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Physiotherapy 95 (2009) 110–119

A treatment schedule of conventional physical therapy provided to enhance upper limb sensorimotor recovery after stroke: Expert criterion validity and intra-rater reliability
Catherine Donaldson, Raymond C. Tallis, Valerie M. Pomeroy ∗
St George’s University of London, Geriatric Medicine, Cramer Terrace, London SW17 0RE, UK

Abstract Background Inadequate description of treatment hampers progress in stroke rehabilitation. Objective To develop a valid, reliable, standardised treatment schedule of conventional physical therapy provided for the paretic upper limb after stroke. Design, setting and participants Eleven neurophysiotherapists participated in the established methodology: semi-structured interviews, focus groups and piloting a draft treatment schedule in clinical practice. Different physiotherapists (n = 13) used the treatment schedule to record treatment given to stroke patients with mild, moderate and severe upper limb paresis. Rating of adequacy of the treatment schedule was made using a visual analogue scale (0 to 100 mm). Mean (95% confidence interval) visual analogue scores were calculated (expert criterion validity). For intra-rater reliability, each physiotherapist observed a video tape of their treatment and immediately completed a treatment schedule recording form on two separate occasions, 4 to 6 weeks apart. The Kappa statistic was calculated for intra-rater reliability. Results The treatment schedule consists of a one-page A4 recording form and a user booklet, detailing 50 treatment activities. Expert criterion validity was 79 (95% confidence interval 74 to 84). Intra-rater Kappa was 0.81 (P < 0.001). Conclusion This treatment schedule can be used to document conventional physical therapy in subsequent clinical trials in the geographical area of its development. Further work is needed to investigate generalisability beyond this geographical area. © 2008 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Rehabilitation; Stroke; Physical therapy

Introduction Upper limb weakness is a frequent occurrence after stroke [1] and recovery is often limited. At 6 months post stroke, only approximately 12% of stroke survivors who initially experienced severe motor impairment were found to regain full use of their arm and hand [2]. Conventional physical therapies, those used in routine clinical practice, are known to contribute to the beneficial effects of stroke units [3] but remain under-evaluated. Further evidence is needed to decide which conventional physical therapy (CPT) interventions are most effective for which patients, at which dose, and at what time in the recovery process [4]. Progress in stroke rehabilitation is
∗ Corresponding author at: Faculty of Health, University of East Anglia, Norwich NR4 7TJ, UK. Tel.: +44 1603 591724; fax: +44 1603 593166. E-mail address: v.pomeroy@uea.ac.uk (V.M. Pomeroy).

impeded by insufficient description of CPT treatment activities [5,6] and lack of use of packages of treatment activities [7], which limits replication of research studies and incorporation of research findings into clinical practice [4]. A central difficulty is that CPT is complex. Indeed, it has been described as both a ‘black box’ and a ‘Russian doll’ [8,9]. Such terms imply that CPT cannot be described precisely [10]. Published reports of evaluative research often describe CPT treatment activities using labels such as ‘routine care’, even though this gives little information about the specific treatment activities that are used [5,11]. However, it is known that the content of CPT differs between clinical settings and over time as it is influenced by what physiotherapists learned during undergraduate training [12]. The use of treatment labels has been questioned further by the finding that even though physiotherapists around a major UK city claimed to use an eclectic approach, they actually used a traditional

0031-9406/$ – see front matter © 2008 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2008.11.005

. / Physiotherapy 95 (2009) 110–119 111 Bobath approach [13]. Continuing to use labels is therefore unsatisfactory.14. one with mild (ARAT score 0 to 19). The alleviation/remediation of hemiplegic shoulder pain forms the focus for two studies [14. 1). one with moderate (ARAT score 20 to 38) and one with severe (ARAT score 39 to 56) loss of upper limb functional ability. For investigation of validity and reliability. For example.C. The interviews were conducted at six different National Health Service (NHS) trusts. as assessed by a score of 56 or less (maximum score 57) on the Action Research Arm Test (ARAT) [18. Treatment labels mean different things to different people. Donaldson et al.15]. district general hospitals and clinical settings in the community. A systematic review [10] identified 15 reports of development of treatment schedules. each rater (physiotherapist) treated three stroke patients. • no obvious unilateral visuospatial neglect on clinical observation of subject’s ability to orientate towards objects and people in their environment. three stroke patients who had suffered a stroke at least 7 days prior to recruitment were recruited for each of the raters (i. The aims of the present study were: • to develop a treatment schedule of CPT treatment activities aimed at enhancing sensorimotor recovery of the upper limb after stroke. n = 14) from different London NHS trusts participated as raters in investigation of validity and reliability of the treatment schedule. Twelve physiotherapists were recruited for participation in development of the treatment schedule. Participants and clinical centres All physiotherapists who participated in this study were experienced in stroke rehabilitation. [10] concentrated on a small part of CPT called ‘mobilisation and tactile stimulation’ which is designed to provide therapist hands-on sensory stimulation for stroke survivors with paralysis or severe paresis. some effective CPT treatment activities could be discarded because a different CPT intervention with the same descriptive label was found to be ineffective.19]. • some voluntary muscle activity in the paretic upper limb. All stroke patients exhibited loss of functional ability in the paretic upper limb. including teaching hospitals. which has sufficient precision to enable treatment activities to be recorded in a standardised way so that they can be communicated to clinicians and researchers. To maximise the likelihood that all treatment activities listed in the treatment schedule were used by the raters. Procedure The treatment schedule was developed using the five stages identified in an earlier systematic review [10] (Fig. Different physiotherapists (band 6 or 7. neither the validity nor reliability of these treatment schedules have been tested. Furthermore. Before CPT can be evaluated. on two separate occasions. and • to determine whether individual senior neurophysiotherapists provide an identical list of treatment activities when. focus groups and piloting of a draft schedule in clinical practice were undertaken [10]. • to determine whether senior neurophysiotherapists agree that the record of the treatment generated using the treatment schedule accurately describes the treatment activities actually given (expert-criterion-related validity) [17]. Validity and reliability were tested using a prospective agreement design [10]. 10 of which are related to stroke care and three to the upper limb. and Hunter et al. Stroke patients were identified from each rater’s NHS caseload so that specific assessment activity required to make decisions about what treatment to provide did not take up time during the recording session. they are focused on relatively small areas for CPT treatment activities for the upper limb after stroke. Using labels as descriptors of physical therapy in evaluative research could result in CPT treatment activities being discarded inappropriately [4].e. they view video tapes of the same treatment sessions given on an earlier occasion (intrarater reliability).16]. Methods Design Semi-structured thematic interviews. it needs to be described in sufficient detail so that a physiotherapist with appropriate training will know exactly what treatment activity was tested and be able to replicate it in clinical practice. content analysis. Generation of a treatment list The themes for the semi-structured interview were provided as questions: • What physiotherapy treatment activities would you give to patients who fit these criteria when they present for rehabilitation? • How would you progress the treatment? The clinical focus for the semi-structured thematic interviews was provided by the study criteria to be used in a subsequent Phase I trial to begin evaluation of the resultant treatment schedule: • infarction of the anterior cerebral circulation (diagnosed through neuro-imaging) between 1 week and 3 months after stroke. Treatment schedules are a means of providing a standardised treatment protocol for evaluation [10. 30 stroke patients). in or around the London area. Although these studies provide sufficient description of CPT and enable recording of both content and dose.

VAS. Differences between the lists were discussed and resolved by the two researchers with reference to the original transcripts. Refinement of list into treatment schedule Audio tapes of the interviews were transcribed verbatim. Content analysis was undertaken independently by two researchers to produce a list of treatments used. Appropriate changes were made and the final treatment schedule was produced. 1. moderate and severe loss of functional ability of the paretic upper limb. prior to their stroke. The resultant treatment list was discussed at a focus group of participating physiotherapists to check for accuracy and omissions. each rater treated three stroke patients. visual analogue scale.112 C. CI. i. Validation of the treatment schedule Each rater was familiarised with the recording form. to use the paretic upper limb to lift a cup to drink from. Each therapist received training in how to use the treatment schedule and was asked to use it over a 2-week period with patients who met the study criteria. Raters were asked . • able. the definitions of terms used.e. The treatment list was modified following the feedback and a draft treatment schedule was produced. Raters had a 2-week period to practice using the treatment schedule in routine clinical practice. Piloting the draft treatment schedule in clinical practice Participating physiotherapists were invited to pilot the draft treatment schedule with their teams in clinical practice. and • able to follow a one-stage command (‘touch your nose with your stronger hand’). Donaldson et al. Flow chart to illustrate study procedure. the associated manual and the method for completing the recording form. Those unable to attend were invited to give written/verbal feedback. mild. one from each category. / Physiotherapy 95 (2009) 110–119 Fig. confidence intervals. Following training.

and their identification can also be recorded. each rater was sent their copy of Tape 2 and completed the recording forms using the same procedure. a horizontal line was projected from the centre of the cross to the VAS line [19]. The recording form is on one side of A4 paper and is divided into five categories: aims of treatment. equipment used and treatment activities (divided into 11 subcategories).e. Specific criteria for the rating of ‘adequacy of description’ were not provided to raters. all tick boxes for the activities section of the recording form were allocated a code of ‘1’ if ticked or not ticked on both occasions.75 [22]. Testing reliability of the treatment schedule Intra-rater reliability was tested.e. and the highest anchor point corresponding to ‘completely described the treatment provided’ (score 100). and then placed into a different computer generated random order and copied on to Tape 2 (10 tapes. Each rater was sent their copy of Tape 1. Content and format of the treatment schedule The treatment schedule consists of a treatment recording form (Fig. Within this broad guidance.C. USA). The first author videotaped the treatment session which lasted for a maximum of 20 minutes and a minimum of 10 minutes. and told raters when the recording started and stopped. Adequate description of treatment was set at a mean score of 75% or above based on recommendations that an acceptable level for reliability is 0. 2) and explanatory booklet (available from corresponding author). Chicago. They immediately rated the adequacy of the description on the recording form of the treatment they had given using a 100 mm vertical visual analogue scale (VAS) with the lowest anchor point corresponding to ‘did not provide a description of the treatment provided’ (score 0). The explanatory booklet is . The mean of the two readings was used for analysis. the specific content of the treatment sessions was decided by the therapist.. the duration of the upper limb treatment intervention. one for each rater) [20]. two gave written feedback. in agreement. The video tapes of the three treatment sessions for each rater were placed into a computer generated random order and copied on to Tape 1 (10 tapes. The same stroke patient treatment session was rated on two separate occasions to avoid change in clinical presentation between treatment sessions on different occasions. i. Results Participants One physiotherapist who consented to participate in the development of the treatment schedule did not adhere to the interview themes despite repeated facilitation. one for each rater). the number of therapists and assistants involved. and therefore this interview could not be used. Thirteen physiotherapists were involved in piloting the draft treatment schedule in inpatient. To test validity and reliability. All collected data were included in the analysis. two community centres and one rehabilitation centre). raters completed the treatment schedule recording form independently by ticking the relevant boxes describing the treatment provided. data were not analysed to investigate this issue. Four physiotherapists attended the focus group. i. outpatient and community clinical settings. setting. Data analysis: validity and reliability The VAS score was measured using an acetate sheet with a 100 mm line divided into 1 mm markings placed over the completed VAS and read by two independent assessors. To estimate expert criterion validity. Raters did not keep copies of completed forms. Information regarding the date. Full sets of data were obtained from 10 physiotherapists. to estimate the level of agreement. not in agreement. IL. gross position of patient during activities used. Donaldson et al. who were simply asked to use their expert clinical judgement. and two could not be contacted due to change of workplace. The reverse of the page gives instructions for completion and a condensed glossary of any abbreviations and terms used (Box 1). Consequently.e. each rater returned them and the tape to the first author (no copies kept by raters). using Statistical Package for the Social Sciences Version 10 (SPSS Inc. viewed each subject session and then completed a recording form to describe the treatment given (i. they completed recording forms for their own treatment sessions). If the centre of the cross was ‘off-line’. 14 physiotherapists and 35 stroke patients were recruited from five different sites (two London teaching hospitals. Immediately after the treatment session. To estimate intra-rater reliability for each pair of recording forms. the mean and 95% confidence intervals (95% CI) of VAS scores were calculated from the 30 separate ratings (three stroke patients per rater). A comparison of the record of treatment activities made immediately after a session and from a videotaped recording on a later occasion was not the focus of this study.75 [21] and in the absence of specific published statistical guidance. 11 physiotherapists participated in the interviews. The video tapes of the treatment sessions were therefore used [20. The acceptable level for reliability was set at 0. The remaining physiotherapists did not respond. Four physiotherapists were unable to complete data collection because of rotating to another post or being placed on long-term sick leave. / Physiotherapy 95 (2009) 110–119 113 to provide a treatment session focused entirely on improving functional ability in the paretic upper limb. Therefore. A code of ‘0’ was allocated if a box was ticked on one occasion but not on the other. Raters used a ballpoint pen to mark the VAS with a cross (x). After completing the three recording forms for Tape 1. The unweighted Kappa statistic and its Pvalue were then calculated. Four to six weeks later.21].

/ Physiotherapy 95 (2009) 110–119 Fig. 2. Donaldson et al.114 C. The treatment schedule recording form. .

London: Lippincott Williams and Wilkins. Physiotherapy 2006. Pomeroy VM. increasing tissue extensibility and promoting ordered alignment of collagen within the tissuesa Lymph drainage techniques A non-gliding technique performed in the direction of lymphatic flow. Please note that this treatment schedule is not suitable for patients demonstrating neglect. one moderate and one severely impaired stroke patient). the compression and release is applied in a direction that is perpendicular to the target tissue. / Physiotherapy 95 (2009) 110–119 115 Box 1 Instructions for completing the treatment schedule recording form. Outcome-based massage. Crome P. 2. lift and glidea Physiotherapist Person with professional physiotherapy qualification Specific compression A non-gliding technique that is applied with a specific contact surface to muscle. 4. glossary of terms and references. 3. shear and release muscle tissue with varying amounts of drag. Validity and reliability Expert validity Ten raters provided three VAS scores (one mild. Completed forms given to research team Completed forms will be collected weekly by Catherine Donaldson (researcher conducting the FST Trial). Four raters . Donaldson et al. Please refer to the booklet for further details of equipment. non-gliding technique that produces movement between the fibres of connective tissue. examples of specific treatment activities. To complete the gross position section Place a tick in the box for every gross position used to deliver physiotherapy treatment during treatment sessions being recorded. 1. b a Abbreviations for glossary of terms used in recording form Effleurage a 10-page manual with the following sections: explanatory background/introduction. duration of session Estimated duration of treatment session Estimated percentage of time on upper limb Estimated percentage of treatment session spent working directly on the upper limb Facilitation The application of an appropriate mode and dose (frequency. sustained tensional force on the muscle and its associated fascia. Unless stated otherwise. the recording form and instructions. To complete the treatment activities section Please place a tick in the boxes which best describe the treatment that was given to the patient during the particular treatment session being recorded. Hunter SM. For further description of items on recording form. To complete the aims section Please place a tick in the box that best describes the aims relevant to the particular treatment session being recorded. Clifford P. it is assumed that the aim is to ‘improve/optimise’ in each case. examples of materials used for splinting. which results in palpable visco-elastic lengthening and plastic deformation of the fasciaa Petrissage A group of related techniques that repetitively compress. 6. Sim J. 7. One form for each treatment session Please complete one form for each treatment session given to patients included as subjects in the Functional Strength Training (FST) Upper Limb Clinical Trial. Donaldson C. examples of equipment used. 5. see overleaf Please refer to the accompanying document ‘Description of Upper Limb Treatment for Patients in FST Trial’. A gliding manipulation performed with light centripetal pressure that deforms subcutaneous tissue down to the investing layer of the deep fasciaa Est. which deforms subcutaneous tissue without engaging musclea Mental imagery Mental rehearsal of a motor act that occurs in the absence of overt motor output Myofascial release A technique that combines a non-gliding fascial traction with varying amounts of orthopaedic stretch to produce a moderate. specific. using short.C. tendon or connective tissue. rhythmical strokes with minimal to light pressure. 2001. duration and intensity) of sensory stimulus provided by the therapist to access a desired active response from the patientb Friction A repetitive. Development of treatment schedules for research: a structured review to identify methodologies used and a worked example of ‘mobilisation and tactile stimulation’ for stroke patients.92:195–207. and the compression is often sustaineda Stroking Gliding over the patient’s skin (unidirectionally) with minimal deformation of subcutaneous tissuesa Rehabilitation assistant Person assisting the physiotherapist but who is not a qualified physiotherapist Andrade C-K. To complete the equipment section Please write the name of any equipment used during the particular treatment session being recorded.

Fig. P < 0. Fig. 2). 2) and frictions (treatment activity 1.001). Table 2 Intra-rater reliability (agreement between treatment recording forms for the same treatment on two different occasions for each rater).1. Fig. 2). • balance and mobility incorporating upper limb activity: in walking (treatment activity 8. Donaldson et al.79 <0. 2) and ultrasound (treatment activity 11.1. Fig.5. 41 (82%) were used by physiotherapists in this study. Fig. Rater Visual analogue score (0 to 100). The Kappa statistic for the 95% agreement was 0. Those not used were: • soft tissue mobilisation: lymph drainage techniques (treatment activity 1.001 Severe 90 94 94 96 90 100 98 92 96 92 86 No data 94 No data 94 0. The mean score for all treatment sessions was 79 (95% CI 74 to 84) which is above the 75% level set for acceptability.5. Fig. all categories for all raters 94.116 C.81. Intra-rater reliability Of the 50 treatment activities.001 Mean.2. all categories for all raters Kappa statistic and P-value. and • other treatment activities/techniques: acupuncture (treatment activity 11.7. • positioning: half lying (treatment activity 4.001 Moderate 94 96 86 96 94 98 96 94 92 92 No data 96 100 No data 95 0. • splinting techniques: shoulder support (treatment activity 6.3. Fig. Data for agreement for the ratings of the same treatment session on two different occasions are shown in Table 2. 2).81 (P < 0. although the lower 95% CI was just below acceptability (Table 1).5 0. 2).2. Fig. • specific sensory input: electrical stimulation (treatment activity 5. 2). loss of functional ability Mild 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Mean (95% confidence interval) 90 100 87 93 77 53 89 88 85 94 No data No data No data No data 86 (76 to 95) Moderate 86 98 79 73 57 75 69 67 50 93 No data 84 60 91 76 (67 to 84) Severe 85 99 90 51 76 64 77 85 54 82 92 No data 65 No data 77 (67 to 86) Mean (95% confidence interval) of all treatments for all raters 79 (74 to 84) did not provide a full set of three VAS scores.4. 2) and elbow support (treatment activity 6.78 <0.85 <0. / Physiotherapy 95 (2009) 110–119 Table 1 Visual analogue readings per rater by loss of functional activity category.001 . 2). Rater Percentage agreement by impairment level Mild 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Mean % agreement Kappa statistic P-value 96 98 94 92 94 100 96 98 94 96 No data No data No data No data 96 0. Fig.

and/or that the relatively small number of stroke patients included meant that not all treatment activities were appropriate. it has not yet been tested for inter-rater reliability. developed using similar methodology. The present treatment schedule therefore adds to our knowledge of the content of CPT by describing treatment activities in sufficient detail to allow for replication of evaluative studies. Although the mean VAS score for accuracy of treatment description exceeded the acceptable level of 75. and ensuring that the treatment schedule was used across different clinical presentations of stroke. In addition. the broad spectrum of clinical areas in which the raters worked. this treatment schedule was developed as a precursor to a trial involving stroke survivors with the specific characteristics which formed the focus for the semi-structured interviews. that restrictions on the treatment activities used were imposed by the need to video tape sessions. A way forward. This possibility needs to be tested for both intra. Intra-rater reliability was found to be acceptable but expert criterion validity was borderline. therefore. to test the generalisability of the treatment schedule beyond the geographical area in which it was developed. Methodological strengths of the study reported in this paper include: the different randomised orders of the two video tapes used for the intra-rater reliability investigation. It is also possible that there might be differences between treatment activities recorded immediately after provision of a treatment session and those recorded from watching a video tape. not all the physiotherapists interviewed attended the subsequent focus groups. and this could have influenced the content of the treatment schedule. it is probably one of the first to have been tested formally for aspects of validity and reliability. distinguishing tactile and proprioceptive stimulation during facilitated movement could be difficult). Two physiotherapists treating the same patient on two separate occasions might therefore provide different treatment activities. that they may be used less frequently. therefore. Testing of inter-rater reliability could be confounded when wanting to investigate whether two different physiotherapists would give the same treatment to the same stroke survivor.C. These strengths enhance internal validity of the results.and inter-rater reliability.79 (P < 0.001) for severe. Thirdly. could be for different physiotherapists to watch the same video tape of a treatment session. guidelines for interpretation would place 74 in the category of ‘substantial agreement’ and the upper 95% CI of 84 in the category of ‘almost perfect’ [25]. although published findings indicate acceptable inter-rater reliability when independent observers decide treatment activities from video tapes of treatment sessions [24].11. Intra-rater reliability was also acceptable for each of the separate stroke patient categories (Table 2): 0. Donaldson et al. intra-rater reliability was found to be above the acceptable level of 0. Such investigation also needs to consider the possibility that treatment activities are missing from this treatment sched- .26–28].78 (P < 0. but whose input resulted in subsequent changes before the final version was produced.23] and precise clinical presentations [14].75. a time limit was imposed on the length of a treatment session for pragmatic reasons. however.001) for moderate and 0. / Physiotherapy 95 (2009) 110–119 117 Thus.13. Discussion The authors have developed a treatment schedule to describe and record CPT provided by physiotherapists to enhance sensorimotor recovery of the upper limb after stroke. and have included activities usually undertaken by other professional groups [24] or specific CPT treatment activities [10]. have focused on other aspects of stroke rehabilitation [15.001 for mild. This treatment schedule is probably the first to codify a comprehensive list of treatments for the upper limb after stroke to enable research evaluation of the content and quantity of CPT. It is therefore important not to withdraw these treatment activities from the schedule until further investigation of its content has been undertaken. If a longer time period had been given. It is important to note that the treatment activities not ticked by raters were nevertheless identified as CPT by senior physiotherapists in the interviews. but the present treatment schedule has more specific items than those tested earlier [24]. However. the draft of the treatment schedule was piloted in clinical practice with physiotherapists who were not interviewed. however. treatment effectiveness). Other CPT treatment schedules. the lower 95% CI was just below at 74. In addition.g. the physiotherapists might have provided different treatments which could have affected the estimates of intra-rater reliability obtained. The absence of records of the use of some treatment activities could indicate that these treatment activities are not used routinely in clinical practice at all. Secondly.85 (P < 0. In the meantime. Firstly. There are. It would be advisable. it cannot be assumed that subject presentation will remain the same between treatment sessions on different occasions (e. Clearly further work is required to test reliability. Caution is needed. natural recovery. Although acceptable intra-rater reliability has been found for this treatment schedule.g. it is recommended that stroke survivors should be treated mainly by one physiotherapist in subsequent clinical trials evaluating this treatment schedule (this recommendation reflects routine clinical practice in the UK). some potential limitations to use of these results. that these treatment activities were not used in practice by the raters. However. It is possible that physiotherapists could make different interpretations of the same activity (e. 0. It is of interest that not all treatment activities were recorded from watching the video tapes of treatment sessions (nine of 50 treatment activities were not used by raters). Investigation of inter-rater reliability will need to consider that different physiotherapists may use different treatment activities for the same clinical presentation [9. in generalising the results of this study to stroke survivors with different clinical characteristics.

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