15 / 0 0.26
number of sessions: median, range 0-5 5 (4-5) 5 (4-5) p = 0.80
- Delivered patient records: 13 14 0.59
PTs lost to analysis in (N) 2 1 p = 0.56
- Completed self-report questionnaires: 13 14 0.59
PTs lost to analysis in (N) 2 1 p = 0.56
2. Participants’ satisfaction (range 0-10)
about:
1.34
- Organization of PEPCiS: mean (SD) 7.7 (0.8) 6.9 (1.9) p=0.19
3.56
- Content of PEPCiS: mean (SD) 8.9 (1.0) 7.8 (1.9) p = 0.02#
3.26
- Knowledge gain by PEPCiS: mean (SD) 8.6 (1.0) 6.5 (2.2) p=0.03#
-0.36
- Own participation in PEPCiS: mean (SD) 6.9 (0.8) 7.1 (1.3) p = 0.72
Overall score of the 4 PEPCIS items: 8.0 6.9

3. Participants’ appreciation of tutoring
style (TBQ)
A. TBQ-subject-matter expertise (total of 3 4.63
scales): mean (SD) 72.7 (5.0) 56.1 (11.9) p< 0.001#
B. TBQ-process facilitation skill (total of 3 5.10
scales) (mean (SD) 71.1 (4.5) 59.7 (6.8) p< 0.001#
C. TBQ-Overall effectiveness (appreciation, 1- 4.87
10 scale): mean (SD) 8.3 (0.5) 6.2 (1.5) p< 0.001#
ETG indicates expert tutor group; NETG, non‐expert tutor group; N, number of physiotherapists;
PT, physiotherapist; SD, standard deviation; TBQ, tutor behaviour questionnaire; and T1, post intervention;
* Self‐reported use of outcome measures is based on a questionnaire about 5 most recently treated patients
(converted to 0‐100% scores)
** Actual use of outcome measures, based on records of 5 most recently treated patients (converted to 0‐100%
scores)
#
significance at p<0.05

165
Table 3 Effectiveness of PEPCiS
166
ETG NETG Total group
Chapter 7
Outcome variables Baseline Post Baseline Post Baseline Post Change in

(T0) intervention (T0) intervention (T0) intervention total group,
(T1) (T1) (T1) T0 to T1#
1. Actual use*: (N) 15 13 15 14 30 27 Wilcoxon (sig)
#
Median (mode) – number out of 7 3 (2) 6 (6) 3 (2) 4 (4) 3 (2) 5 (6) 3.4 (p=0.001 )
RCOMs: [range] [0-6] [0-7] [0-6] [0-6] [0-6] [0-7]
Mean use % (SD)
#
-Motricity Index 26 (34) 76 (31) 31 (36) 51 (41) 28 (34) 63 (38) 3.7 (p<0.001 )
#
-Trunk Control Test 33 (34) 74 (36) 44 (39) 59 (37) 39 (37) 66 (37) 3.0 (p=0.003 )
#
-Berg Balance Scale 37 (36) 72 (37) 39 (28) 65 (38) 38 (31) 68 (37) 3.0 (p=0.003 )
#
-Functional Ambulation Categories 37 (38) 89 (28) 43 (39) 66 (36) 40 (38) 77 (34) 3.4 (p=0.001 )
#
-Ten Metre Walk 8 (21) 40 (33) 11 (18) 16 (28) 10 (20) 27 (32) 2.4 (p=0.015 )
-Frenchay Arm Test 0 (-) 17 (34) 8 (26) 1 (29) 4 (19) 9 (25) 0.9 (p=0.35)
-Barthel Index 26 (39) 53 (40) 9 (21) 16 (20) 18 (32) 34 (36) 1.6 (p=0.11)
Summarizing the use of all 7 RCOMs 24 60 26 39 25 49

(%)
ETG NETG Total group

Outcome variables Baseline Post Baseline Post Baseline Post Change in
(T0) intervention (T0) intervention (T0) intervention total group,
(T1) (T1) (T1) T0 to T1#
2. Self-reported use**: (N) 15 13 15 14 30 27 Wilcoxon (sig)
#
Median (mode) – number out of 7 4 (5) 6 (7) 4 (4) 5 (5) 4 (4) 6 (5) 4.2 (p<0.001 )
RCOMs: [range] [0-6] [5-7] [0-6] [4-7] [0-6] [4-7]
Mean use % (SD)
#
-Motricity Index 31 (36) 80 (22) 28 (36) 61 (32) 29 (36) 70 (29) 4.0 (p<0.001 )
#
-Trunk Control Test 47 (42) 79 (30) 53 (38) 69 (25) 50 (39) 73 (27) 2.7 (p=0.007 )
#
-Berg Balance Scale 41 (36) 85 (23) 40 (33) 70 (27) 41 (34) 77 (26) 4.0 (p<0.001 )
#
-Functional Ambulation Categories 49 (44) 92 (15) 47 (43) 90 (22) 48 (43) 91 (19) 3.6 (p<0.001 )
#
-Ten Metre Walk 19 (23) 49 (31) 13 (22) 29 (27) 16 (23) 39 (30) 3.0 (p=0.003 )
#
-Frenchay Arm Test 0 (-) 39 (38) 3 (10) 7 (13) 1 (7) 22 (32) 3.0 (p=0.003 )
#
-Barthel Index 31 (46) 74 (37) 20 (41) 33 (45) 25 (43) 53 (46) 2.3 (p=0.019 )
Summarizing the use of all 7 RCOMs 31 71 29 51 30 61

(%)
ETG indicates expert tutor group; NETG, non-expert tutor group; N, number of physiotherapists; RCOMs, recommended core outcome measures;
SD, standard deviation; T0, baseline and T1, post intervention
#
Significance at p<0.05;
* Actual use of outcome measures, based on records of 5 most recently treated patients (converted to 0-100% scores)
** Self-reported use of outcome measures based on a questionnaire about 5 most recently treated patients (converted to 0-100% scores)
167
Chapter 7
Figure 2. Median actual and self‐reported use of recommended outcome measures

Median Use of
recommended outcome measures
7
6
5
Median 4
3
2
1
0
ETG (n=15) NETG (n=15)
Actual use T0 Self-reported use T0
Actual use T1 Selfreported use T1

ETG indicates expert tutor group; NETG, non‐expert tutor group; T0, baseline; and T1, post intervention

Figure 3. Actual and self‐reported use of outcome measures

Expert Tutor Group
(Actual and Self-reported Use)
100
Percentage of use
80
60
40

20

0
MI TCT BBS FAC TMW FAT BI
Outcome measures
Non-Expert Tutor Group
(Actual and Self-reported Use)

100
Percentage of use
80
60
40
20
0

MI TCT BBS FAC TMW FAT BI
Outcome measures
Actual Use T0 Self-reported T0
Actual Use T1 Self-reported Use T1
T0 indicates baseline and T1, post intervention
168
Discussion

The newly developed PEPCiS educational programme was well appreciated
by physiotherapists participating in this pilot study. The absence of drop‐
outs, the high attendance rate and the participants’ satisfaction with the
programme substantiate its feasibility (Table 2). Moreover, after the 30
participants had attended PEPCiS, their average actual use and self‐reported
use of the recommended CPGPS outcome measures almost doubled. A
secondary objective in this feasibility study was to detect differences
between participants trained by a tutor who had extensive experience with
outcome measures in stroke versus those trained by a tutor with less
experience. Both groups increased their use of outcome measures, going
from a median of 3 to 6 different outcome measures for those trained by the
expert‐tutor and from 3 to 4 for the non‐expert group, these between‐group
differences were statistically non‐significant (p=0.07). Physiotherapists in
both groups appreciated the PEPCiS content, their knowledge gain and all
tutor style aspects, but those in the ETG did so significantly more than those
in the NETG.
The use of clinical assessment instruments in different phases of a
disorder to assess or monitor the health status of patients for the purpose of
diagnosis, prognosis and therapy evaluation is considered an aspect of good
clinical practice in physiotherapy.13,14,29 Outcome measures assist
physiotherapists to in specifying relevant and attainable treatment goals,
getting feedback on the effect of interventions and optimizing
communication with patients and other professionals in an interdisciplinary
team.30 There is an increasing need to prove the effectiveness of therapeutic
interventions and to improve the transparency of the clinical decision‐
making process by health care professionals such as physiotherapists.
However, physiotherapists often wonder when they need to monitor
patients, and what functional impairments or limitations in terms of
activities or participation should be assessed.31 Our attempt to teach
physiotherapists to integrate the use of outcome measures in the clinical
reasoning process in the management of patients with stroke (by means of
the PEPCiS programme) led to a significant increase in the use of the
recommended clinical assessment instruments of the Dutch guidelines
(CPGPS), and hence to greater transparency of physiotherapy stroke care.
The relationship between patients’ preferences, therapeutic goals and chosen
outcome measures remains to be studied in future research.
Unlike their colleagues in e.g. Australia, where the Australian
Physiotherapy Association recommends that ‘a clinical justification for
169
Chapter 7
physiotherapy services would routinely include the use of outcome

measures’,32, Dutch physiotherapists are not yet obliged to use outcome
measures as an integral part of daily professional practice. We hypothesized
that the use of outcome measures would increase when physiotherapists
were educated about the integrated use of these outcome measures in their
daily clinical practice and decision‐making during the rehabilitation of
patients with stroke.12
The increased use of recommended outcome measures by the
participating physiotherapists in this brief study is in line with the findings
of comparable studies in which the behaviour of health care providers was
observed over periods of 6 months1 to 5 years6,33. However, physiotherapists
tended to overestimate their use of outcome measures. This overestimation
may have been caused by their tendency to give socially desirable answers,
because recommendations in clinical practice guidelines and ethical
professional requirements imply that they are expected to use outcome
measures. The post‐hoc analysis at the baseline of the present study showed
that the self‐reported use of outcome measures among participants was non‐
significantly higher (median=4) than actual use (median=3). After the
intervention, the participants reported a median use of 6 recommended
outcome measures, whereas our analysis found an actual use of 5 measures.
The physiotherapists participating in this study were self‐selected and
the majority worked in nursing homes. They probably volunteered because
they had a more than average interest in caring for patients with stroke and
hence a greater intention to use the CPGPS and its recommended outcome
measures (Table 1), so they can be regarded as a preferred group of interest.
Moreover, they might represent a specific subgroup of ‘innovators’ or ‘early
adopters’.34 Overall the physiotherapists in this study claimed a more
frequent use of outcome measures before PEPCiS than those who responded
to a recent survey in the Netherlands (N=167).12 In line with this survey, a
notable finding of the present study is the extremely infrequent use of the
FAT. Since the FAT was only introduced among Dutch physiotherapists in
2002, it is still a relatively unknown outcome measure for classifying arm
and hand use of patients with stroke.12
The present study had certain methodological limitations, in that tutors
were not blinded and the physiotherapists, who were unaware of the precise
objectives of the study, were semi‐blinded.
Although several authors35,36 have advised against using statistical
analysis in feasibility studies, our analysis demonstrated a potential effect of
the level of tutor expertise in the educational programme investigated in the
present study (p=0.07).
170
A power analysis on the basis of the results presented here demonstrates
that an adequate sample size in an RCT to test the hypothesis ‘PEPCiS
results in an enhanced use of 2 or more outcome measures by
physiotherapists’ would be 140 physiotherapists in each of the experimental
arms. A post hoc univariate logistic regression analysis (significance set at
p<0.2) on the entire set of data from the present study revealed the following
factors that were associated with a change score of 2 or more outcome
measures before and after PEPCiS: (1) initial use of outcome measures, that
is, before the start of PEPCiS (≤ 2 outcome measures; p<0.01), (2) experience
with patients with stroke (≤ 9 years; p<0.01), (3) age of physiotherapist (≤ 34
years; p=0.02), (4) number of patients with stroke treated per week (p=0.10),
(5) physiotherapists’ intention to use outcome measures at baseline (TPB;
p=0.11), (6) gender (female; p=0.14) and (7) appreciation of the tutor (≥ 7 on
1‐10 scale; p=0.16). Since the tutors’ performance was one of the predicting
factors this might be investigated in future multilevel analysis in a larger
trial.
The present feasibility trial was designed with two tutors. Because of the
cross‐level interaction between the participants and their allocated tutor, a
multilevel analysis randomized at tutor level would be necessary to detect
effects at the level of the participants. Using these techniques, in more robust
future trials (N=280) would allow corrections for the effects of other factors,
such as ‘intention’ on the numbers of outcome measures recorded in
electronic patient records. In addition, we need to examine the impact of
improved use of outcome measures by therapists on the outcome and
quality of care at the level of the patients, nested within therapists. A more
powerful trial comparing more expert and non‐expert tutors could preclude
bias by aspects of tutors not related to their content expertise. This is in line
with what has been found in tutor studies in university education.23,37,38
To our knowledge, this is the first study to examine the effects of
differences in content expertise between tutors in physiotherapy education.
In the present study, the tutors differed in content expertise as regards
clinical experience with using clinical assessments in stroke. Although the
study participants evaluated several important aspects of tutoring style
(knowledge of subject matter, skill in process facilitation and overall
effectiveness of the tutor), other aspects, such as personality and seniority,
were disregarded. In a future study with sufficient power, we intend to
investigate the influence of PEPCiS as well as interfering factors, such as
expertise and performance of tutors, in order to establish and improve the
effectiveness of educational interventions as a part of implementation
strategies for the regular use of outcome measures by physiotherapists.
171
Chapter 7
Acknowledgement
We would like to thank the physiotherapists who participated in this study,
as well as Meta Wildenbeest (MW) for her tutorship and Dr Gert Kwakkel
for his constructive comments.
Appendix

Physiotherapists’ Educational Programme on Clinimetrics in Stroke
(PEPCiS)
The PEPCiS course book is based on the recommendations for the use of
clinical assessments in the Dutch Clinical Practice Guideline on
Physiotherapy management of patients with Stroke (CPGPS)9 and consists of
89 pages of text, including detailed explanations on the 25 unique outcome
measures, including the 7 outcome measures recommended in the CPGPS.
PEPCiS supports physiotherapists to enhance the use of the recommended
outcome measures by integrating the triad of clinical reasoning in
physiotherapeutic stroke management,39 objectifying patients’ functional
recovery with the help of outcome measures,31 and recording these
outcomes.40 The physiotherapists participating in PEPCiS use the data of
their own patients. The content of the programme, summarized in Box 1, is
based on (1) evidence‐based practice (EBP) principles, as described by
Haynes et a,41; (2) learning strategies, such as interactive teaching,
measurement skills training, peer learning, discussions and reflective
thinking, and (3) professional education tools such as: (a) the Rehabilitation
Problem Solving Form (RPS),42 based on the International Classification of
Functioning, Disability and Health (ICF)43 and (b) the Hypothesis‐Oriented
Algorithm for Clinicians II (HOAC II)39 for neurological physiotherapy
practice.44 The core set of 7 recommended outcome measures of the CPGPS
included in the present study consisted of the Motricity Index (MI), Trunk
Control Test (TCT), Berg Balance Scale (BBS), Functional Ambulation
Categories (FAC), Ten Metre Walk (TMW), Frenchay Arm Test (FAT) and
Barthel Index (BI).9 This core set should be applied to all patients with stroke
in all phases after stroke, in each setting where physiotherapists work.9 The
time required to administer all 7 recommended outcome measures is about
45 to 60 minutes.9 The programme is offered in a fully‐equipped
‘clinimetrics‐classroom’, with software available for the recording of patient
data.
172
Box 1 – Content of PEPCiS
Session 1 - Introduction to EBP, ICF and RPS as educational tools

- Peer learning and reflective thinking about outcome measures used by
participating physiotherapists
- Discussions about the use of outcome measures in clinical reasoning and clinical
decision making
- General introduction to physiotherapeutic stroke management
- Participants’ own patient records guiding participants in PEPCiS
Session 2 Theme: Walking and mobility-related activities

- Introduction of software for recording patients’ data
- Introduction of 3 recommended outcome measures: interactive teaching on FAC,
TMW and BBS
- Training measurement skills and peer learning
- Discussions about prediction models (walking)
Session 3 Theme: Hand and arm use

- Introduction of HOAC II
- Introduction of 2 recommended outcome measures: interactive teaching on MI and
FAT
- Discussions about prediction models (hand and arm use)
Session 4 Theme: Integration of outcome measures, therapeutic (SMART) goals and

evaluations
- Introduction of 2 recommended outcome measures: interactive teaching the TCT
and BI
- Peer learning with RPS and patients’ data (platform presentations by participating
physiotherapists)
Session 5 Theme: How to communicate outcome measure data

- Peer learning, using HOAC II and RPS in physiotherapeutic stroke management
during everyday practice
SMART = specific, measurable, attainable, realistic and timely
173
Chapter 7
References

measure usage in physiotherapy. Man Ther 2006; 11(1):46‐53.
2. Akinpelu AO, Eluchie NC. Familiarity with, knowledge, and utilization of standardized
outcome measures among physiotherapists in Nigeria. Physiother Theory Pract 2006;
22(2):61‐72.
3. Chesson R, Macleod M, Massie S. Outcome measures used in therapy departments in
Scotland. Physiotherapy 1996; 82(12):673‐679.
4. Lennon S. Physiotherapy practice in stroke rehabilitation: a survey. Disabil Rehabil 2003;
25(9):455‐461.
5. Maher C, Williams M. Factors influencing the use of outcome measures in physiotherapy
management of lung transplant patients in Australia and New Zealand. Physiother Theory
Pract 2005; 21(4):201‐217.
6. Mayo N, Cole B., Dowler J., Gowland C, Finch E. Use of outcome measures in
physiotherapy: survey of current practice. Canadian Journal of Rehabilitation 1994; 7:81‐82.
7. Oostendorp RAB, Pluimers DJ, Nijhuis‐van der Sanden MWG et al. Physiotherapy patient
documentation: the Achilles heel of evidence‐based practice? [In Dutch:
Fysiotherapeutische verslaglegging: de Achilleshiel voor Evidence‐based Practice (EBP)?].
Ned Tijdschr v Fysioth 2006; 116(3):56‐61.
8. Van Peppen RPS, Kwakkel G, Harmeling BC et al. Clinical Practice Guideline on
available evidence. Disabil Rehabil 2007; 29(10):767‐783.
10. Turner‐Stokes L, Turner‐Stokes T. The use of standardized outcome measures in
rehabilitation centres in the UK. Clin Rehabil 1997; 11(4):306‐313.
rehabilitation. Clin Rehabil 2000; 14(6):611‐617.
12. Van Peppen RPS, Maissan JF, Van Genderen FR et al. Outcome measures in physiotherapy
management of patients with stroke: a survey into self‐reported use, and barriers to and
facilitators for use. Disabil Rehabil. (Submitted)
behaviors of physical therapists. Phys Ther 2003; 83(9):786‐805.
15. Van Peppen RPS, Stutterheim EC, Wildenbeest M., Wittink H. Physiotherapists
Educational Programme on Clinimetrics in Stroke (PEPCiS) [in Dutch: KNGF IOF
Jaarprogramma: Klinimetrie CVA]. 2006. Amersfoort, KNGF.
174
17. Davis D, OʹBrien MA, Freemantle N et al. Impact of formal continuing medical education:
do conferences, workshops, rounds, and other traditional continuing education activities
change physician behavior or health care outcomes? JAMA 1999; 282(9):867‐874.
18. Powell CV. How to implement change in clinical practice. Paediatr Respir Rev 2003;
4(4):340‐346.
19. Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision
Processes 1991; 50:179‐211.
change in patientsʹ care. Lancet 2003; 362(9391):1225‐1230.
21. Wittink H, Van Peppen RPS, Stutterheim EC et al. Physiotherapists Educational
Programme on Clinimetrics (PEPC) [in Dutch: KNGF IOF Jaarprogramma: Klinimetrie].
2005. Amersfoort, KNGF.
22. Groves M, Rego P, OʹRourke P. Tutoring in problem‐based learning medical curricula: the
influence of tutor background and style on effectiveness. BMC Med Educ 2005; 5(1):20.
23. Schmidt HG, van der Arend A., Moust JH, Kokx I, Boon L. Influence of tutorsʹ subject‐
matter expertise on student effort and achievement in problem‐based learning. Acad Med
1993; 68(10):784‐791.
24. Francis JJ, Eccles MP, Johnston M et al. Constructing questionnaires based on the theory of
planned behaviour, a manual for health services researchers. 2004. Newcastle upon Tyne,
Centre for Health Services Research, University of Newcastle.
25. Armitage CJ, Conner M. Efficacy of the Theory of Planned Behaviour: a meta‐analytic
review. Br J Soc Psychol 2001; 40(Pt 4):471‐499.
26. Eccles M, Grimshaw J, Walker A et al. Changing the behavior of healthcare professionals:
the use of theory in promoting the uptake of research findings. J Clin Epidemiol 2005;
58(2):107‐112.
27. Portney LG, Watkins MP. Foundations of clinical research, applications to practice. 2nd
edition ed. New Jersey: Prentice‐Hall, 2000.
28. Field AP. Discovering Statistics using SPSS. second ed. London: SAGE Publications Ltd,
2005.
29. Haigh R, Tennant A, Biering‐Sorensen F et al. The use of outcome measures in physical
medicine and rehabilitation within Europe. J Rehabil Med 2001; 33(6):273‐278.
30. Hammond R. Evaluation of physiotherapy by measuring outcome. Physiotherapy 2000;
86(4):170‐172.
330(7492):644‐648.
175
Chapter 7
33. Kay TM, Myers AM, Huijbregts MP. How far have we come since 1992? A comparative
survey of physiotherapistsʹ use of outcome measures. Physiother Can 2001;(Fall):268‐275.
34. Rogers EM. Diffusion of innovations. New York: The Free Press, 1983.
35. Beurskens AJ, de Vet HC, Kant I. [Roaming through the methodology. VIII. Pilot studies:
sense and nonsense]. Ned Tijdschr Geneeskd 1998; 142(39):2142‐2145.
36. Lancaster GA, Dodd S, Williamson PR. Design and analysis of pilot studies:
recommendations for good practice. J Eval Clin Pract 2004; 10(2):307‐312.
small‐group process and on student performance. Acad Med 1992; 67(7):470‐474.
38. Dolmans DH, Gijselaers WH, Moust JH et al. Trends in research on the tutor in problem‐
based learning: conclusions and implications for educational practice and research. Med
Teach 2002; 24(2):173‐180.
39. Rothstein JM, Echternach JL, Riddle DL. The Hypothesis‐Oriented Algorithm for Clinicians
II (HOAC II): a guide for patient management. Phys Ther 2003; 83(5):455‐470.
40. Vreeman DJ, Taggard SL, Rhine MD et al. Evidence for electronic health record systems in
physical therapy. Phys Ther 2006; 86(3):434‐446.
42. Steiner WA, Ryser L, Huber E et al. Use of the ICF model as a clinical problem‐solving tool
in physical therapy and rehabilitation medicine. Phys Ther 2002; 82(11):1098‐1107.
Health. 2001. Geneve.http://www.who.int/classification/icf/intros/ICF‐Eng‐Intro.pdf
44. Schenkman M, Deutsch JE, Gill‐Body KM. An integrated framework for decision making in
neurologic physical therapist practice. Phys Ther 2006; 86(12):1681‐1702.
176
CHAPTER
General discussion

Chapter 8
Introduction

In this chapter the main conclusions of this thesis in combination with the
applied methods will be discussed. Furthermore, essentials for further
research in the field of physiotherapy practice and education will be
considered in the light of the findings and experiences in developing and
implementing evidence‐based guidelines for patients with stroke. Finally, I
elaborate on implications for future management by rehabilitation specialists
of patients with stroke, including the professional role of disciplines
involved such as physiotherapy.
In the present thesis the steps of the Lomas model1 were followed (Figure 1).
This implementation model is defined by Kitson et al2 as an acceptable
representation of issues, contexts and processes suggesting that
implementation occurs when evidence meets everyday practice. The aim of
the work described in this thesis was: 1) to collect and review systematically,
and appraise critically the evidence, based on research in physiotherapy and
physiotherapy‐related studies in patients with stroke (research findings and
credible dissemination, see Figure 1), and 2) to integrate the recommendations
that emerged from the aforementioned review activities concerning the use
of outcome measures into the daily practice of the physiotherapists involved
in the management of patients with stroke (educational environment and
implementation into daily practice of practitioner and patient, Figure 1).

Figure 1. Steps in present thesis based on implementation model by Lomas.2
Implementation model described by Steps of Lomas in the present thesis

Lomas
Systematic reviews
Research findings
(chapters 2, 3 and 4)
Clinical practice guideline

Credible dissemination (chapter 5)
and survey (chapters 6)
Educational programme
Educational environment PEPCiS
(chapter 7)
Practioner
Implementation PEPCiS
&
(chapter 7)
Patient
178
General Discussion
Main conclusions

Collecting, reviewing and appraising the evidence
With regard to the first aim, I concluded that the application of
physiotherapy improves performance to execute regular daily activities by
patients with stroke. In particular, strong evidence was found that patients
benefit from therapeutic exercise programmes, when the exercise training
was applied intensively and started as soon as possible after stroke occurred
(Chapter 3). In about 90% of the 151 reviewed studies, therapy effects were
mainly restricted to tasks directly trained in the exercise programme
(Chapters 2, 3 and 4; idem), thereby underscoring the principle of specificity
of training.3 As our systematic reviews 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, over ground or on a treadmill, with and
without body weight support (Chapter 2). Functional use of the paretic arm
and hand can best be improved by for instance constraint‐induced
movement therapy (CIMT), and activities of daily living (ADL), for instance
sit‐to‐stand transfers by frequent training of taking a seat and standing up
(Chapter 2). Based on the review results the small to large effect‐sizes and
the results of the best‐evidence syntheses, physiotherapists involved in
stroke management were recommended to train their patients intensively
and in a task‐ and context specific manner.
The results of our review‐activities (Chapters 2, 3 and 4) formed the
fundament of the Clinical Practice Guideline on Physiotherapy management
of patients with Stroke (CPGPS), a guideline initiated, developed and
approved by the Royal Dutch Society for Physical Therapy (Koninklijk
Nederlands Genootschap voor Fysiotherapie: KNGF). The CPGPS is the first
physiotherapy specific stroke guideline worldwide (Chapter 5), and was
recently translated in English4 and German5 Besides these, the Royal College
of Physicians came with a compilation of the physiotherapy elements of the
UK multidisciplinary stroke guideline.6
The CPGPS aims to give decision support for physiotherapists involved
in stroke management, and thus has to be a helpful assistant in applying
evidence‐based practice by physiotherapists.7,8 The CPGPS states 72
recommendations which concern three important aspects of physiotherapy:
1) prediction of functional recovery of activities of daily living (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
179
Chapter 8
impairments and activity limitations. Each recommendation is based on

systematic literature search, analysis of methodological quality of the
included studies, and quantitative analysis of the effectiveness (Chapter 2).
Furthermore each recommendation is provided with a level of evidence and
connected to a recommended set of outcome measurements to monitor the
patients with stroke. As such, these recommendations combine quantity and
quality of evidence with practically, in my opinion useful tools for
physiotherapists in the management of patients with stroke.

Implementing the evidence
The second aim of this thesis addressed the integration of the recommended
outcome measures into the daily practice of the physiotherapists involved in
the management of patients with stroke. Two months after disseminating the
CPGPS by the KNGF (see Figure 1) we carried out a survey on Dutch
physiotherapists involved in stroke management (N=400; effective response:
43%). On the base of this survey we concluded that in general responders
demonstrate a positive attitude for the use of outcome measures but still
claim to use only three out of the seven recommended instruments. The
survey also indicated several barriers to and facilitators for the use of these
instruments, such as problems with changing routines’, ‘too much time
investment’, and ‘lack of financial compensation’ (Chapter 6). In order to
enhance the use of the recommended outcome measurements an educational
programme was developed (see Figure 1), the Physiotherapists’ Educational
Programme on Clinimetrics in Stroke (PEPCiS) (Chapter 7) and tested for its
feasibility in thirty volunteering physiotherapists. During the PEPCiS, which
was well appreciated by the highly compliant therapists, the use of clinical
measurements increased from a median of three per patient to five. A
secondary objective in this feasibility study was to detect differences
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 (tutor allocation was random). Both groups
reported the use of outcome measures more often in their patient records,
from a median of 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). Physiotherapists in the expert tutor
group (ETG) appreciated the PEPCiS‐content, gain in knowledge, and the
education style of tutor, more than those in the non‐expert tutor group
(NETG). These findings are in line with other non‐physiotherapy education
studies.9‐11 On the base of this feasibility study we thus hypothesised that
tutor content expertise shows the promise of being more effective in the
180
General Discussion
education of physiotherapy groups than non‐content tutors, a proposition

worth further experimentation in a fully powered trial, preferably an RCT.

Strengths and considerations

Elaborating on the first aim of this thesis and the systematically collected,
reviewed and appraised evidence, I want to address the following issues:
a) understanding of recovery after stroke (Chapters 2, 3, and 4; idem), an
important question in our search to the most effective treatment
approaches.
b) process of development of the CPGPS (Chapter 5),
c) methodology of the research, that aims to select prognostics (Chapter 5),
interventions (Chapters 2 tot 5) and outcome measures (Chapters 5 and
6).

Dwelling on the second aim of the thesis, to integrate the clinical guideline
where it concerns its recommendations, I would like to discuss:
a) process of implementation of evidence into the daily practice of
physiotherapists (Chapters 5, 6 and 7; idem), and
b) optimising physiotherapy‐services in rehabilitation management of
patients with stroke (Chapters 5 and 7; idem).

1a. Understanding recovery after stroke
The clinically relevant outcomes (Chapters 2, 3, and 4; idem) are beneficial
for the profession of physiotherapists and address the demand for more
understanding of the underlying mechanisms of recovery after stroke. We
also need to gain more insight into how exactly a patient with stroke learns
when showing improvement in motor performance. An example of this
based on recent studies, relates to a change in the assumption of ‘normal
motor behaviour’ as a common reference to describe the ‘abnormal’
asymmetric motor behaviour of people with stroke.12‐14 Asymmetrical weight
transfer in patients with stroke does not necessarily imply that these patients
are more unstable and less able to control their balance in order to prevent
falling.15,16
In Chapter 4 we systematically studied the effects of ‘visual feedback
therapy’ (VFT) on postural control in bilateral standing in patients with
stroke. We can conclude, in agreement with Barclay‐Goddard,17 that training
symmetry in weight distribution while standing on balance equipment tools
181
Chapter 8
fails to generalise to more effective control when walking. For example,
improvement in control of standing balance occurs without significant
changes in EMG activation on the paretic side18 or weight bearing on the
paretic leg.15 Also for regaining gait control Kautz et al.19 as well as Buurke12
found that therapy‐induced improvements in gait speed and walking ability
occur without significant changes in EMG timing of the paretic leg while
walking. In addition, longitudinal research shows that improvement of
walking ability is only weakly associated with observed changes in strength
and synergism of the paretic leg20 and that recovery of hand orientation for
grasping with the paretic upper limb strongly depends on adaptive trunk
movements in the event of distal deficits.21 On the basis of this clinically
relevant evidence it now seems invalid for physiotherapists to continue to
strive for ‘normal motor behaviour’ during the treatment of patients with
stroke.
Manufacturers, who produce rehabilitation tools, such as balance
masters, seem to promote these tools for improving stance symmetry
without obeying the longitudinal changes needed to restore control in
standing balance after stroke.13
In other words, normal movement characterised by symmetry in weight
bearing13 and arm and leg swing while walking22, may not serve as an
appropriate reference for the treatment of hemiplegic patients with stroke if
incomplete recovery is expected. In contrast, it suggests that patients can
continue to adapt to their existing deficits while showing functional
improvement in gait or upper limb performance. Unfortunately, previous
neurological approaches such as Bobath, Johnstone and Affolter have
characterised these behavioural movement strategies as pathologic, and
recent research now suggests that these adaptations may in fact be optimal
for the state of independent movement control.23

1b. Developing clinical practice guidelines
There is strong evidence that stroke rehabilitation is effective when
delivered by an expert team that is well coordinated.24 Teamwork and goal
setting are considered to be the core skills associated with multidisciplinary
rehabilitation.25 Stroke patients who receive organised inpatient
multidisciplinary rehabilitation in a stroke unit are more likely to survive
and participate independent and to live in their own home setting one year
after stroke.24 For every 100 patients receiving organised inpatient
multidisciplinary rehabilitation in a stroke unit, an extra five return home in
an independent state.26 Based on these findings several multidisciplinary
stroke guidelines were developed.27‐34 However, it is uncertain which
182
General Discussion
particular parts of multidisciplinary rehabilitation are specifically effective

and which are not. The need for more applicable and more specific, detailed
information35 was a part of the first aim of this thesis, resulting in the
development of the CPGPS. This guideline (Chapter 5) was derived from
systematically research (Chapters 2, 3 and 4; idem) and mainly constructed
according to internationally accepted standards.36‐38 The CPGPS complied 19
out of 23 AGREE‐criteria. The four missing criteria are concerned about
considering of health benefits, side effects and risks or potential cost
implications of applying the recommendations. However, the CPGPS offers
physiotherapists detailed information to foster and enrich their clinical
decisions where it concerns functional prognosis, design of an intervention
programme, and selecting of the measures to monitor and evaluate
functional outcome pending time. Furthermore, the development process of
the CPGPS was considered as a blueprint for other professional groups in
stroke rehabilitation, which planned to develop their own specific and
detailed monodisciplinary guideline, e.g. occupational therapy39 and nursing
care40.

1c. Methodological considerations
Best‐evidence interventions are just one aspect of EBP. At the least
knowledge about (and adequate use of) prognostic factors and methods of
evaluating patients recovery are as important. Physiotherapists are in need
of more sophisticated prognostic tools in order to formulate more specific
and realistic intervention goals. Considerations about these aspects, i.e.,
prognostics, interventions and outcome measures used in our systematic
reviews and CPGPS are described below.

With reference to prognostics
The generalisability of the results of studies of prognostic factors is often
limited due to methodological flaws and the often arbitrary timing of
predicting outcome after stroke.41 The linear regression model used in
Chapter 5 is instructive and illustrative for physiotherapists to use the initial
Barthel Index score to predict ADL‐outcomes at six months after stroke.42
However, recently, new logistic regression models were developed in which
the longitudinal relationship of observed changes in body functions, such as
strength and synergism, is related to improvements in activities such as
gait.20 The advantage of such longitudinal regression models is that time is
used as a covariate that independently determines the accuracy of
outcome.20 In addition, most regression models have not been cross‐
validated in an independent group of stroke patients, which makes the
183
Chapter 8
validity of the derived model questionable. There is a need for long‐term
studies to validate these models with patients from the acute till chronic
phase in order to identify those patients who are susceptible for functional
decline, for instance in gait performance43 or dexterity of the paretic arm44. In
line with McGinn et al we could conclude that there is a need to develop and
validate clinical decision rules and more valid and trustworthy outcome
measures to increase the accuracy of physiotherapists’ diagnostic and
prognostic assessments.45

With reference to interventions
The interventions described in this thesis were classified as
‘physiotherapy‐related’ interventions. Some of these interventions are also
applicable for related disciplines, such as occupational therapy. However,
the primary aim of this thesis was dedicated to the professional domain of
physiotherapy. This latter does not preclude that other professions in stroke
care management can underpin their own professional activities with found
evidence from the present thesis.
The CPGPS provides detailed descriptions of numeric variables of
therapy in order to facilitate replication of interventions in daily practice
(Chapter 5). Uncertainty however remains about the identification of which
interventions might be most beneficial for patients with stroke.46 It would be
helpful to accompany guideline recommendations with advices concerning
‘what’, ‘who’, ‘when’, ‘where’ and ‘how’ to treat and monitor patients.
Considering the methodological choices made in the present thesis, three
aspects have to be discussed, namely 1) methodological quality, 2) statistical
power and 3) best‐evidence synthesis. First, after a comprehensive search
strategy, identifying 322 relevant articles, the methodological quality of the
individual studies was assessed with the reliable PEDro scale.47 In line with
other scales, such as the Cochrane collaboration scale,48 Delphi scale,49 Jadad
scale,50 nonpharmacological trials scale (Clear NPT),51 the PEDro scale52 as
well provides a comprehensive measure of methodological quality of stroke
studies.53 Most of the included studies exhibited one or more methodological
flaws such as lack of randomisation, or omitted intention‐to‐treat analyses
and the use of un‐blinded assessors. In agreement with Foley et al. studies
with a PEDro score below four points were felt to be ‘low‐quality’ studies,
and studies scoring four or more points as ‘high‐quality’ studies.54 Each cut‐
off point for the methodological quality of studies measured with one of
many quality lists can be denoted as an arbitrary choice.55‐57 We need to
reach consensus about the most appropriate, probably higher cut‐off point to
indicate studies as ‘high‐quality studies’. Besides methodological quality,
184
General Discussion
individual studies have to be rated on aspects of relevance. However, high‐
methodological studies, measured with any of the accepted scoring scales,
might provide little information about the clinical relevance for the
profession.58 So in future, researchers need to describe patients, interventions
and treatment settings in more detail and to report on experiments using
clinically relevant outcomes and comparisons between treatment benefits
and potential harms.58 In the present thesis a significant association was
detected between year of publication and PEDro‐score (r = 0.42; p < 0.01).
The quality improvement probably suggests an increased awareness by
researchers to aim for studies with higher quality and involvement of
epidemiology, leading to maturation of research‐qualities in the profession
of physiotherapy. Based on the scores in our reviews (explained variance
~17%), we would like to urge researchers to comply to the rules more
intentionally, for instance by using the PEDro scale52 for the methodological
quality and the CONSORT statement59 for the report. This statement consists
of a list of 21 recommended items which should be included in a trial report.
Besides methodological quality of individual studies, a second aspect to
be considered, concerns statistical power (Chapters 2, 3 and 4; idem). Due to
the relatively small numbers of patients (mean 49, range from 6 to 466
patients) involved in the 123 included RCTs (Chapter 2) and the low amount
of measurement‐points in time (2 on average, which might be proper in the
light of research questions; the CPGPS recommended for clinicians at least
five times at fixed time points), there was a low statistical power to reveal
true or false statistically significant effects. Caused by the diversity of
selected outcomes and intervention strategies of included RCTs, pooling of
the data in those studies was in most cases impossible. In this thesis
individual effect sizes, if possible, were pooled, resulting in weighted
summary effect sizes (SESs).60,61 Recently, a study reported a diversity of
used statistical methods in meta‐analyses to calculate standardised mean
differences (SMDs).62 Even when researchers use the meanwhile widely
accepted Cochrane method to calculate SMDs still errors were found, for
instance using wrong standard deviations or wrong time points.62,63
Consensus about a scheme for unambiguous data extraction is necessary.
The third aspect considers the qualitative best‐evidence synthesis (BES).
If pooling was not possible due to a lack of comparability of intervention
types, outcomes, patient characteristics and lack of point estimates and/or
measures of variability, a BES was used to analyse the results. In this thesis
the criteria used by Steultjens et al.56 were modified by integrating the PEDro
scores. Further improvement of defining the levels of evidence of BES and
their subsequent validation is desirable because there are variable
185
Chapter 8
interpretations and claims of strength of evidence. BES will conclude
inconsistent levels of evidence, using different BES.55‐57,64 For example,
analysis of five comparable, low‐quality studies with insignificant results
(i.e., two RCTs, two controlled clinical trials and one pre‐experimental
study), BES lead to conclusions such as ‘insufficient evidence’56, ‘limited
evidence’57, ‘no evidence’64 or ‘moderate evidence’.55 To minimise bias in BES
conclusions a rating system based on consensus is necessary to assess the
strength of evidence, and of course such a system has to be validated before
further use.

With reference to outcome measures
The CPGPS recommends a core set of seven outcome measures that was
compiled in consensus meetings with eight experienced physiotherapists in
stroke research and daily practice as well. The core set was tested on its
applicability by a randomly selected group of physiotherapists (N=169)
(Chapter 6). For the final inclusion in the core set, the outcome measures
needed a) to be classified into the International Classification of Functioning,
Disability and Health (ICF)65; b) to show adequate psychometric properties66,
i.e. reliability (inter‐ and intrarater), validity and responsiveness in studies
with adult stroke patients; and good clinical utility (easy and quick to
administer); c) to minimally overlap each other; and d) to be consistent with
current physiotherapy practice. Choices that were made are in essence
arbitrary. In international stroke research we have to strive for a compilation
of a feasible multidisciplinary core set of outcome measures. Recently in 491
RCTs, examining stroke rehabilitation therapies, 489 assessment tools were
identified, resulting in an attempt to compile a core set of 30 cited tools.67
Five out of the seven recommended instruments in the CPGPS, i.e. Motricity
Index, Berg Balance Scale, Ten Metre Walk, Functional Ambulation
Categories, and Barthel Index, are reported in the list of Salter et al.67

The CPGPS core set is considered to evaluate walking and mobility‐
related activities, hand and arm use, and ADL, and should be applied to all
stroke patients in all phases after stroke. The use of a core set of outcome
measures is needed to objectify changes in body functions and activities of
the patient and to improve communication between physiotherapists and
their patients and between professionals of the multidisciplinary team
together, such as neurologists, rehabilitation physicians, general
practitioners, nursing home doctors, geriatricians, psychologists, (district)
nurses, occupational therapists, speech therapists.28

186
General Discussion
2a. Implementing evidence into daily practice
“Evidence‐based practice is the integration of best research evidence with
clinical expertise and patient values”. In this concept it is accepted that new
evidence invalidates previously validated treatments and replaces them
with new ones that are more powerful, more accurate and more efficacious
and safer to apply. Evidence, as only one element in the clinical decision
making process, can inform, refine, and enrich clinical expertise of the
professionals. In this way it might be better to use the term “evidence in
support of practice”,68 or “evidence in support of a patient’s decision” after
publication of the Sicily‐statement.69 Furthermore, EBP demands that the
decisions in physiotherapy are made ‐and this is essential‐ by informed
patients, based on the best available, current, valid and relevant evidence,
combined with optimal clinical experience of the professionals.69
Consequently, physiotherapists have to formulate and thereafter suggest to
the patient treatment plans based on patients’ preferences, prognostic
determinants, available best‐evidence interventions and knowledge about
using outcome measures. In my opinion future guideline developers have to
involve patients in decision making by communicating evidence, leading to
guidelines that are accessible, readable, and understandable for patients.69,70
However, to optimise the integration of all aspects of EBP in daily practice,
we need to detect potentially constraints or barriers, such as time available
to apply a guideline or a core set of outcome measures. We also need to
identify facilitators which might enhance a successful implementation of
evidence or guideline recommendations into daily practice. In this line,
guidelines have to be updated when necessary, e.g., as new or conflicting
evidence comes up, or when politics drastically changes and the construct of
the guideline should be prepared for this, or in case of a paradigm shift as
might the result from the Sicily‐statement.
Guideline development is approved, but without an implementation
quite meaningless. The CPGPS is a huge document of 317 pages including 72
recommendations for clinical practice (Chapter 5). It will be difficult to
implement such a complex guideline. Consequently, with regard to the
second aim of the thesis, one part of the CPGPS, the core set of outcome
measures, was implemented into daily practice of a select group of
physiotherapists involved in the management of patients with stroke. The
use of outcome measures by professionals can be seen as a useful indicator
of guideline adherence.71
First, an analysis under representatives of the involved professionals
(N=167 physiotherapists) was performed to detect perceived barriers and
facilitators, regarding to Dutch physiotherapists’ attitude and opinion
187
Chapter 8
towards using outcome measures (Chapter 6). The analysis was performed
with the Barriers and Facilitators Questionnaire (BFQ), modified for the
purpose of this population. The BFQ might in time be used as a diagnostic
tool to select implementation strategies for instance to promote the use of
outcome measures by physiotherapists involved in stroke management.
Second, in a feasibility study a select group of Dutch physiotherapists
were educated (PEPCiS) to enhance their use of recommended outcome
measures (Chapter 7). Pilot studies are primary designed to analyse
feasibility.72,73 The survey study (Chapter 6) as well as the PEPCiS study
(Chapter 7) were shown to be feasible. We recommend a full trial in order to
investigate the dependency of the physiotherapists to their allocated tutor in
an appropriate multilevel analysis method to detect differences between
groups with different tutors. To preclude bias by non‐content expertise
dependent aspects of each tutor, a larger cluster randomised study is
necessary with, based on power calculation consisted of 280
physiotherapists, a comparison of 10 expert and 10 non‐expert tutors, each
of them educating a group of 14 physiotherapists will be adequate. Such a
trial is needed in which the effects of implementation of CPGPS in different
stroke settings are evaluated. In particular acknowledging that greater levels
of adherence to multidisciplinary stroke guidelines74 are associated with
improved outcomes in terms of ADLs and health‐related quality of life.75
With that, compliance with guidelines may be viewed as a quality‐of‐care
indicator with which to evaluate new organisational and funding changes
involving stroke rehabilitation.75
Not only guideline implementation studies are important, also the
education of future physiotherapists, the present students, needs attention.
In my opinion CPGs have to be an integrated part in the education of
physiotherapists in programmes at the universities or polytechnics, and in
the postgraduate courses, and can be used as a knowledge transfer tool to
educate physiotherapists to use scientific research findings in their daily
practice. At the same time one might test whether the guidelines can be
understood and the recommendations been followed up by the students.
We based or investigations concerning implementation on a model
described by Lomas1,2 in which education plays an important role. Prior to
the education of the professionals we detected potentially barriers and
facilitators76, and integrated solutions for the barriers and facilitators in our
educational programme. With these, we performed a diagnostic analysis of
our target group, the physiotherapists, with the modified BFQ (Chapter 6).
The BFQ, coming from a validated questionnaire,77 includes statements
about a four domains‐model, i.e., characteristics of the innovation, the care
188
General Discussion
provider, the patient and the context. Both the model by Lomas and that by
Peters seemed valuable and complemented each other for the aims of this
thesis, based on integrating detailed information to specific target groups in
daily practice.
The newly developed, well appreciated and feasible PEPCiS aims to
enhance the infrequent use of outcome measures in the management of
patients with stroke (Chapter 6). PEPCiS might be used to assist tutors in the
education of physiotherapists and students in linking interventions to
outcome measures. The late Rothstein already stated that “measurement is
the sine qua non for effective practice in physiotherapy. Without
measurement, there can be no effective practice”.78 In Chapter 6 we detected
why the physiotherapists included in the survey did not regularly use
measurement instruments. In line with findings from other studies,79,80 main
barriers why physiotherapists do not use these instruments on a regular
basis are lack of time and lack of knowledge about outcome measures. By
integrating outcome results in discharge letters to colleagues in a further
stroke service setting and by visualising patients’ outcome data in web‐
based electronic patient records81 physiotherapists and their patients will
appreciate the added value of monitoring change in body functions and
activities by using valid measurement instruments. As a result, I expect that
the continuity, transparency, and accuracy of physiotherapy stroke
management will be improved, an expectation that remains to be
underscored by further investigations.

2b. Optimising of physiotherapy stroke management
Based on the findings of the present thesis, I infer that the management by
physiotherapists of patients with stroke can be optimised. For instance to
formulate SMART designed clinical questions (specific, measurable,
attainable, realistic and timely) based on patients’ preferences before starting
a (multidisciplinary) treatment. In order to do so, physiotherapists have to
gain explicit knowledge of the recommendations in the CPGPS and use their
clinical expertise to critically appraise 1) patient’s functional prognosis, 2)
treatment goals, and 3) evaluative measurements in (ICF) terms of functions
and structures, activities and participation. Therapists then ought to treat
patients with stroke on an intensive, task‐specific way and monitor and
communicate clinical changes explicitly, both in the multidisciplinary team
as well with the patient. However, the evidence that more intensive
rehabilitation improves outcome after stroke has to be reflected in today’s
rehabilitation practice.82 The intensity of rehabilitation programmes is often
limited.83‐85 For example, in stroke units or other inpatient rehabilitation
189
Chapter 8
settings the usual direct contact therapy practice time of all stroke team
members is about two hours per working day.83‐85 It should also be
acknowledged that more than 2 hours of therapy each day is not feasible for
every patient or clinical setting. The most pragmatic way to create more
therapy practice time is by adding on (task‐specific) group training
programmes.86 For example, constraining the non‐paretic arm for several
hours per day,87 or offering patients circuit training in groups in a
progressive functional way.88 Moreover, impairment‐focused programmes
such as biofeedback, neuromuscular or transcutaneous nerve stimulation fail
to generalise to functional improvements. Therapists have to be aware that a
mix of components from different treatment approaches89, an eclectic
approach, integrated in a multidisciplinary stroke team26,90 is more effective
in attaining functional independence, and that impairment‐focused
neuromuscular treatment approaches lead to longer lengths of stay
compared to activity‐focused therapy.91 With the sharp rise in the ageing
population and the increasing prevalence of the number of patients with
stroke, it is necessary that the treatment approaches in rehabilitation be
optimised and that the professionals become specialists with knowledge
about prognostics, interventions and outcomes.

Recommendations in future research

Addressing fundamental key questions
Longitudinal kinetic and neurophysiological studies are needed to explain,
or to improve the understanding of the underlying mechanisms of
functional recovery as a function of time.20,23 For this purpose, more
knowledge is needed about the ‘nature’ of movement coordination deficits
as well as their adaptation strategies to accomplish functional tasks such as
reaching activities with the paretic arm or gait.23 New clarifying models are
needed to explain why recovery after stroke occurs to a large extent through
behavioural compensation rather than through recovery of for instance
cerebral tissues and neural plasticity.23 With a better understanding of these
recovery strategies, we may find relationships between behavioural
adaptations and improved skills and activities after stroke. Clear
relationships will change our future therapeutic approaches of patients with
stroke. At the moment, in our research to the most effective rehabilitation
interventions we have to focus on intensive, task‐specific approaches which
are more effective than traditional approaches focusing on impairments.92

190
General Discussion
Innovating interventions with help of fundamental research findings
Research is also needed to address specific questions about for instance the
type of functional electro stimulation (FES) that might be most effective, in
what dose and at what time after stroke,93 or to study the additional value of
new treatment interventions such as ‘upper limb robotics’,94 ‘virtual
reality’,95 mirror therapy’,96 or bilateral movement training,97 e.g.,
‘BATRAC’.98
To find answers to these questions we have to join forces with other
research fields, i.e., human movement sciences, biomechanics, biology,
ecological psychology and neuroradiology to connect fundamental and
clinical research into transversal lines of research.

Selecting patients and clinical decision rules
In the CPGPS almost 90% of the recommendations were based on the results
of intervention studies, involving patients in the post acute and chronic
phase of stroke, and patients who had experienced a less severe or
uncomplicated stroke. Further specification of patients’ characteristics (e.g.
stroke severity) and the content of interventions in individual studies is
needed to select the appropriate patients for specific therapeutic
interventions.99 However, future research has to be better attuned to patients
with co‐morbidities, acknowledging that these patients are often not selected
for controlled trials. As long as patients with stroke are recruited in RCTs
without stratification for their prognosis of functional recovery any effort to
find cost‐effectiveness will be in vain. Consequently, future research should
focus on a) stratifying patients with stroke into different functional profiles,
according to their prognosis in their recovery of functional health status;20,23
b) obtaining clinical decision rules for professionals, available for each
stratum;100 c) implementing these rules and changing clinical behaviour of
professionals45 and d) developing concepts concerning longitudinal
monitoring (with high‐quality outcome measures) of functional health status
of patients with stroke,71 and observational studies on single subjects or
small cohorts with high frequency sampling of data (for instance daily) in
order to detect day‐to‐day dynamics of functioning of these patients.

Monitoring changes of functional health
In future research we also have to emphasise on longitudinal monitoring
processes of patients with stroke during their rehabilitation.71 Using change
scores in studies gives the opportunity to explore the longitudinal
relationship between time‐independent changes of functional recovery
profiles after stroke, for instance in functions as walking speed and
191
Chapter 8
endurance, and observed changes in extended daily activities such as
community walking.20,23 Besides we have to learn physiotherapists and other
health care providers to interpret the monitored data coming from outcome
measurements and to communicate these data to their patients.

Involving patients and caregivers
Based on new insights, an important aspect of improving stroke care is to
enhance the involvement of patients and care givers in the rehabilitation
process. In my opinion a freely and easily accessible website might be a
useful tool to stimulate the involvement of patients and caregivers as well.
According to the Canadian Stroke Network (CSN) an evidence‐based stroke
rehabilitation intervention website for patients, caregivers and professionals
(StrokEngine: http://www.medicine.mcgill.ca/strokengine) can be developed in
the Netherlands. The CSN took an effort to bridge this gap between research
findings and current clinical practice. The StrokEngine targeted three
groups: 1) individuals who have had a stroke, their families, friends or care
partners; 2) clinicians with varying stroke expertise; and 3) administrators
and policy makers who need quick accurate information about interventions
and their effectiveness.

Improving clinical practice guidelines
Stroke research needs a more structured and detailed way of reporting study
results. With that, guideline recommendations can be more specific about
the content, selected patients, intensity and duration of the interventions.101
International and multidisciplinary collaboration in guideline development
is advisable, because many countries and professions pass through the same
processes and debates during their development but at different phases.102 In
fact, the aim to improve healthcare decision‐making process globally has
been started already by the Cochrane Collaboration. They combined forces
in systematic literature searches, methodological quality ratings and grading
levels of evidence. However, cultural and national care specific differences
between countries in the formulations of recommendations for clinical
practice will always remain.103 Therefore the foundation of a global network
for stroke‐neurorehabilitation is crucial for an efficient worldwide
cooperation, aiming to enable and advance national organisations within
neuroscience physiotherapy and their individual members by supporting
and facilitating research, sharing clinical specialisation, selecting
multidisciplinary core sets of measurements instruments, sharing good
practice with developing countries and enhancing the transferability of
physiotherapy guidelines. Recently, the initiative was taken by an
192
General Discussion
international group of physiotherapists to create a new association that

should facilitate communication and collaboration among neuroscience
physiotherapists throughout the world and to promote the physiotherapy
perspective within the sphere of neuroscience. The current working title for
this new association is the International Neuroscience Physiotherapy
Association.

Improving implementation of research findings
Taskforces have to be set up to promote collaboration between stroke
rehabilitation research and implementation research. These research
domains are in line with each other, but nowadays unsatisfactory linked and
ad hoc combined. Those who found evidence in fundamental and clinical
research have to cooperate with those who implement these findings in daily
practice of the health care professionals. Taskforces have to create objective
methods to define when an implementation of a CPG is successful. In that
process taskforces have to develop outcome measures to evaluate a)
compliance to guidelines by professionals and patients; b) ‘successful’
implementation of guidelines; and c) ‘successful’ knowledge exchange from
guidelines to daily practice.
Implementation research in the field of physiotherapy science is
relatively new and mainly focused on current models in general health care.
Developing physiotherapy specific implementation models is necessary to
create tailored implementation strategies. Parallels can be drawn between
the implementation models and physiotherapy treatment models. Both need
a well performed diagnostic analysis (target group versus patient), a plan
(implementation versus treatment), and an evaluation (process indicators
versus outcome indicators). Furthermore, in future guideline
implementation research not only effects have to be investigated at the level
of physiotherapists (do they act according to the guideline), but also at the
level of patients (does guideline‐driven therapy result in better patient
outcomes?).
Physiotherapy students in graduate programmes, and practicing
colleagues in post‐graduate education programmes need to gain explicit
knowledge and skills about the ‘state of the art’ in stroke rehabilitation.
After graduating physiotherapists have to adopt the principles of lifelong
learning (i.e., continuous physiotherapy education and professional
development to enhance a professional attitude and opinion about
physiotherapy stroke management). In my opinion, physiotherapy as a
crucial part of stroke management is a profession with a relatively young
history and with many challenges for further growth in the future.
193
Chapter 8
References

3. McDonnell MN, Hillier SL, Miles TS et al. Influence of combined afferent stimulation and
task‐specific training following stroke: a pilot randomized controlled trial. Neurorehabil
Neural Repair 2007; 21:435‐443.
available evidence. Disabil Rehabil 2007; 29:767‐783.
5. Van Peppen RPS, Kwakkel G, Wood‐Dauphinee S et al. Einfluss der Physiotherapie auf das
funktionelle Outcome nach Schaganfall: Evidenzen. In: Dettmers C, Bülau P, Weiller CH,
editors. Schlaganfall Rehabilitation. Bad Honnef: Hippocampus Verlag, 2007: 137‐174.
6. Hammond R, Lennon S, Walker MF et al. Changing occupational therapy and
physiotherapy practice through guidelines and audit in the United Kingdom. Clin Rehabil
2005; 19:365‐371.
7. Miller M, Kearney N. Guidelines for clinical practice: development, dissemination and
implementation. Int J Nurs Stud 2004; 41:813‐821.
8. Field MJ, Lohr KN. Guidelines for clinical practice. From development to use. Washington
DC: National Academy Press, 1992.
9. Schmidt HG, van der Arend A., Moust JH et al. Influence of tutorsʹ subject‐matter expertise
on student effort and achievement in problem‐based learning. Acad Med 1993; 68:784‐791.
small‐group process and on student performance. Acad Med 1992; 67:470‐474.
11. Dolmans DH, Gijselaers WH, Moust JH et al. Trends in research on the tutor in problem‐
based learning: conclusions and implications for educational practice and research. Med
Teach 2002; 24:173‐180.
12. Buurke JH. Walking after stroke, co‐ordination patterns and functional recovery.
Universiteit Twente, 2005.
13. De Haart M. Recovery of standing balance in patients with a supratentorial stroke.
Radboud Universiteit Nijmegen, 2005.
14. Latash ML, Anson JG. What are ʹnormal movementsʹ in atypical populations? Behavioral
and Brain Science 1996; 19:55‐106.
15. De Haart M, Geurts AC, Huidekoper SC et al. Recovery of standing balance in postacute
stroke patients: a rehabilitation cohort study. Arch Phys Med Rehabil 2004; 85:886‐895.
16. Sackley CM. Falls, sway, and symmetry of weight‐bearing after stroke. Int Disabil Stud
1991; 13:1‐4.
194
General Discussion
17. Barclay‐Goddard R, Stevenson T, Poluha W et al. Force platform feedback for standing
balance training after stroke. Cochrane Database Syst Rev 2004;(4):CD004129.
18. Garland SJ, Willems DA, Ivanova TD et al. Recovery of standing balance and functional
mobility after stroke. Arch Phys Med Rehabil 2003; 84:1753‐1759.
19. Kautz SA, Duncan PW, Perera S et al. Coordination of hemiparetic locomotion after stroke
rehabilitation. Neurorehabil Neural Repair 2005; 19:250‐258.
21. Cirstea MC, Levin MF. Compensatory strategies for reaching in stroke. Brain 2000; 123 ( Pt
5):940‐953.
22. Kwakkel G, Kollen BJ, Wagenaar RC. Long term effects of intensity of upper and lower
limb training after stroke: a randomised trial. J Neurol Neurosurg Psychiatry 2002; 72:473‐
479.
24. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke.
Cochrane Database Syst Rev 2002;(1):CD000197.
25. Wade DT, de Jong BA. Recent advances in rehabilitation. BMJ 2000; 320:1385‐1388.
Stroke 2001; 32:268‐274.

national clinical guideline (no: 64). 64. 2002. Edinburgh, SIGN.
32. Hanger HC, Wilkinson T, Keeling S et al. New Zealand guideline for management of
stroke. N Z Med J 2004; 117(1192):U863.
33. National Stroke Foundation. Clinical Guidelines for Stroke Rehabilitation and Recovery
(Australian Government). 2005.
34. Khadilkar A, Phillips K, Jean N et al. Ottawa panel evidence‐based clinical practice
guidelines for post‐stroke rehabilitation. Top Stroke Rehabil 2006; 13:1‐269.
195
Chapter 8
35. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ
2004; 328:343‐345.
36. AGREE Collaboration. Development and validation of an international appraisal
instrument for assessing the quality of clinical practice guidelines: the AGREE project.
Qual Saf Health Care 2003; 12:18‐23.
37. Shaneyfelt TM, Mayo‐Smith MF, Rothwangl J. Are guidelines following guidelines? The
methodological quality of clinical practice guidelines in the peer‐reviewed medical
literature. JAMA 1999; 281:1900‐1905.
39. Cup EHC, Steultjens EMJ. Occupational Therapy Guideline Stroke [in dutch:
Ergotherapierichtlijn Beroerte]. 2005. Utrecht, Nederlandse Vereniging voor Ergotherapie
(NVE).
40. Hafsteinsdottir TB, Schuurmans MJ. Clinical Nursing Rehabilitation Guideline Stroke [in
Dutch: Verpleegkundige Revalidatierichtlijn Beroerte]: in preparation. 2008.
41. Kwakkel G, Wagenaar RC, Kollen BJ, Lankhorst GJ. Predicting disability in stroke ‐ a
critical review of the literature. Age Ageing 1996; 25:479‐489.
42. Kwakkel G, van Dijk GM, Wagenaar RC. Accuracy of physical and occupational therapistsʹ
early predictions of recovery after severe middle cerebral artery stroke. Clin Rehabil 2000;
14:28‐41.
43. Van de Port I, Kwakkel G, van Wijk I et al. Susceptibility to deterioration of mobility long‐
term after stroke: a prospective cohort study. Stroke 2006; 37:167‐171.
44. Kwakkel G, Kollen BJ, Van der Grond J et al. Probability of regaining dexterity in the
flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke
2003; 34:2181‐2186.
45. McGinn TG, Guyatt GH, Wyer PC et al. Usersʹ guides to the medical literature: XXII: how
to use articles about clinical decision rules. Evidence‐Based Medicine Working Group.
JAMA 2000; 284:79‐84.
46. Pomeroy VM. Stroke rehabilitation. Disabil Rehabil 2006; 28:813‐814.
47. Foley NC, Bhogal SK, Teasell RW et al. Estimates of quality and reliability with the
physiotherapy evidence‐based database scale to assess the methodology of randomized
controlled trials of pharmacological and nonpharmacological interventions. Phys Ther
2006; 86:817‐824.
48. Van Tulder MW, Assendelft WJ, Koes BW et al. Method guidelines for systematic reviews
in the Cochrane Collaboration Back Review Group for Spinal Disorders. Spine 1997;
22:2323‐2330.
49. Verhagen AP, de Vet HC, de Bie RA et al. The Delphi list: a criteria list for quality
assessment of randomized clinical trials for conducting systematic reviews developed by
Delphi consensus. J Clin Epidemiol 1998; 51:1235‐1241.
50. Jadad AR, Moore RA, Carroll D et al. Assessing the quality of reports of randomized
clinical trials: is blinding necessary? Control Clin Trials 1996; 17:1‐12.
196
General Discussion
51. Boutron I, Moher D, Tugwell P et al. A checklist to evaluate a report of a
nonpharmacological trial (CLEAR NPT) was developed using consensus. J Clin Epidemiol
2005; 58:1233‐1240.
52. Sherrington C, Herbert RD, Maher CG et al. PEDro. A database of randomized trials and
systematic reviews in physiotherapy. Man Ther 2000; 5:223‐226.
53. Bhogal SK, Teasell RW, Foley NC et al. The PEDro scale provides a more comprehensive
measure of methodological quality than the Jadad scale in stroke rehabilitation literature. J
Clin Epidemiol 2005; 58:668‐673.
54. Foley NC, Teasell RW, Bhogal SK et al. Stroke Rehabilitation Evidence‐Based Review:
methodology. Top Stroke Rehabil 2003; 10:1‐7.
55. Lenssen AF, Köke AJA, de Bie RA et al. Continuous passive motion following primary
total knee arthroplasty: short‐ and long‐term effects on range of motion. A systematic
review. Phys Ther Review 2003;:113‐121.
56. Steultjens EM, Dekker J, Bouter LM et al. Occupational therapy for stroke patients: a
systematic review. Stroke 2003; 34:676‐687.
57. Van Tulder MW, Cherkin DC, Berman B et al. The effectiveness of acupuncture in the
management of acute and chronic low back pain. A systematic review within the
framework of the Cochrane Collaboration Back Review Group. Spine 1999; 24:1113‐1123.
58. Heymans MW, van Tulder MW, Esmail R et al. Back schools for nonspecific low back pain:
a systematic review within the framework of the Cochrane Collaboration Back Review
Group. Spine 2005; 30:2153‐2163.
59. Altman DG. Better reporting of randomised controlled trials: the CONSORT statement.
BMJ 1996; 313:570‐571.
60. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Control Clin Trials 1986; 7:177‐188.
261‐282.
62. Gotzsche PC, Hrobjartsson A, Maric K et al. Data extraction errors in meta‐analyses that
use standardized mean differences. JAMA 2007; 298:430‐437.
63. Jones AP, Remmington T, Williamson PR et al. High prevalence but low impact of data
extraction and reporting errors were found in Cochrane systematic reviews. J Clin
Epidemiol 2005; 58:741‐742.
64. Van Peppen RP, Kwakkel G, Wood‐Dauphinee S et al. The impact of physical therapy on
functional outcomes after stroke: whatʹs the evidence? Clin Rehabil 2004; 18:833‐862.
65. Geyh S, Cieza A, Schouten J et al. ICF Core Sets for stroke. J Rehabil Med 2004;(44
Suppl):135‐141.
66. Bot SD, Terwee CB, van der Windt DA et al. Clinimetric evaluation of shoulder disability
questionnaires: a systematic review of the literature. Ann Rheum Dis 2004; 63:335‐341.
67. Salter KL, Teasell RW, Foley NC et al. Outcome Assessment in Randomized Controlled
Trials of Stroke Rehabilitation. Am J Phys Med Rehabil 2007; 86:1007‐1012.
197
Chapter 8
Sinai J Med 1999; 66:75‐83.
69. Dawes M, Summerskill W, Glasziou P et al. Sicily statement on evidence‐based practice.
BMC Med Educ 2005; 5:1‐7.
70. Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision
making. JAMA 2004; 291:2359‐2366.
330:644‐648.
72. Beurskens AJ, de Vet HC, Kant I. [Roaming through the methodology. VIII. Pilot studies:
sense and nonsense]. Ned Tijdschr Geneeskd 1998; 142:2142‐2145.
73. Lancaster GA, Dodd S, Williamson PR. Design and analysis of pilot studies:
recommendations for good practice. J Eval Clin Pract 2004; 10:307‐312.
74. Gresham GE, Duncan PW, Statson WB. Priorities for future research: clinical practice
guidelines, number 16. US Dept Health and Human Services ‐ Agency for Health Care
Policy and Research, editor. AHCPR publication no. 95‐0662. 1995. Rockville.
75. Duncan PW, Horner RD, Reker DM et al. Adherence to postacute rehabilitation guidelines
is associated with functional recovery in stroke. Stroke 2002; 33:167‐177.
77. Peters MAJ, Harmsen M, Laurant MGH et al. Room for improvement? Barriers to and
opportunities for improvement of patient care [dutch: Ruimte voor verandering?
Knelpunten en mogelijkheden voor verbeteringen in de patientenzorg]. Centre for Quality
of Care Research (WOK), editor. 2003. Nijmegen, The Netherlands, Radbout University
Medical Centre.
78. Rothstein JM. Measurement and clinical practice: Theory and application. In: Rothstein JM,
editor. Measurement in Physical Therapy: Clinics in Physical Therapy. New York:
Churchill Livingstone, 1985: 1‐46.
measure usage in physiotherapy. Man Ther 2006; 11:46‐53.
rehabilitation. Clin Rehabil 2000; 14:611‐617.
81. Swinkels IC, van den Ende CH, de Bakker D et al. Clinical databases in physical therapy.
Physiother Theory Pract 2007; 23:153‐167.
82. De Wit L, Putman K, Dejaeger E et al. Use of time by stroke patients: a comparison of four
83. Bernhardt J, Chan J, Nicola I et al. Little therapy, little physical activity: rehabilitation
within the first 14 days of organized stroke unit care. J Rehabil Med 2007; 39:43‐48.
84. De Weerdt W, Selz B, Nuyens G et al. Time use of stroke patients in an intensive
rehabilitation unit: a comparison between a Belgian and a Swiss setting. Disabil Rehabil
2000; 22:181‐186.
198
General Discussion
85. Tinson DJ. How stroke patients spend their days. An observational study of the treatment
regime offered to patients in hospital with movement disorders following stroke. Int
Disabil Stud 1989; 11:45‐49.
86. Kwakkel G. Impact of intensity of practice after stroke: issues for consideration. Disabil
Rehabil 2006; 28:823‐830.
87. Hakkennes S, Keating JL. Constraint‐induced movement therapy following stroke: a
systematic review of randomised controlled trials. Aust J Physiother 2005; 51:221‐231.
88. Van de Port I, Wood‐Dauphinee S, Lindeman E et al. Effects of Exercise Training Programs
on Walking Competency After Stroke: A Systematic Review. Am J Phys Med Rehabil 2007;
86:935‐951.
89. Pollock A, Baer G, Langhorne P, Pomeroy V. Physiotherapy treatment approaches for the
recovery of postural control and lower limb function following stroke: a systematic review.
Clin Rehabil 2007; 21:395‐410.
90. Wade D. Investigating the effectiveness of rehabilitation professions‐‐a misguided
enterprise? Clin Rehabil 2005; 19:1‐3.
91. Patel M, Potter J, Perez I et al. The process of rehabilitation and discharge planning in
stroke: a controlled comparison between stroke units. Stroke 1998; 29:2484‐2487.
92. Teasell RW, Kalra L. Whatʹs new in stroke rehabilitation: back to basics. Stroke 2005;
36:215‐217.
93. Pomeroy VM, King LM, Pollock A et al. Electrostimulation for Promoting Recovery of
Movement or Functional Ability After Stroke. Systematic Review and Meta‐Analysis.
Stroke 2006; 37:2441‐2442.
94. Kwakkel G, Kollen BJ, Krebs HI. Effects of Robot‐Assisted Therapy on Upper Limb
Recovery After Stroke: A Systematic Review. Neurorehabil Neural Repair 2007.
95. Crosbie JH, Lennon S, Basford JR et al. Virtual reality in stroke rehabilitation: still more
virtual than real. Disabil Rehabil 2007; 29:1139‐1146.
96. Sutbeyaz S, Yavuzer G, Sezer N et al. Mirror therapy enhances lower‐extremity motor
recovery and motor functioning after stroke: a randomized controlled trial. Arch Phys Med
Rehabil 2007; 88:555‐559.
97. Stewart KC, Cauraugh JH, Summers JJ. Bilateral movement training and stroke
rehabilitation: a systematic review and meta‐analysis. J Neurol Sci 2006; 244:89‐95.
98. Richards LG, Senesac CR, Davis SB et al. Bilateral Arm Training With Rhythmic Auditory
Cueing in Chronic Stroke: Not Always Efficacious. Neurorehabil Neural Repair 2007.
99. Bode RK, Heinemann AW, Semik P et al. Relative importance of rehabilitation therapy
characteristics on functional outcomes for persons with stroke. Stroke 2004; 35:2537‐2542.
100. Craik RL. Thirty‐Sixth Mary McMillan Lecture: Never satisfied. Phys Ther 2005; 85:1224‐
1237.
101. Hurdowar A, Graham ID, Bayley M et al. Quality of stroke rehabilitation clinical practice
guidelines. J Eval Clin Pract 2007; 13:657‐664.
199
Chapter 8
102. Van der Wees PJ, Hendriks EJ, Custers JW, Burgers JS, Dekker J, de Bie RA. Comparison of
international guideline programs to evaluate and update the Dutch program for clinical
guideline development in physical therapy. BMC Health Serv Res 2007; 7:191.
103. South African Medical Association (Neurological Association of South Africa Stroke
Working Group). Stroke therapy clinical guideline. S Afr Med J 2000; 90(3 Pt 2):276‐9, 292.
200

Summary

Summary
Summary

In Chapter 1 several aspects of evidence‐based physiotherapy in patients
with stroke are introduced. Stroke is the leading cause of severe long term
disability in adults in the Western World. Every year, an estimated 34,500
people a have a stroke in the Netherlands.1 Approximately 70% of the stroke
surviving patients experience long term problems in their activities of daily
living (ADL) and social participation.2 In the absence of any cure for the
initial pathology, rehabilitation is the most universally adopted treatment
strategy to improve quality of life in patients with stroke. In the Netherlands
patients with stroke generally rehabilitate in different settings, usually
started in an acute stroke‐unit care and continued in a rehabilitation centre, a
nursing home, or in the community by physiotherapists employed in health
centres or private practices. Physiotherapy is perceived as one of the key
disciplines in providing organised‐stroke care. In stroke care several
multidisciplinary guidelines are available; however these guidelines do not
review in depth all available evidence with regard to physiotherapy practice.
Physiotherapists need to have more detailed information to foster and enrich
their clinical decision making process. This includes making a valid
functional prognosis of outcome, selecting the most effective intervention
and the most appropriate measures to evaluate functional change. These
aspects have to be an integrated part of everyday practice. Accordingly, in
the present thesis two main aims were studied.
The first aim was to collect and review systematically, and to appraise
critically the available evidence stemming from physiotherapy and
physiotherapy related studies in patients with stroke. On the basis of these
findings, recommendations were made that permitted guidance in the
process of clinical decision‐making. The results of these review‐activities will
be presented as a Clinical Practice Guideline on Physiotherapy management
of patients with Stroke (CPGPS).
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. Based on an analysis of barriers and facilitators of
implementation, an educational program was performed to implement the
recommendations into daily practice in a selected group of physiotherapists
who were dedicated to management of patients with stroke.

202
Summary
In Chapter 2 a systematic review was performed to establish the scientific
value of the evidence of physiotherapy interventions related to improving
functional outcomes after stroke and to convert this evidence in an overview
of the efficacy of physiotherapy interventions in patients with stroke.
Databases (MEDLINE, CINAHL, Cochrane Central Register of Controlled
Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE
and DocOnline) were systematically searched for randomised controlled
trials (RCTs) or controlled clinical trials (CCTs) by two independent
researchers. For this systematic review, physiotherapy was classified into 10
intervention categories to evaluate the effectiveness of: 1) traditional
neurological treatment approaches; 2) programs for training sensory‐motor
function or influencing muscle tone; 3) cardiovascular fitness and aerobic
programs; 4) methods for training mobility and mobility related activities; 5)
exercises for the upper limb; 6) biofeedback therapy for the upper and lower
limb; 7) functional and neuromuscular electrical stimulation for both limbs;
8) orthotics and assistive devices for both limbs; 9) treatments for hemiplegic
shoulder pain and hand oedema; and 10) intensity of exercise therapy. The
following inclusion criteria were applied: 1) participants had be diagnosed
with stroke and older than 18 years; 2) studies had to evaluate the
effectiveness of physiotherapy interventions in one of the intervention
categories; and 3) the publication had to be in English, German or Dutch.
Studies were collected up to January 2004 and their methodological quality
was assessed using the 10‐point PEDro scale. One hundred and fifty one
studies were included: 123 RCTs and 28 CCTs. All included RCTs had a
median of 5 points on the PEDro scale (range 2‐8 points). Meta‐analysis
showed significant summary effect sizes (SES; p<0.05) for therapies that
were focused on functional training of the upper limb such as constraint‐
induced movement therapy (SES 0.46; 95% CI: 0.07 – 0.91), treadmill training
with or without body weight support (respectively SES 0.70; 95% CI: 0.29 –
1.10 and SES 1.09; 95% CI: 0.56 – 1.61), aerobics (SES 0.39; 95% CI: 0.05 –
0.74), external auditory rhythms during gait (SES 0.91; 95% CI: 0.40 – 1.42),
improving symmetry when moving from sitting to standing (SES 0.92; 95%
CI: 0.54 –1.29), and effects of high intensity of exercise training on ADL (SES
0.13; 95% CI: 0.03 –0.23) and neuromuscular stimulation for glenohumeral
subluxation (SES 1.41; 95% CI: 0.76 – 2.06). No or insufficient evidence in
terms of functional outcome was found for: traditional neurological
treatment approaches; exercises for the upper limb; biofeedback; functional
and neuromuscular electrical stimulation aimed at improving dexterity or
gait performance; orthotics and assistive devices; and physiotherapy
interventions for reducing hemiplegic shoulder pain and hand oedema. We
203
Summary
concluded that this review showed small to large effects for task‐oriented
exercise training, in particular when applied intensively and early after
stroke onset. In almost all studies the effects were mainly restricted to tasks
directly trained in the exercise program.

The overall review in Chapter 2 suggested that early provision of
intensive stroke rehabilitation is associated with enhanced and faster
improvement of the performance of activities in patients after stroke.
Consequently, in Chapter 3 a research synthesis was performed to examine
the effects of augmented exercise therapy time in patients with stroke.
Therefore studies were systematically reviewed by evaluating the effects of
intensity of practice, expressed as time dedicated to practice, on ADL, gait
and dexterity. The hypothesis was that the extra treatment time provided to
the augmented therapy group would result in clinically relevant
improvements. SES were calculated for ADL, walking speed and dexterity,
using fixed and random effect models. Twenty RCTs, involving 2686 stroke
patients, were included in the synthesis. The methodological quality ranged
from 2 to 11 out of the maximum score of 14 points on an adapted
methodological scoring list. Pooling reported differences resulted in a small,
but statistically significant random SES with regard to ADL measured at the
end of the intervention phase (SES 0.13; 95% CI, 0.03 to 0.23). Further
analysis showed a significant homogeneous SES for 17 studies that
investigated effects of increased exercise intensity within the first 6 months
post stroke. No significant homogeneous SES was observed for the 3 studies
conducted in the chronic phase. On average the experimental groups daily
received twice as much physiotherapy (49 min) and occupational therapy
(23 min) as the control groups (23 and 11 min. respectively). Cumulative
meta‐analysis, adjusted for the difference in treatment intensity in each
study, strongly suggests that at least a 16 hour difference in treatment time
between experimental and control groups provided in the first 6 months
after stroke is needed to obtain significant differences in ADL. A significant
SES supporting a higher intensity was also observed for instrumental ADL
(SES 0.23; 95% CI: 0.13 – 0.33) and walking speed (SES 0.19; 95% CI: 0.01 –
0.36), whereas no significant SES was found for dexterity (SES 0.03; 95% CI: ‐
0.13 – 0.19).

Improving symmetry of weight distribution while bilateral standing, is
one of the main treatment goals in the rehabilitation of patients with stroke.
In Chapter 4, the evidence for applying additional ‘visual feedback therapy’
(VFT) on postural control in bilateral standing was systematically studied in
204
Summary
patients with stroke. The primary aim was to establish whether VFT reduces
postural sway and improves left‐right symmetry of weight distribution in
bilateral standing after stroke compared with conventional treatment. In
addition, the effects of VFT on parameters of gait and gait‐related activities
including ADL were evaluated. Eight out of 78 studies (6 RCTs and 2 CCTs),
presenting 214 subjects, were included for qualitative and quantitative
analysis. The methodological quality ranged on the PEDro scale ranged from
3 to 6 points. The additional value of visual feedback therapy in bilateral
standing compared with conventional therapy shows no statistically
significant effects on symmetry of weight distribution between paretic and
non paretic leg, postural sway in bilateral standing, gait and gait‐related
activities. Visual feedback therapy should not be favoured over conventional
therapy. These results are of great clinical value indicating that training of
postural control should preferably be applied while performing the gait‐
related tasks itself. The question remains as to exactly how asymmetry in
weight distribution while standing is related to balance control in patients
with stroke.

In Chapter 5 the available evidence was collected and described to guide
the clinical decision‐making process of physiotherapists dealing with the
rehabilitation of patients with stroke especially with respect to the selection
of prognostic factors, physiotherapy interventions, and outcome measures.
This evidence is presented as a Clinical practice guideline on Physiotherapy
management of patients with Stroke (CPGPS) in the Netherlands. A
systematic computerised literature search was performed to identify
evidence concerning the use of: 1) prognostic factors related to functional
recovery; 2) physiotherapy interventions in patients with stroke; and 3)
outcome measures to assess patients’ progress in functional health.
Physiotherapists working in the field of stroke rehabilitation and a
multidisciplinary group of health professionals reviewed the clinical
applicability and feasibility of the recommendations for clinical practice and
their comments were used to compose the definitive guideline. Of 9482
relevant articles, 322 were selected and screened for methodological quality.
Seventy‐two recommendations for clinical practice were retrieved from
these articles and included in the guideline: 6 recommendations concerned
the prediction of functional recovery of activities of daily living (ADL),
including walking ability and hand/arm use; 65 recommendations
concerned the choice of physiotherapy interventions; and 1 recommendation
concerned the choice of outcome instrument to use. A core set of seven
reliable, responsive, and valid outcome measures was established, to
205
Summary
determine impairments and activity limitations in patients with stroke. The
guideline provides physiotherapists evidence‐based recommendations to
assist them in their clinical decision making regarding patients with stroke.
As most of the recommendations included in the guideline came from
studies of patients in the post acute and chronic phase of stroke, and in
general involved patients with less severe and uncomplicated stroke, more
needs to be learned about the more complex cases.

The core set of measurement instruments in the CPGPS includes the
Motricity Index (MI), Trunk Control Test (TCT), Berg Balance Scale (BBS),
Functional Ambulation Categories (FAC), Ten Metre Walk (TMW), Frenchay
Arm Test (FAT) and Barthel Index (BI). Assessing and monitoring the health
status of patients is considered an aspect of good clinical practice in
physiotherapy. Consequently, in Chapter 6, after disseminating the CPGPS,
physiotherapists’ self‐reported use of outcome measures as recommended in
the CPGPS was investigated, and the perceived barriers to and facilitators
for the use of outcome measures in everyday practice were assessed. A 41‐
item survey, including the Barriers and Facilitators Questionnaire (BFQ),
was sent by post to 400 physiotherapists in acute care hospitals (ACH;
N=100), rehabilitation centres (RC; N=100), nursing homes (NH; N=100) and
private physiotherapy practices (PPP; N=100). One hundred and eighty‐nine
physiotherapists returned the survey (47%; ACH, N=57; RC, N=67; NH,
N=26 and PPP, N=39); the surveys of 167 physiotherapists involved in stroke
settings were analysed. These physiotherapists reported regularly using
three (median; range 0‐7) of the seven recommended measurement
instruments, with those working in ACH or RC reporting a significantly
higher use than their colleagues in PPP (4 vs. 0 and 3 vs. 0; p<0.001 and
p=0.02 respectively). The BFQ revealed that there were specific facilitators,
such as ‘a positive attitude towards outcome measures’ (as mentioned by
93% of the physiotherapists) and ‘familiarity with outcome measures’ (90%),
and barriers such as ‘changing routines’ (32%), ‘time investment’ (29%), and
‘financial compensation’ (21%). Despite an almost uniformly positive
attitude, Dutch physiotherapists infrequently use the outcome measures
recommended in the CPGPS. Robust setting‐specific and tailored
implementation strategies based on the reported barriers and facilitators are
recommended.

To promote self‐reported use and actual use of the recommended
outcome measures by physiotherapists in stroke management a new
educational programme was developed, the Physiotherapists’ Educational
206
Summary
Programme on Clinimetrics in Stroke (PEPCiS). In Chapter 7 feasibility and
effectiveness were determined in an RCT with thirty voluntarily
participating physiotherapists involved in stroke management who were
randomised into two numeric equal groups, an expert tutor group (ETG)
and a non‐expert tutor group (NETG). The two tutors differed in their
clinical experience with outcome measures in stroke. Feasibility was
estimated by physiotherapists’ adherence to PEPCiS, satisfaction with
PEPCiS and appreciation of tutoring style of their allocated tutor;
effectiveness was estimated by counting the frequencies with which
outcome measures were mentioned in the records of patients entrusted to
the participating therapists. Secondary to this aim, the influence of tutor
style will be explored. The participants’ attendance record was generally
good (a median of 5 of the 5 sessions; range 4‐5) and they were satisfied with
PEPCiS (mean: 7.5 on a 0‐10 scale). In the entire group (N=30) the use of
outcome measures increased from 3 per patient before PEPCiS to 5 thereafter
(p=0.001). Between‐group differences were non‐significant for the totals of
the instruments used (median 3 to 6 in the ETG vs. 3 to 4 in the NETG;
p=0.07). Physiotherapists in the ETG appreciated the PEPCiS content, their
knowledge gain and all tutor style aspects, significantly more than those in
the NETG (p<0.05). The present pilot study suggests that education by
PEPCiS enhanced the use of clinical outcome measures by physiotherapists
in the management of patients with stroke. A future study with sufficient
power will investigate the influence of PEPCiS as well as the interfering
factors, e.g. tutor expertise and performance, in order to establish and
improve the effectiveness of educational interventions as a part of
implementation strategies for the regular use of outcome measures by
physiotherapists.

Chapter 8 presents a general discussion reflecting on the main
conclusions of this thesis and discusses the strengths and limitations of the
applied methods. In addition, chapter 8 offers clinical implications
concerning physiotherapy stroke management, recommendations for future
research on patients with stroke and suggestions for education and
implementation of research findings into everyday practice of professionals
in stroke care.
207
Summary
References

LATM, Koek HL, Van Trijp MJCA et al., editors. Hart‐en vaatziekten in Nederland 2005,
208

Nederlandse samenvatting

Samenvatting

In Hoofdstuk 1, de inleiding, worden verschillende aspecten van evidence‐
based fysiotherapie bij patiënten met een beroerte (cerebrovasculair
accident; CVA) geïntroduceerd. Beroerte (in het Engels ‘stroke’) is een
verzameling ziektebeelden waarbij sprake is van een stoornis in de
bloedvoorziening van de hersenen. In Westerse landen is CVA bij
volwassenen de meest belangrijke reden voor het ontstaan van een ernstige
chronische beperking. Elk jaar worden ongeveer 34.500 mensen in
Nederland getroffen door een CVA.{Struijs, 2005 1171 /id} Ongeveer 70%
van de patiënten die het CVA overleven ondervinden onomkeerbare
problemen in de activiteiten van hun dagelijks leven (ADL) en sociale
participatie.{Koek, 2005 990 /id} De initiële pathologie waardoor een CVA
ontstaat is niet te genezen, waardoor revalidatie internationaal gezien de
meest geaccepteerde behandelstrategie blijkt om het fysiek functioneren en
de kwaliteit van leven voor patiënten met een CVA te verbeteren. In
Nederland revalideren patiënten met een CVA in verschillende settings,
doorgaans startend in een stroke‐unit voor acute zorg en vervolgend in een
revalidatiecentrum, verpleeghuis of in de eerste lijn in een
fysiotherapiemaatschap of gezondheidscentrum. Fysiotherapie wordt
beschouwd als een van de kerndisciplines in het verstrekken van
georganiseerde CVA‐zorg, waarvoor de laatste jaren verschillende
multidisciplinaire richtlijnen zijn gepubliceerd. Deze richtlijnen beschouwen
echter niet gedetailleerd alle beschikbare bewijs met betrekking tot de
fysiotherapeutische handelingspraktijk. Fysiotherapeuten hebben de
gedetailleerde informatie juist nodig om hun klinisch besluitvormingsproces
te voeden en te verrijken. De fysiotherapeuten moeten bij deze
besluitvorming in staat zijn een valide functionele prognose te stellen, de
meest effectieve interventie te kiezen en de meest geschikte
meetinstrumenten te selecteren om functionele verandering bij patiënten
met een CVA te meten. Deze aspecten moeten een geïntegreerd onderdeel
zijn van het dagelijks handelen. Derhalve worden in dit proefschrift twee
hoofddoelstellingen bestudeerd.
De eerste doelstelling betreft het systematisch verzamelen, analyseren
en kritisch beoordelen van beschikbaar bewijs uit wetenschappelijke
literatuur afkomstig van fysiotherapie gerelateerde studies bij patiënten met
een CVA. Gebaseerd op deze bevindingen zijn richtinggevende
aanbevelingen geformuleerd die medebepalend zijn in het klinisch
besluitvormingsproces van fysiotherapeuten. De resultaten van de
systematische werkwijze zijn gepresenteerd als de Richtlijn‐Beroerte van het
210
Koninklijk Nederlands Genootschap voor Fysiotherapie. Deze KNGF‐

Richtlijn Beroerte heeft als Engelse naamgeving meegekregen: ‘Clinical
practice guideline on Physiotherapy management of patients with Stroke’
(CPGPS).
De tweede doelstelling is gericht op het integreren van de
aanbevelingen uit de richtlijn in de dagelijkse handelingspraktijk van
fysiotherapeuten die betrokken zijn bij het revalideren van patiënten met
een CVA. Hierbij is het deel van de KNGF Richtlijn Beroerte
geïmplementeerd dat gerelateerd is aan het ‘meten van
patiëntenuitkomsten’ met de geadviseerde basisset meetinstrumenten.
Gebaseerd op een analyse van belemmerende en bevorderende factoren
voor het gebruik van meetinstrumenten door fysiotherapeuten is een
educatieve scholingsmodule ontwikkeld (Physiotherapists’ Educational
Programme on Clinimetrics in Stroke: PEPCiS). PEPCiS is in een later
stadium geïmplementeerd bij een geselecteerde groep fysiotherapeuten die
betrokken zijn bij de zorg van patiënten met een CVA.

Hoofdstuk 2 beschrijft de resultaten van een systematische review over het
effect van fysiotherapeutische interventies gericht op het verbeteren van het
functioneren van patiënten met een CVA. Om de effectiviteit van
fysiotherapeutische interventies te beoordelen werden tien verschillende
interventiecategorieën bepaald, namelijk 1) traditionele neurologische
oefenmethoden c.q. behandelconcepten; 2) programma’s voor het trainen
van sensomotoriek en/of het beïnvloeden van spiertonus en stijfheid; 3)
cardiovasculaire fitness‐ en aerobicprogramma’s; 4) methoden voor het
trainen van loopvaardigheid en mobiliteitsgerelateerde vaardigheden; 5)
oefeningen voor de bovenste extremiteit; 6) biofeedback‐therapie voor de
onderste en bovenste extremiteit; 7) functionele elektrostimulatie en
neuromusculaire stimulatie voor beide extremiteiten; 8) het gebruik van
orthesen, slings en/of hulpmiddelen; 9) behandelingen van hemiplegische
schouderpijn of handoedeem; en 10) intensiteit van oefentherapie. In de
databestanden MEDLINE, CINAHL, Cochrane Central Register of
Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro,
EMBASE en DocOnline werd systematisch gezocht door twee onderzoekers
naar gerandomiseerde studies (randomised controlled trials: RCT’s) of
quasi‐experimentele studies (controlled clinical trials: CCT’s). Deze studies
moesten gepubliceerd zijn voor 1 januari 2004. De gehanteerde
inclusiecriteria waren: 1) participerende patiënten moesten gediagnosticeerd
zijn met CVA en 18 jaar en ouder zijn; 2) studies moesten de effectiviteit van
fysiotherapie evalueren in een van de tien interventiecategorieën; en 3)
211
studie waren gepubliceerd in Engels, Duits of Nederlands. De

methodologische kwaliteit van de geïncludeerde studies werd beoordeeld
met de 10‐punts PEDro‐schaal. Honderdeenenvijftig studies zijn
geïncludeerd: 123 RCT’s en 28 CCT’s. De geïncludeerde studies hadden een
mediaanscore van 5 punten op de PEDro‐schaal (range: 2‐8 punten). Meta‐
analyses lieten significante ‘Summary Effect Sizes’ (SES; p<0.05) zien voor
therapie gericht op functionele training van de bovenste extremiteit, zoals
‘constraint‐induced movement therapy’ (SES 0.46; 95% BI: 0.07 – 0.91),
loopbandtraining met en zonder gewichtsondersteuning (respectievelijk SES
0.70; 95% BI: 0.29 – 1.10 en SES 1.09; 95% BI: 0.56 – 1.61), aerobics (SES 0.39;
95% BI: 0.05 – 0.74), het aanbieden van externe auditieve ritmen tijdens het
lopen (SES 0.91; 95% BI: 0.40 – 1.42), het verbeteren van de symmetrie tijdens
het opstaan vanuit een zittende positie (SES 0.92; 95% BI: 0.54 –1.29), effecten
van een hogere intensiteit van oefentherapie (SES 0.13; 95% BI: 0.03 –0.23) en
neuromusculaire elektrostimulatie in geval van glenohumerale subluxatie
(SES 1.41; 95% BI: 0.76 – 2.06). Onvoldoende evidentie werd gevonden voor
het geven van oefentherapie volgens traditionele neurologische
behandelconcepten; oefentherapie voor de bovenste extremiteit;
biofeedback‐therapie; neuromusculaire en functionele elektrostimulatie
gericht op het verbeteren van armhand‐ of loopvaardigheid; het geven van
orthesen voor de onderste extremiteit, loophulpmiddelen en/of slings.
Evenmin werd evidentie gevonden voor interventies die gericht waren op
het verminderen van hemiplegische schouderpijn of handoedeem.
Geconcludeerd kan worden dat in deze systematische review kleine tot
grote effect sizes zijn gevonden voor functionele taakgeoriënteerde
oefentherapie, vooral wanneer deze intensief in de eerste maanden na het
ontstaan van het CVA werd gegeven. In bijna alle geïncludeerde studies
beperkten de effecten zich voornamelijk tot de activiteiten die direct in het
oefenprogramma waren getraind.

De allesomvattende review (Hoofdstuk 2) suggereert dat intensieve
oefentherapie, gestart in de eerste 6 maanden na het ontstaan van het CVA,
geassocieerd is met een sneller herstel van de uitvoering van activiteiten
door patiënten met een CVA. Hierop gebaseerd is in Hoofdstuk 3 een studie
uitgevoerd om ten aanzien van oefentherapie het effect van intensiteit van
therapie te onderzoeken bij patiënten met een CVA. Intensiteit werd hierbij
uitgedrukt in de tijd (aantal minuten) die praktisch werd besteed aan het
behandelen van patiënten met een CVA. Hiertoe zijn gerandomiseerde
studies systematisch beoordeeld door middel van het evalueren van de
effecten van intensiteit van therapie op ADL, loopvaardigheid en
212
armhandvaardigheid. De hypothese hierbij was dat de extra therapietijd die
de experimentele groepen werd toebedeeld, zou resulteren in klinisch
relevante verbeteringen. Door middel van het gebruik van ‘fixed’ en
‘random’ effect modellen werden voor ADL, loopsnelheid en
armhandvaardigheid SES’s berekend. Twintig RCT’s, waarin 2686 patiënten
met een CVA participeerden, werden geïncludeerd in deze studie. De
methodologische kwaliteit varieerde van 2 tot 11 punten (max. score 14
punten) op een aangepaste methodologische scorelijst. Statistische pooling
van data die bij beëindiging van de interventieperiodes werden verzameld,
resulteerde in een kleine maar statistisch significante random SES voor ADL
(SES 0.13; 95% BI, 0.03 ‐ 0.23). Verdere analyses lieten een significante
homogene SES zien voor 17 studies die de effecten van een toegenomen
intensiteit van oefentherapie onderzochten in de eerste 6 maanden na
ontstaan van het CVA. Geen significante homogene SES werd gevonden
voor de 3 studies die plaats vonden in de chronische fase na het CVA.
Gemiddeld ontvingen de experimentele groepen twee keer zoveel
fysiotherapie (49 min.) en ergotherapie (23 min.) dan de controlegroepen
(resp. 23 en 11 min.). Een cumulatieve meta‐analyse voor het verschil in
behandelintensiteit van elke individuele studie suggereert in sterke mate dat
tenminste 16 uur verschil in behandeltijd, aangeboden in de eerste 6
maanden na het ontstaan van een CVA, nodig is om een significant verschil
in ADL te verkrijgen. Een significante SES, in het voordeel van een hogere
behandelintensiteit, werd ook aangetoond voor instrumentele ADL (SES
0.23; 95% BI: 0.13 – 0.33) en loopsnelheid (SES 0.19; 95% BI: 0.01 – 0.36),
terwijl geen significante SES werd gevonden voor armhandvaardigheid (SES
0.03; 95% BI: ‐0.13 – 0.19).

Verbetering van een symmetrische gewichtverdeling over beide benen
tijdens het rechtop staan is een van de belangrijkste behandeldoelen
gebleken bij het revalideren van patiënten met een CVA. In Hoofdstuk 4, is
systematisch de evidentie bestudeerd voor het effect van de toepassing van
additionele ‘visuele feedback therapie’ (VFT) op het evenwicht tijdens het
rechtop staan bij patiënten met een CVA. Het hoofddoel was te onderzoeken
of VFT bij patiënten met een CVA de houdingszwaai kan reduceren en de
links‐rechts symmetrie tijdens bilateraal staan kan verbeteren, vergeleken
met patiënten die conventionele therapie ondergingen. Tevens werden de
effecten van VFT bestudeerd op parameters zoals evenwicht, lopen en ADL.
Acht van de 78 verzamelde studies (6 RCT’s en 2 CCT’s), waarin 214
patiënten participeerden, werden geïncludeerd voor een kwalitatieve en
kwantitatieve analyse. De methodologische kwaliteit op de PEDro‐schaal
213
varieerde van 3 tot 6 punten. De toegevoegde (additionele) waarde van VFT
tijdens bilateraal staan vergeleken met conventionele therapie liet geen
statistisch significant effect zien op symmetrie van gewichtsverdeling tussen
het paretische en niet‐paretische been, houdingszwaai, evenwicht, lopen en
ADL. Visuele feedback therapie moet derhalve niet de voorkeur krijgen
boven conventionele therapie. Deze resultaten van hoogklinische waarde
geven aan dat het trainen van evenwicht bij voorkeur plaats moet vinden
tijdens de te trainen loopgerelateerde activiteiten zelf. De vraag blijft bestaan
hoe asymmetrie in gewichtverdeling zich verhoudt tot controle van het
evenwicht bij patiënten met een CVA.

In Hoofdstuk 5 is de beschikbare evidentie verzameld en beschreven om
fysiotherapeuten te assisteren in hun klinisch besluitvormingsproces tijdens
het revalideren van patiënten met een CVA. Dit is vooral toegespitsts op het
selecteren van 1) geschikte prognostische factoren, 2) fysiotherapeutische
interventies en 3) meetinstrumenten die in staat zijn functionele vooruitgang
van patiënten met een CVA te evalueren. Deze evidentie is in Nederland
gepresenteerd als de KNGF‐Richtlijn Beroerte (Clinical Practice Guideline on
Physiotherapy management of patients with Stroke: CPGPS). In
verschillende databestanden werd systematisch gezocht naar evidentie met
betrekking tot prognostiek, interventies en meetinstrumenten.
Fysiotherapeuten werkzaam in de CVA‐revalidatie en een multidisciplinaire
groep professionals die ook betrokken zijn bij CVA‐zorg hebben de klinische
bruikbaarheid van de richtlijn en de praktische toepassing van de
aanbevelingen beoordeeld. Hun commentaar werd gebruikt om de
definitieve richtlijn op te stellen. Van de 9482 relevante artikelen zijn er 322
geselecteerd en op methodologische kwaliteit beoordeeld. Uit de
geselecteerde artikelen zijn 72 aanbevelingen voor de klinische praktijk
opgesteld en opgenomen in de richtlijn: 6 aanbevelingen betreffen het
voorspellen van functioneel herstel na CVA voor activiteiten van het
dagelijks leven, loopvaardigheid en armhandvaardigheid; 65 aanbevelingen
betreffen de keuzes voor fysiotherapeutische interventies; en 1 aanbeveling
betreft de keuze voor het gebruik van meetinstrumenten. Een basisset van 7
betrouwbare, responsieve en valide meetinstrumenten is vastgesteld om
stoornissen in functies en beperkingen in activiteiten en participatie te
kunnen bepalen bij patiënten met een CVA. De richtlijn geeft
fysiotherapeuten evidence‐based aanbevelingen die hen assisteren in de
klinische besluitvorming ten aanzien van het behandelen en evalueren van
patiënten met een CVA. De meeste aanbevelingen die in de richtlijn zijn
opgenomen, zijn afkomstig van studies waarin patiënten participeerden die
214
zich in de postacute en chronische fase na een CVA bevonden. Tevens
hebben de meeste studies die in de richtlijn zijn opgenomen minder ernstig
aangedane patiënten en patiënten met weinig of geen co‐morbiditeit
geïncludeerd, terwijl juist behoefte is aan meer kennis omtrent ernstige en
gecompliceerde patiënten met een CVA.

De basisset meetinstrumenten uit de KNGF‐Richtlijn Beroerte bestaat uit de
Motricity Index (MI), Trunk Control Test (TCT), Berg Balance Scale (BBS),
Functional Ambulation Categories (FAC), Ten Metre Walk (TMW), Frenchay
Arm Test (FAT) en Barthel Index (BI). Het meten, evalueren en monitoren
van de functionele status van patiënten wordt beschouwd als een aspect van
goede klinische praktijkvoering door fysiotherapeuten. Zodoende is na
disseminatie van de KNGF‐Richtlijn Beroerte in Hoofdstuk 6 onderzocht, in
welke mate fysiotherapeuten aangeven de geadviseerde meetinstrumenten
uit de KNGF‐Richtlijn Beroerte te gebruiken. Tevens is bestudeerd welke
belemmerende en bevorderende factoren door hen worden ervaren om
meetinstrumenten al dan niet in de dagelijkse handelingspraktijk te
gebruiken. Een vragenlijst bestaande uit 41 items, waaronder de vragen naar
belemmerende en bevorderende factoren (Barriers and Facilitators
Questionnaire, BFQ), was per post verzonden naar 400 fysiotherapeuten,
werkzaam in ziekenhuizen (acute care hospitals: ACH; N=100),
revalidatiecentra (RC; N=100), verpleeghuizen (nursing homes: NH; N=100)
en 1e lijnfysiotherapie praktijken (private physiotherapy practices: PPP;
N=100). De vragenlijst werd door 198 fysiotherapeuten geretourneerd (47%;
ACH, N=57; RC, N=67; NH, N=26 en PPP, N=39). De 167 vragenlijsten
afkomstig van fysiotherapeuten betrokken bij CVA‐zorg konden worden
geanalyseerd. Deze fysiotherapeuten rapporteerden een regulier gebruik
van drie (mediaan; range 0‐7) van de zeven geadviseerde meetinstrumenten,
waarbij de fysiotherapeuten werkzaam in ACH of RC een significant hoger
gebruik rapporteerden dan hun collega’s in PPP (resp. 4 versus 0 en 3 versus
0; p<0.001 en p=0.02). De BFQ laat specifieke bevorderende factoren zien,
zoals ‘positieve attitude ten aanzien van meetinstrumenten’ (genoemd door
93% van de fysiotherapeuten) en ‘bekendheid met meetinstrumenten’ (90%)
en belemmerende factoren, zoals ‘veranderen van routines’ (32%),
‘tijdsinvestering’ (29%), en ‘financiële compensatie’ (21%). Ondanks een
door vrijwel alle therapeuten geopperde positieve attitude, gebruiken
Nederlandse fysiotherapeuten de geadviseerde meetinstrumenten niet in
voldoende mate. Krachtige settingspecifieke en op maat gesneden
implementatiestrategieën gebaseerd op de gerapporteerde bevorderende en
belemmerende factoren worden aanbevolen.
215
Om het zelfgerapporteerde en actuele gebruik van meetinstrumenten door

fysiotherapeuten in de CVA‐zorg te verhogen, is een nieuwe
scholingsmodule ontwikkeld, het zogenoemde Physiotherapists Educational
Program Clinimetrics in Stroke (PEPCiS). In Hoofdstuk 7 wordt de
haalbaarheid en effectiviteit van deze scholingsmodule onderzocht in een
gerandomiseerd onderzoek. In deze RCT werden 30 fysiotherapeuten,
werkzaam in de CVA‐zorg, gerandomiseerd over twee numeriek gelijke
groepen, een ‘expert tutor groep’ (ETG) en ‘non‐expert tutor groep’ (NETG).
De twee tutoren verschilden in de mate van klinische ervaring met
meetinstrumenten bij patiënten met CVA. Tevens werd de invloed van
tutorstijl verkend in deze haalbaarheidsstudie. De haalbaarheid van de
studie werd beoordeeld door middel van het evalueren van de
betrokkenheid van de geïncludeerd fysiotherapeuten, de tevredenheid ten
aanzien van PEPCiS, en de waardering van tutorstijl van de aan hen
toegewezen tutor. Effectiviteit door het berekenen van het aantal keer
genoteerd gebruik van meetinstrumenten in de patiëntenstatussen door de
participerende fysiotherapeuten. Over het algemeen waren de
fysiotherapeuten goed betrokken (mediaan van 5 scholingssessies; range 4‐5)
en tevreden met PEPCiS (gemiddeld cijfer: 7.5 op een 0‐10 schaal). In de
totale groep (N=30) steeg het gebruik van meetinstrumenten van 3 per
patiënt voorafgaand aan PEPCiS tot 5 na afloop (p=0.001). De ‘tussen‐groep’
verschillen zijn niet significant voor het totaal aantal gebruikte
meetinstrumenten (mediaan van 3 naar 6 in de ETG versus van 3 naar 4 in
de NETG; p=0.07). Fysiotherapeuten in the ETG waarderen de inhoud van
PEPCiS, hun kennistoename en alle tutorstijl aspecten significant beter dan
hun collega’s in de NETG (p<0.05). Deze pilotstudie suggereert dat educatie
door middel van PEPCiS het gebruik van klinische meetinstrumenten door
fysiotherapeuten die betrokken zijn bij de zorg van patiënten met een CVA,
doet toenemen. In een toekomstig onderzoek met voldoende statistische
power zal de invloed van PEPCiS en interfererende factoren zoals ervaring
en performance van de tutoren bestudeerd moeten worden om daarmee de
effectiviteit van educatieve interventies, als onderdeel van een
implementatiestrategie, te verbeteren, zoals bijvoorbeeld het reguliere
gebruik van meetinstrumenten door fysiotherapeuten.

Hoofdstuk 8 presenteert een algemene discussie waarin de hoofdconclusies
van dit proefschrift besproken worden en de sterke en zwakkere punten van
de gehanteerde methoden bediscussieerd worden. Tevens geeft Hoofdstuk 8
klinische implicaties betreffende fysiotherapie bij patiënten met een CVA,
aanbevelingen voor toekomstig CVA‐onderzoek en suggesties voor educatie
216
en implementatie van onderzoeksresultaten in de dagelijkse

handelingspraktijk van professionals in de CVA‐zorg.
References

LATM, Koek HL, Van Trijp MJCA et al., editors. Hart‐en vaatziekten in Nederland 2005,
217

218

Dankwoord

Dankwoord
Dankwoord
Tijdens de jaren die ik als fysiotherapeut werkzaam was in revalidatiecentra,
stelde ik mij meer en meer de vraag of fysiotherapie bij patiënten met een
CVA er wel toe doet. Is er bewijs voorhanden dat bepaalde behandelingen
effectief zijn? Is het mogelijk om beter te voorspellen welke activiteiten een
patiënt na een beroerte weer kan uitoefenen? Zijn veranderingen in het
herstel van deze patiënten objectief te beschrijven? Dat deed mij besluiten
om bewegingswetenschappen te gaan studeren. De antwoorden die ik
tijdens die studie kreeg hebben mij geholpen om ‘fysiotherapie bij patiënten
met een CVA’ kritischer te gaan bekijken. Maar niet alle vragen kregen een
antwoord. Er lag nog een groot onderzoeksveld braak. Het was eigenlijk
nooit mijn ambitie te gaan promoveren, ik rolde min of meer vanzelf in dit
promotietraject. Ik kreeg de kans om mijn interessegebied verder te
onderzoeken, waarbij ik zowel de ‘wetenschap’ als de ‘praktijk’ wilde
voeden. Maar zoals, ‘towards’, het startwoord van mijn thesistitel al doet
vermoeden, is nog niet alles bekend, onderbouwd of bewezen op het gebied
van evidence‐based fysiotherapie bij patiënten met een beroerte.
De jaren van mijn promotie vormde een prachtige leerzame periode waarin
veel vragen zijn gesteld, veel antwoorden zijn gegeven, maar ook veel
nieuwe vragen zijn ontstaan. Het interessante van een promotietraject is dat
het je ook samen brengt met veel mensen die ieder op zijn of haar eigen
wijze een bijdrage leveren aan de totstandkoming van het proefschrift.

In het bijzonder wil ik dan ook de volgende personen bedanken:

Professor dr. Eline Lindeman, beste Eline, je bent als mijn promotor op
een rijdende trein gesprongen. Ik was al deels op gang gekomen toen ik in
Utrecht kwam werken. Jouw hoogleraarschap bij de Divisie Hersenen van
het UMC Utrecht maakte het logisch dat ik, als medewerker van dezelfde
divisie, bij jou ging promoveren. Mijn verzoek of je als mijn promotor wilde
fungeren heb je direct en enthousiast opgepakt. Zelfs op de momenten dat je
fysieke tegenslag kende, maakte je tijd vrij voor mij. Ons interessegebied qua
onderzoek ligt bij het revalideren van patiënten met een CVA en dat was
merkbaar in de discussies die we voerden. Bedankt voor de begeleiding en
het vertrouwen dat ‘promoveren’ mij zou lukken.

Dr. Gert Kwakkel, beste Gert, ik ben jou veel dank verschuldigd. Jij hebt
mij als onderzoeker een plek heeft gegeven in de wetenschappelijke wereld.
In 2002 kreeg jij mijn scriptie over ‘het meten van evenwicht bij patiënten
220
Dankwoord
met een CVA’ onder ogen, waarmee ik de universitaire opleiding
bewegingswetenschappen had afgerond. Deze scriptie hebben we samen
omgevormd tot onze eerste gezamenlijke publicatie in het Jaarboek
Fysiotherapie. Later hebben we ook andere hoofdstukken en artikelen
samen geschreven. Ook bood je me de gelegenheid om als
projectmedewerker in het VU medisch centrum te komen werken, waar
onder jouw bezielende en vakkundige leiding de KNGF‐Richtlijn Beroerte
tot stand is gekomen. Daar is ook het idee ontstaan om te gaan promoveren.
Uiteraard werd jij mijn co‐promotor, voor een promotorschap was het nog
net te vroeg, anders had ik het je zeker gevraagd. Je hebt me veel bijgebracht
op zowel methodologisch als vakinhoudelijk gebied. Inmiddels heb je
wereldwijd faam opgebouwd als vooraanstaand wetenschapper op het
gebied van ‘stroke rehabilitation’. Bedankt voor jouw begeleiding. Ik ben er
trost op dat je mijn opleider bent geweest en hoop de samenwerking nog
lang met je voort te zetten .

Dr. Nico van Meeteren, beste Nico, mijn tweede co‐promotor. In 2004
heb je mij aangenomen als stafmedewerker Onderwijs, Onderzoek &
Ontwikkeling voor de opleiding Fysiotherapiewetenschap (FW). Een
opleiding die jij ‘smoel’ hebt gegeven. Ik werd onderdeel van jouw
docenten‐ en onderzoekersteam, een dedicated team. De drie FW‐jaren zal ik
om meerdere redenen niet snel vergeten. Naast onze reguliere drukke
onderwijswerkzaamheden heb je altijd tijd gevonden mij positiefkritisch bij
te staan in het afronden van mijn proefschrift. In onze gesprekken heeft jouw
passie voor wetenschap en fysiotherapie mij enorm geïnspireerd. Net als de
andere pioniers van de opleiding Fysiotherapiewetenschap heb jij inmiddels
een nieuwe uitdagende baan gevonden. Succes op jouw nieuwe stek. Ik kijk
met een goed gevoel terug op onze samenwerking en wil je daar uiteraard
voor bedanken. In de toekomst hoop ik dat we elkaar zullen blijven treffen
en inspireren.

Dr. Marieke Schuurmans, beste Marieke, mijn derde co‐promotor. Ik
werk pas een jaar in ‘jouw lectoraat’ op de Hogeschool Utrecht en heb
daarin volop ruimte gekregen om mijn proefschrift af te ronden. Ook jij bent
op de rijdende trein gesprongen, maar voordat je dat deed, heb je me
duidelijk gemaakt dit alleen te doen als je een relevante bijdrage kon leveren
aan mijn proefschrift. Inmiddels een jaar verder is dat duidelijk
waarneembaar. Je hebt me ‘achter de oren laten krabbelen’ als ik in de
conceptversies van mijn manuscript jouw potloodkanttekeningen las. Het
proefschrift is er door jouw inbreng zeker beter van geworden. Bedankt, ik
221
Dankwoord
hoop in het Kenniscentrum ‘Innovatie van Zorgverlening’ nog veel projecten
samen met je op te pakken. Het is prettig met je samenwerken.

Om alle schijn van voorkeur te voorkomen pak ik de ‘bedankdraad’
chronologisch en alfabetisch op.

Als fysiotherapeut‐in‐opleiding ben ik door docenten en studenten
gevormd op de Haagse Academie voor Lichamelijke Opvoeding &
Fysiotherapie. Op mijn stageadres, het Nederlands Zeehospitium in
Kijkduin, heb ik mijn eerste patiënt met een CVA behandeld. En bij mijn
eerste werkgever, het revalidatiecentrum De Trappenberg in Huizen ben ik
door het volgen van de cursus Neuro Developmental Treatment (NDT)
begonnen met het specialiseren op het specifieke domein CVA. Daarna nog
een uitstap gemaakt naar De Adriaanstichting in Schiebroek, waar ik met
veel plezier en met een hoop toegewijde collega’s, kinderen met diverse
aandoeningen heb gerevalideerd. Hoewel de aangereikte kennis met
betrekking tot het behandelen van patiënten met een CVA uit deze jaren
enigszins is veranderd, wellicht verouderd, heb ik in die tijd veel
opgestoken. Een ieder die mij in die periode op weg heeft geholpen wil ik,
zonder namen te noemen, bedanken.

Vanaf 1995 ben ik gaan werken in het revalidatiecentrum Rijndam in
Rotterdam. Vanaf de bouw ben ik bij dit centrum betrokken geweest, en hoe
kan het anders, de eerste patiënt die ik op de klinische behandelafdeling 2
(KBA‐2) ging behandelen was een patiënt met een CVA. Rijndam heeft mij
de mogelijkheid gegeven om de deeltijdopleiding bewegingswetenschappen
in Maastricht op te pakken. Ook heb ik op KBA‐2 mijn eerste pilotstudy uit
kunnen voeren om de relatie tussen evenwicht en loopfunctie te
onderzoeken bij patiënten met een CVA. Hier is ook het besef gekomen dat
‘klinimetrie’ (het in kaart brengen, meten, van mogelijkheden en
onmogelijkheden van patiënten met meetinstrumenten) een belangrijk
hulpmiddel is. Uit de ‘Rijndamtijd’ wil ik alle collega’s bedanken die het
werken in dit centrum tot een plezier maakten. Een aantal Rijndam‐collega’s
wil ik in het bijzonder bedanken, omdat zij samen met de eerste
‘klinimetrische stappen’ hebben gezet (Mariella Aarden, Irene de Bruijn,
Arne Goedhart, Gerard Hommes, Leonie Oostveen, Karin Postma) of mij
gestimuleerd hebben bij mijn eerste ‘wetenschappelijke stappen’ (Michael
Bergen, Hans Bussman en Gerard Ribbers).

222
Dankwoord
Tijdens mijn opleiding Bewegingswetenschappen aan de Universiteit

Maastricht ben ik in een enorme enthousiaste groep medestudenten
terechtgekomen. Tijdens de studie zijn Jan Willem de Bruijn, Roland van
Grinsven, Hans Hobbelen, Ton Lenssen, Karin Postma en Walter van der
Weegen, vrienden geworden en hebben we met elkaar het Instituut voor
Bewegingsvraagstukken (IBV) opgericht. Door onze drukke reguliere
werkzaamheden is deze IBV‐denktank verworden tot een reünieclub die
elkaar één à twee keer per jaar treft bij een sportieve activiteit, een biertje of
een etentje. Maar ook Rob de Bie, Eric van Rossum en Henk Seelen wil ik
bedanken voor het begeleiden van mijn afstudeerproducten in Maastricht.

De twee jaar die ik op het Vrije Universiteit medisch centrum in
Amsterdam heb gewerkt bij de Dienst Fysiotherapie zullen me altijd bij
blijven. Met Marc Rietberg en Benno van Tol als kamergenoten hebben we
naast heel hard werken ook veel plezier kunnen hebben. Niet iedereen kon
in Amsterdam mijn liefde voor Feijenoord begrijpen, helaas speelden Ajax
(Marc) en AZ (Benno) in die tijd regelmatig beter voetbal dan Feijenoord,
maar mijn pantser heeft altijd stand gehouden. Ook met Erwin van Wegen
heb ik destijds een geweldige tijd beleefd in het VUmc en zeker onze
gezamenlijke trip naar de World Confederation for Physical Therapy
(WCPT) in Barcelona zal onuitwisbaar blijven. Ook alle andere collega’s van
de Dienst Fysiotherapie van het VUmc wil ik bedanken voor de prettige
samenwerking. En speciaal Rob van Klaveren voor zijn vertrouwen in mij
en zijn inspanningen om mijn tijdelijke aanstelling telkens maar weer te
verlengen, totdat de rek er uit was.

Daarna zocht, en vond, ik mijn heil in Utrecht. Ik kwam in een enorm
inspirerend team te werken bij de opleiding Fysiotherapiewetenschap van
de Universiteit Utrecht met collega’s die zowel gedreven docenten,
onderzoekers als onderwijsontwikkelaars waren. Met alle collega’s uit die
tijd was het fantastisch samenwerken. Rob van Dolder, Jaap Dronkers,
Frank van Genderen (ook bedankt voor de waardevolle tips hoe je zelf de
lay‐out van tekst en tabellen in het proefschrift kunt verzorgen), Janke de
Groot, Nico van Meeteren, Jan Prins, Carin Schröder (ook bedankt voor de
jouw suggesties met betrekking tot de Theory of Planned Behaviour),
Miranda Velthuis en Harriet Wittink zijn inmiddels allemaal bij de
opleiding Fysiotherapiewetenschap vertrokken. Onderling hebben, en
houden, wij een sterke en vriendschappelijke band, dat weet ik zeker. Het
waren drie inspirerende, leerzame jaren.

223
Dankwoord
Naast mijn deeltijdbaan bij de Universiteit Utrecht startte ik in die tijd
ook als docent ‘centraal neurologische aandoeningen’ (CNA) bij de
opleiding Fysiotherapie van de Hogeschool Utrecht. Ook daar trof ik het met
Henk Dekkers, Joost Leonhard, Mient Riddersma, Mariska van Vugt en
Els Veekens als naaste CNA collega‐docenten. Na een jaar heb ik de
overstap gemaakt naar de Professional Masteropleiding Fysiotherapie (PMF)
en heb me daar ingezet om de implementatie van ‘best‐practice ontwerpen’
door masterstudenten in het fysiotherapeutisch werkveld gestalte te geven.
Het kernteam van de PMF is klein en ook weer gedreven. Het is prettig
samenwerken in dit team met Ina Bettman, Rob van Dolder, Jaap
Dronkers, Rutger IJntema, Han Kingma, Els de Lange, Jacqueline
Nuijsink, Jorrit Rehorst en Dammis Vroegindeweij. Maar niet alleen mijn
collega’s van het kernteam PMF wil ik bedanken, zeker ook de collega’s die
als projectbegeleiders dagelijks met onze studenten optrekken in het BPO‐
onderwijs. De laatste tijd heb ik veel drukte aan mijn hoofd gehad met het
afronden van mijn thesis, maar met elkaar hebben we toch het BPO‐
onderwijs op de kaart gezet en draaiende gehouden. Liesbeth Bosma,
Mohamed Elhadouchi, Raoul Engelbert, Hans Heneweer, Hans Hobbelen,
Erik Hulzebos, Jaap Jansen, Sandra Jorna, Barbara Kölzer, Francois
Maissan, Jacqueline Outermans, Edwin de Raaij en Kitty Meijer, bedankt.
En mijn speciale dank gaat uit naar Mieke Klootwijk, Harm Drost,
Harriët Wittink en Marieke Schuurmans die mogelijkheden wisten te
creëren waarmee het promoveren via de Hogeschool Utrecht voor mij
mogelijk werd. En ook de andere collega’s van de hogeschool zijn een factor
waardoor ik toch telkens weer met een positieve insteek de reis van Delft
naar Utrecht onderneem. En dat we deze zomer tijdens de Tour de France
met veel hogeschoolcollega’s weer om de ‘wisselfiets’ kunnen strijden. Lars
(van Rijswijk), ‘patron’ van ons tourspel, ik heb nu weer alle tijd om mij
optimaal voor te bereiden op de editie 2008, alle uitslagen zal ik in het
voorseizoen weer punctueel napluizen. Dat het wederom een mooi jaar mag
worden. Bij de prijsuitreiking van de ‘wisselfiets’ op de Beaujolaisavond ben
ik er zeker bij.

De lectoren en mijn collega’s van het Lectoraat ‘Verpleegkundige en
paramedische zorg voor mensen met chronische aandoeningen’ van de
Hogeschool Utrecht, Ilse Arts, Mia Duijnstee, Roelof Ettema, Thóra
Hafsteinsdóttir, Jita Hoogerduijn, Michel Jansen, Anneke de Jong,
Marijke Rensink, Maaike Smole, Marieke Schuurmans en Carolien Sino,
wil ik bedanken dat ik mijn aandacht in het eerste jaar van mijn aanstelling
volledig heb kunnen richten op het afronden van mijn proefschrift.
224
Dankwoord

Bij de verschillende werkgevers tijdens mijn promotietraject heb ik goede
en prettige secretariële ondersteuning gehad. Inge Kuurman
(Fysiotherapiewetenschap), Sue McClelland (UMCU), Marjan van de
Monde (VUmc) en Maaike Smole (HU), bedankt voor de werkzaamheden
die jullie mij uit handen hebben genomen.

Bij het tot stand komen van de KNGF‐Richtlijn Beroerte heb ik met een
achttal zeer bekwame en in CVA‐zorg gespecialiseerde fysiotherapeuten
kunnen samen werken, die als klankbordgroep hebben gefungeerd. Ik wil
Meike Berns, Jaap Buurke, Barbara Harmeling, Jos Halfens, Hans
Hobbelen, Boudewijn Kollen, Matthijs Vogel en Lydia Wagenborg
bedanken voor hun specialistische bijdrage en plezierige samenwerking.

Ook veel dank aan de medeauteurs van de artikelen die de afgelopen
jaren zijn geschreven en zijn opgenomen in dit proefschrift: Ann Ashburn,
Joost Dekker, Rob van Dolder, Frank van Genderen, Paul Helders, Erik
Hendriks, Michiel Kortsmit, Gert Kwakkel, Peter Langhorne, Eline
Lindeman, Nadina Lincoln, Francois Maissan, Nico van Meeteren,
Kimberly Miller, Cecily Partridge, Carol Richards, Marieke Schuurmans,
Eric Stutterheim, Robert Wagenaar, Philip van der Wees, Ian Welwood en
Sharon Wood‐Dauphinee. Zonder jullie inbreng was de kwaliteit van de
artikelen waarschijnlijk minder goed geweest.

Meta Wildenbeest ben ik dank verschuldigd voor haar inzet als ‘tutor’ in
een van de studies van dit proefschrift. Tevens wil ik een aantal studenten
van de opleiding Fysiotherapiewetenschap bedanken: Ivo Daanen, Hans
Herik, Erwin Huiszoon, Han Kingma, Leny de Ligny, Koert Nederbragt,
Eric Passchier, Peter Viehoff, Judith Weijman en Elles Zock. Zij hebben
geholpen bij het uitvoeren van een deelproject dat nu deel uitmaakt van dit
proefschrift.

Boudewijn Kollen, Cas Kruitwagen en Paul Westers, bedankt voor jullie
suggesties met betrekking tot de statistische analyses die ik heb uitgevoerd.
Statistiek blijft een vak apart.

Verder ben ik dankbaar, dat ik in juni 2007 in Canada tijdens de World
Confedaration for Physical Therapy (WCPT) in Vancouver een zeer
gemotiveerde internationale groep fysiotherapeuten heb ontmoet. Deze
fysiotherapeuten en onderzoekers uit Amerika, Australië, Canada,
225
Dankwoord
Engeland, Zuid‐Afrika en Nederland zijn voornemens de International

Neuroscience Physiotherapy Association op te richten. Louise Ada, Ralph
Hammond, Fiona Jones, Cherry Kilbride, Mindy Levin and Mary Solomon
thanks for inviting me. A collaboration to look forward to.

Het manuscript ben ik vlak voor de kerstvakantie gaan afleveren bij alle
leden van de beoordelingscommissie. In plaats van vakantie vieren hebben
ze tijd vrij gemaakt voor mijn proefschrift. Ik wil Prof. dr. R.A. De Bie, Prof.
dr. G. Croiset, Prof. dr. J. Dekker, Prof. dr. L.J. Kappelle en Prof. dr. Th.J.M.
Verheij, als voorzitter van deze commissie, hartelijk danken voor het
kritisch beschouwen van het manuscript.

Mijn paranimfen, Rob van Dolder en Frans van der Zon.
Beste Rob, we zijn in 2004 ongeveer tegelijk gaan werken bij de opleiding
Fysiotherapiewetenschap en sindsdien zijn we onafscheidelijk gebleken. We
hebben op diverse plekken intensief samen gewerkt en doen dat nog steeds
op innige en humoristische wijze. Niet alleen als collega ook als vriend heb
je een plek veroverd. Laten we nog veel mooie dingen samen gaan maken en
doen. En laat de spreuk op jouw toilet, thuis in Zeist, altijd hangen: ‘No
Brain, No Headache’. Ik weet namelijk nog steeds niet of je dan blij moet zijn
met hoofdpijn of juist niet.
Beste Frans, wij kennen elkaar al een aanzienlijke tijd. Een vriendschap
vanaf de 1e klas van de Cornelius Musiusschool, onze lagere school in Delft.
In augustus 2007 vierden we onze veertigjarige vriendschap. Onze wegen
liepen lang parallel, zelfde lagere en middelbare school, zelfde
sportverenigingen, gezamenlijke vakanties. Dat we er nog minstens 40 jaar
aan vast mogen knopen en nog lang samen kunnen biken, schaatsen,
hardlopen (je weet het nooit), skeeleren, voetballen (nee, dat is echt voorbij,
toch?) en korfballen (maar uitsluitend kijken hoor!).
Rob en Frans, vrienden hoef je eigenlijk niet op schrift te bedanken, dat
blijkt uit andere dingen. Ik hoop nog veel plezier uit onze vriendschappen te
halen. En het etentje bij de Heeren van Delft is voor herhaling vatbaar.

Mijn fietsmaten, William Lustig, Edward Nijboer, Cinco Veldman,
Gerco Vredeveldt, Mario van der Wel en Frans van der Zon, zonder onze
asfalt‐ of terreintochten op zondagochtend had ik nu stijf, dik en humorloos
aan de kant gezeten. Ik kijk weer uit naar de stormachtige ritten door het
Westland of het Groene Hart, de acrobatische hoogstandjes in Sweet Lake
City of in Warempage, de verhalen die vaak nergens over gaan en natuurlijk
naar het koffiedrinken bij de Klimwand of De Snor (hoewel die gevlogen
226
Dankwoord
lijkt). In plaats van de wekelijkse korte en krachtige fietsoproep per e‐mail,
nu alvast (is weer eens wat anders) een oproep voor aanstaande zondag:
“Bikers, zondag 1 juni 2008, 9.15 uur, V16, terrein, noppenbanden,
akkoord?”

Mijn andere vrienden en vriendinnen die ik ondanks de hectiek van
alledag die we allemaal ervaren, toch met regelmaat blijf zien. Door het
schrijven van het proefschrift is bij sommige vrienden de regelmaat wel in
een zeer lage frequentie terechtgekomen (maar dan zit er toch regelmaat in).
De afronding van het proefschrift is een goede aanleiding om weer bij
vrienden langs te gaan voor een kop koffie of gewoon een avondje de kroeg
in te duiken. En niemand hoeft zich meer op voorhand bezwaard te voelen
om spontaan bij ons aan te bellen.

Ik dank mijn schoonouders, Krijna en Henny Kouwenhoven, mijn zus,
Angelique, maar bovenal mijn ouders, Coby en Martin van Peppen, die mij
stimuleerden en ook altijd hun belangstelling toonden over de voortgang
van mijn promotie. Ik draag het proefschrift op aan mijn ouders. Ook al was
het voor jullie soms lastig om inhoudelijk te kunnen doorgronden waar ik
mee bezig was. Jullie hebben mijn basis gelegd, me klaar gestoomd voor
deze wereld en me in staat gesteld om mijn eigen keuzes te leren maken. Ik
hoop voor jullie en mijn andere familieleden en vrienden de komende
periode meer tijd vrij te kunnen maken om elkaar te zien. Mijn kinderen Tim
& Lara zagen mij in de avonduren en weekenden vaak achter mijn laptop
zitten. “Is dat nou promoveren?”, hoorde ik ze regelmatig mompelen. In de
weekenden maakte ik gelukkig steeds tijd vrij om als supporter bij hun
korfbalwedstrijden te zijn. Blijf lekker sporten, is beter dan achter de PC
zitten. Ik ga, nu het leven (hopelijk) iets minder ‘vol’ zal worden, ook minder
‘computeren’ en meer sporten. Blijk ik toch opeens aan voornemens te doen!
Maar de meeste dank en waardering gaat natuurlijk uit naar Marianne.
Ze heeft me, om in wielertermen te spreken, ‘uit de wind gehouden’. Ik heb
de afgelopen jaren vrijwel niets meer in het huishouden gedaan, terwijl ik
me daar voorheen toch wel hard voor maakte. Albert Heijn heb ik al lang
niet meer van binnen gezien. Marianne, jouw schaarse vrije tijd ging op aan
dingen waar ik niet aan toe kwam. Wat ik van jou vind, weet je al en zeg ik
liever rechtsreeks tegen je dan dat ik het via dit proefschrift kenbaar maak.

En mocht ik iemand vergeten zijn in dit dankwoord. Dat was niet mijn
bedoeling. Ook alle niet bij naam genoemden bedankt.

227
Dankwoord

228

Publications

Publications
International journals

Van Peppen RPS. Guest Editorial ‐ International collaboration in
physiotherapy management of people with stroke. Physiotherapy
Research International, 2008;13(1):3‐8
Van Peppen RPS; Hendriks HJM; Van Meeteren NLU; Helders PJM;
Kwakkel G. The development of a clinical practice stroke guideline
for physiotherapists in the Netherlands: a systematic review of
available evidence. Disability and Rehabilitation, 2007;29(10):767‐783
Van Peppen RPS, Kortsmit M, Lindeman E, Kwakkel G. Effects of visual
feedback therapy on postural control in bilateral standing after
stroke: a systematic review. Journal of Rehabilitation Medicine, 2006;38
(1):3‐9
Hobbelen JS, Koopmans RT, Verhey FR, Van Peppen RP, de Bie RA.
Paratonia: a delphi procedure for consensus definition. Journal of
Geriaticr Physical Therapy, 2006;29(2):50‐56
Smidt N, De Vet HC, Bouter LM, Dekker J, Arendzen JH, De Bie RA, Bierma‐
Zeinstra SM, Helders PJ, Keus SH, Kwakkel G, Lenssen T,
Oostendorp RA, Ostelo RW, Reijman M, Terwee CB, Theunissen C,
Thomas S, Van Baar ME, Van ʹt Hul A, Van Peppen RP, Verhagen A,
Van der Windt DA; Exercise Therapy Group. Effectiveness of
exercise therapy: a best‐evidence summary of systematic reviews.
Australian Journal of Physiotherapy, 2005;51(2):71‐85
Van Peppen RPS; Kwakkel G; Wood‐Dauphinee S; Hendriks HJM, Van der
Wees Ph; Dekker J. The impact of physical therapy on functional
outcomes after stroke: whatʹs the evidence? Clinical Rehabilitation,
2004;18(8):833‐862
Kwakkel G; Van Peppen R; Wagenaar RC; Wood Dauphinee S; Richards C;
Ashburn A; Miller K; Lincoln N; Partridge C; Wellwood I;
Langhorne P. Effects of augmented exercise therapy time after
stroke: A meta‐analysis. Stroke, 2004;35(11):2529‐2536

230
Publications
Dutch journals

Outermans J, Van Peppen RPS.Trainen na een beroerte: dat kan! Training
van de fysieke fitheid bij CVA‐patiënten voor het verbeteren van de
loopvaardigheid. Sportgericht, 2007;61(6):37‐40
Kleijn A, Schuurmans R, De Raaij E, Van de Hart M, Baijens H, Van Peppen
RPS. Manuele Therapie bij heuparthrose: Een evidence‐based
manueeltherapeutisch behandelprotocol met objectivering van
behandelresultaten. MoveMens, 2007;8(5):44‐45
Vereijken A, Sijbers R, Outermans J, Meijer A, Portegies S, Stok K, Baijens H,
Van Peppen RPS. Sporthervatting na voorste kruisband
reconstructie. InFysio, 2007; 3(11):14‐15
Van Peppen RPS. ‘Uw Vraag, Ons Project’: Praktijkveld en masterstudenten
fysiotherapie maken samen Best‐Practice Ontwerp. FysioPraxis, 2007;
16(11):18‐21
Outermans JC; Van Peppen RPS; Takken T. Fysieke Fitheidstraining na een
CVA: een review. Nederlands Tijdschrift voor Fysiotherapie,
2007;117(4):135‐141
Prins JCM; Velthuis JM; Van Peppen RPS; Van Meeteren NLU. Peer support
in de Utrechtse opleiding Fysiotherapiewetenschap. Tijdschrift voor
Hoger Onderwijs & Management (TH&MA), 2007 (1):58‐63
Van Peppen RPS; Harmeling‐van der Wel BC; Kollen BJ; Hobbelen JSM;
Buurke JH; Halfens J; Wagenborg L; Vogel MJ; Berns M, Van
Klaveren R, Hendriks HJM, Heldoorn M; Van der Wees PhJ; Dekker
J; Kwakkel G. Effecten van fysiotherapeutische interventies bij
patiënten met een beroerte: een systematisch literatuuronderzoek.
Nederlands Tijdschrift voor Fysiotherapie, 2004;114(5):126‐153.
This article was awarded with the ‘KNGF Auteursprijs 2006’ for the best
original paper of vol. 2005‐2006 in the Dutch Journal of Physical Therapy
Van Peppen RPS; De Bie R. Systematisch meten van evenwicht en loop‐
vaardigheid bij patiënten met een CVA. Stimulus, 2003‐4: 300‐315

231
Publications
Bookchapters

Van Peppen RPS; Kwakkel G; Wood‐Dauphinee S; Hendriks HJM; Van der
Wees Ph;Dekker J. Einfluss der Physiotherapie auf das funktionelle
Outcome nach Schaganfall: Evidenzen. In: Ch. Dettmers,P. Bülau, C.
Weiller (editors). Schlaganfall Rehabilitation. ISBN 978‐936817‐20‐1
Hippocampus Verlag. Bad Honnef 2007. Chapter 8, p137‐174
Kwakkel G, Van Peppen RPS, Cup EHC, Kalf JG, Fasotti L. Hoofdstuk 27
Revalidatie na een beroerte 3: Effectiviteit. In: CL Franke, M
Limburg (editors). Handboek Cerebrovasculaire aandoeningen.
Enschede: De Tijdstroom, 2006: 347‐368
Van Peppen R; Kwakkel G. Welke Klinimetrie is het meest geschikt voor het
meten van evenwicht bij een CVA‐patiënt? In: Vaes P (editor).
Jaarboek Fysiotherapie‐Kinesitherapie 2002. Houten: Bohn Stafleu
Van Loghum, 2002: 59‐85
Kwakkel G; Van Peppen R. De CVA‐patiënt in evenwicht. In: Vaes P
(editor). Jaarboek Fysiotherapie‐Kinesitherapie 2002. Houten: Bohn
Stafleu Van Loghum, 2002: 45‐58

Books

Beurskens AJHM, Van Peppen RPS, Stutterheim EC, Swinkels RAHM en
Wittink H (redactie). Meten in de Praktijk: Stappenplan voor gebruik
van meetinstrumenten in de gezondheidszorg. Bohn Scheltema
Lochem. Utrecht. In preparation, expected in Summer 2008
- Hoofdstuk 1. Meten met behulp van het stappenplan. Beurskens
AJHM, Stutterheim EC, Swinkels RAHM, Van Peppen RPS.
- Hoofdstuk 4. Zoeken naar meetinstrumenten. Swinkels RAHM, Van
Peppen RPS, Wolters P.
- Hoofdstuk 6. Klinimetrische eigenschappen van meetinstrumenten.
De Vet HCW, Beurskens AJHM, Van Peppen RPS
- Hoofdstuk 8. Interpreteren en rapporteren van meetgegevens.
Stutterheim EC, Swinkels RAHM, Van Peppen RPS
232
Publications
Clinical Practice Guidelines

Dutch version:
Van Peppen RPS, Kwakkel G, Harmeling‐van der Wel BC, Kollen BJ,
Hobbelen JSM, Buurke JH, Halfens J, Wagenborg L, Vogel MJ, Berns
M, Van Klaveren R, Hendriks HJM, Dekker J.
KNGF‐richtlijn Beroerte (V‐12/2004), ISSN 1567‐6137.
Amersfoort, September 2004

English version:
Van Peppen RPS, Kwakkel G, Harmeling‐van der Wel BC, Kollen BJ,
Hobbelen JSM, Buurke JH, Halfens J, Wagenborg L, Vogel MJ, Berns
M, Van Klaveren R, Hendriks HJM, Dekker J.
KNGF Clinical Practice Guideline for Physical Therapy in Patients
with Stroke. Supplement to the Dutch Journal of Physical Therapy.
Volume 114 / Issue 5 / 2004. September 2004, English version: April
2008
233
Publications
234

About the author

About the author
About the author
Roland (PS) van Peppen was born on March 15, 1961 in Delft, the
Netherlands. After completing secondary school (Atheneum) at the ‘Sint
Stanislascollege’ in Delft in 1979, he studied between 1979 and 1983
Physiotherapy at the ‘Haagse Academie voor Lichamelijke Opvoeding &
Fysiotherapie’ in The Hague. After graduating he worked for 19 years as a
physiotherapist in several Dutch rehabilitation centres. The last years he
worked mainly patients with stroke, traumatic brain injuries and lower limb
amputees.
Roland studied Human Movement Sciences at the Maastricht University
from 1998 until 2001. After his graduation he worked for two years as a
research assistant at the Vrije University medical centre (VUmc) in
Amsterdam. In that period he developed the Clinical Practice Guideline on
Physiotherapy management in patients with Stroke (CPGPS). In 2004, he
started as a lecturer/researcher at the Graduate Programme of Physiotherapy
Science at the Utrecht University and also as a lecturer in the Institute for
Human Movement Studies, Department of Physiotherapy of the University
of Applied Sciences Utrecht.
In 2004 he started his PhD‐project in Utrecht where he performed research to
evidence‐based physiotherapy for patients with stroke. Currently he is
working as senior lecturer, staff member and researcher at the University of
Applied Sciences Utrecht. Roland is still living in Delft.

236

Peppen Ebook Clinicalreahabilitation Stroke

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Peppen Ebook Clinicalreahabilitation Stroke

Uploaded by

Copyright:

Available Formats

Roland PS van Peppen

© 2008, Roland PS van Peppen

The printing of this thesis was financially supported by:

Printed by: Gildeprint Drukkerijen, Enschede, The Netherlands

© Original Artwork cover: Arno Overdevest

Rolandus Petrus Stephanus van Peppen

geboren op 15 maart 1961 te Delft

Co-promotoren: Dr. G. Kwakkel

Dr. N.L.U. van Meeteren

Dr. M.J. Schuurmans

Chapter 2 The impact of physiotherapy on functional outcome after 23

Patient preferences Research evidence

effectiveness were determined in a randomised controlled trial with thirty

6. Commissie CVA‐Revalidatie. Rehabilitation after a stroke, guidelines and

Table 1 – Best-evidence synthesis

Strong evidence provided by statistically significant findings in outcome measures in

Moderate evidence provided by statistically significant findings in outcome measures in

Limited evidence provided by statistically significant findings in outcome measures in

Indicative findings provided by statistically significant findings in outcome measures in at least

Table 2 Physiotherapy intervention categories

(range) mean (range) range

Intervention Type of N Mean time Intensity of Results M.Q. References

(range) mean (range) range

Intervention Type of N Mean time Intensity of Results M.Q. References

stroke mean (range) range

position61,120 the Timed Up&Go124,126,127, postural sway/symmetry121‐125,129 and

statistically significant SES150‐152,154,155 in support of CIMT. No significant

parameters of NMS that were used. Best‐evidence synthesis showed

Table 3 Quantitative analysis of RCTs

* statistical significant summary effect size (SES):p < 0.05 ;

Intervention N Item on PEDro scale Median/

67,81- 67,81-87 67,81,84-86 67,81,82,86 67,84,87 67,81-87 67,81,83-85,87

92-94,96,100- 71,84,91- 92- 71,84,91- 94-96,100,104- 84,92,94- 100,102,106 71,84,91- 71,84,91,

61,77,80,86,1 61,77,80,86, 113,117,124, 61,77,80,86,113, 77,80,86,117- 61,117,118, 137,139,144 61,77,80,86,113, 61,77,80,113,

65,69,7 65,69,73,82, 65,69,110, 65,69,73,110, 65,69,73,82, 65,73,87,110, 110,151,152, 65,69,73,82,83,87, 65,69,73,83,87,

81,160- 81,140, 162,168,175 81,162-164, 81,140,159, 158-160,163, 81,140,159- 81,158,159,

75,162,184- 63,75,162, 162,184,185, 63,162,184,186, 75,186,188,189, 184,185,189- 185,198 63,75,162,184- 63,75,162,184-

59,202 59,202 59,202 59,202 59,202 59 202 59,202 59,202

TOTAL (RCTs) 142 116 142 46 108 0 0 83 81 21 127 111 -

TOTAL without 123 100 123 39 93 0 0 72 74 19 109 97 5 / 5.1

172. Wolf SL, Binder‐MacLeod SA. Electromyographic biofeedback applications to the

182. Wolf SL, Binder‐MacLeod SA. Electromyographic biofeedback applications to the

218. The Glasgow Augmented Physiotherapy Stroke Group. Can augmented physiotherapy

Table 1 – Operationalisation of validity criteria (modification of list Kwakkel et al 3)

Methodological Criteria for operationalisation: Operationalisation:

A. Randomisation 1. concealed allocation is applied (i.e. sealed envelopes) 1. yes / no

3. those performing statistical analysis are kept unaware of the 3. yes / no

4. patients are kept unaware with respect to the condition to 4. yes / no

6. the number of intercurrent drop-outs are described for each 6. yes / no

7. intention-to-treat analysis has been applied: 7. yes / no

D. Measurement 8. statistically significant test-retest correlation coefficient(s) 8. yes / no

9. the relevant measurement instruments are compared 9. yes / no

14. predetermined rehabilitation time (in minutes or hours) 14. yes / no

Table 2 Study characteristics of trials on intensity of stroke rehabilitation

Total 2686 (1515/1171) 48.6/ 22.9/ Weighted

Author, y 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total Co- Reported

Smith, 1981 1 1 0 0 1 0 0 1 1 0 0 0 0 1 6 No Positive

Sivenius, 1985 1 0 0 0 1 0 0 0 0 0 0 0 0 0 2 Yes Positive

Sunderland, 1992 0 1 0 0 1 0 0 1 1 0 0 1 0 1 6 No Positive

Wade, 1992 0 1 0 0 1 0 0 1 1 0 0 1 0 0 5 No Positive

Richards, 1993 0 1 0 0 1 0 0 1 1 0 0 1 1 1 7 No Positive

Werner, 1996 0 1 0 0 1 0 0 1 1 1 0 0 1 0 6 No Positive

Logan, 1997 1 1 0 0 1 0 1 1 1 0 0 1 0 0 7 No Positive