Physiotherapeutic theory for neurorehabilitation
of stroke
Introduction
Aims of this course
After completing this course, the student:
• has acquired a profound knowledge on clinical signs and symptoms of a variety of
neurological disorders;
• has an in-depth knowledge of assessment of people with neurological conditions;
• learned to select and apply appropriate evidence- based treatment methods for individual
patients.
FAME
Fundamental building blocks of neurological physiotherapy
,Feedback
Frequency: how often? All or some of the time?
• Do not give feedback on every trial
Timing: before/during/after
Mode: visual/verbal/manual
• Manual: early stage of skill acquisition
• Associative and autonomous stage: let patient actively problem-solve
Consider
• Using feedback with external focus
• Instructions and communication (with all involved)
Therapeutic alliance
Build connection with your patient
• Personal connection: more than just a therapist–patient interaction
o Not interaction, but connection
• Professional collaboration
o Be a coach, motivator
• Family collaboration
To do
1. Introduce yourself
2. Ask how the patient is doing
3. Ask expectations and their goals
4. Explain what you will do and why
Movement analysis & motor learning
Seeing deviations and compensations of patients
Sit-to-stand
Know normal movement
• COM over BOS to stand up (knees over ankles, trunk forward)
• Keep COM within BOS when standing and keeping balance
Observed diXiculties in stroke
• Supporting only on healthy side
• DiXiculty keeping balance
• Falling to hemiplegic side
,Environment
• Learning
• Stimulating
• Safe
• Adapted to the patient
Therapy
• Separately or in group
• Cognitive problem (diXiculty planning sequence of movement) à diXerent approach
o Treatment: foot placements on the floor to visualize where the feet need to go
Motor learning principles
I: intensity
V: variation
T: task-specificity
G: goal-directed
P: progression
F: feedback
Neurorehabilitation
= a process that assists individuals who experience disability to achieve and maintain optimal
function and health in interaction with their environment (WHO 2011; 2017)
Global estimate of the need for rehabilitation: 1/3 people in the world needs rehab at some point in
the course of their illness or injury
Interpretation
Studies
Phases
• Phase I: investigating in small group whether intervention has eXect (no control group)
• Phase II: pilot/feasibility study (with control group), first indication, hypothesis generating, no
definitive evidence, phase III needed (power calculation)
• Phase III: big trial, definitive trial (positive/neutral/negative), eXectiveness
PICO: patients/intervention/control/outcome
• Patients: functional/afunctional
• Intervention vs control: diXerence in therapy, dosing
• Outcome: body function, activity (capacity, performance), participation, quality of life
Statistical analysis
• Is there a statistically significant between-group diXerence?
o EXect between intervention and control group
o In favour of which group?
§ Positive: in favour of experimental group
§ Neutral: no statistical diXerence between intervention and control group
§ Negative: in favour of control group
o How small or large is this diXerence? à eXect size
o Does it exceed the measurement error/MID/MCID?
• Proportion of patients exceeding the threshold of MCID
o Look at number of patients that benefit from experiment
, Meta-analysis
Review with/ without meta-analysis
• With meta-analysis: pooled studies
• Without meta-analysis: descriptively reporting what benefits are
Define PICO of review
• Patients/intervention/control/outcomes
Interpretation depends on outcome measures
• DiXerent outcomes used in trials à pool outcomes together across trials
o Standardized mean diXerence (SMD) = eXect size
• All trials have the same outcome measure
o Mean diXerence (MD) = diXerence on score range of outcome
Significance
• Diamond: width = 95% CI, height = eXect (SMD/MD)
o If diamond touches the vertical line, there is no significant eXect
• Odds ratio: if 95% CI contains 1 à not significant
• SMD/MD: if 95% CI contains 0 à not significant
Clinical relevance
• SMD: diXicult to interpret clinically
• MD: easy to interpret clinically à MCID or 10%rule
Station exam
OSCE: Objective Structured Clinical Examination
• 2 hours
• 10-ish (short) questions
• Covering nearly all course elements
• Oral or written, theoretical or practical questions
“The final score for this course is an average of the scores obtained at the diXerent stations. Each
station has the same weight. The student has to pass 60% of all stations or more, otherwise the
maximum final score a student can obtain for this course is 8 out of 20.
of stroke
Introduction
Aims of this course
After completing this course, the student:
• has acquired a profound knowledge on clinical signs and symptoms of a variety of
neurological disorders;
• has an in-depth knowledge of assessment of people with neurological conditions;
• learned to select and apply appropriate evidence- based treatment methods for individual
patients.
FAME
Fundamental building blocks of neurological physiotherapy
,Feedback
Frequency: how often? All or some of the time?
• Do not give feedback on every trial
Timing: before/during/after
Mode: visual/verbal/manual
• Manual: early stage of skill acquisition
• Associative and autonomous stage: let patient actively problem-solve
Consider
• Using feedback with external focus
• Instructions and communication (with all involved)
Therapeutic alliance
Build connection with your patient
• Personal connection: more than just a therapist–patient interaction
o Not interaction, but connection
• Professional collaboration
o Be a coach, motivator
• Family collaboration
To do
1. Introduce yourself
2. Ask how the patient is doing
3. Ask expectations and their goals
4. Explain what you will do and why
Movement analysis & motor learning
Seeing deviations and compensations of patients
Sit-to-stand
Know normal movement
• COM over BOS to stand up (knees over ankles, trunk forward)
• Keep COM within BOS when standing and keeping balance
Observed diXiculties in stroke
• Supporting only on healthy side
• DiXiculty keeping balance
• Falling to hemiplegic side
,Environment
• Learning
• Stimulating
• Safe
• Adapted to the patient
Therapy
• Separately or in group
• Cognitive problem (diXiculty planning sequence of movement) à diXerent approach
o Treatment: foot placements on the floor to visualize where the feet need to go
Motor learning principles
I: intensity
V: variation
T: task-specificity
G: goal-directed
P: progression
F: feedback
Neurorehabilitation
= a process that assists individuals who experience disability to achieve and maintain optimal
function and health in interaction with their environment (WHO 2011; 2017)
Global estimate of the need for rehabilitation: 1/3 people in the world needs rehab at some point in
the course of their illness or injury
Interpretation
Studies
Phases
• Phase I: investigating in small group whether intervention has eXect (no control group)
• Phase II: pilot/feasibility study (with control group), first indication, hypothesis generating, no
definitive evidence, phase III needed (power calculation)
• Phase III: big trial, definitive trial (positive/neutral/negative), eXectiveness
PICO: patients/intervention/control/outcome
• Patients: functional/afunctional
• Intervention vs control: diXerence in therapy, dosing
• Outcome: body function, activity (capacity, performance), participation, quality of life
Statistical analysis
• Is there a statistically significant between-group diXerence?
o EXect between intervention and control group
o In favour of which group?
§ Positive: in favour of experimental group
§ Neutral: no statistical diXerence between intervention and control group
§ Negative: in favour of control group
o How small or large is this diXerence? à eXect size
o Does it exceed the measurement error/MID/MCID?
• Proportion of patients exceeding the threshold of MCID
o Look at number of patients that benefit from experiment
, Meta-analysis
Review with/ without meta-analysis
• With meta-analysis: pooled studies
• Without meta-analysis: descriptively reporting what benefits are
Define PICO of review
• Patients/intervention/control/outcomes
Interpretation depends on outcome measures
• DiXerent outcomes used in trials à pool outcomes together across trials
o Standardized mean diXerence (SMD) = eXect size
• All trials have the same outcome measure
o Mean diXerence (MD) = diXerence on score range of outcome
Significance
• Diamond: width = 95% CI, height = eXect (SMD/MD)
o If diamond touches the vertical line, there is no significant eXect
• Odds ratio: if 95% CI contains 1 à not significant
• SMD/MD: if 95% CI contains 0 à not significant
Clinical relevance
• SMD: diXicult to interpret clinically
• MD: easy to interpret clinically à MCID or 10%rule
Station exam
OSCE: Objective Structured Clinical Examination
• 2 hours
• 10-ish (short) questions
• Covering nearly all course elements
• Oral or written, theoretical or practical questions
“The final score for this course is an average of the scores obtained at the diXerent stations. Each
station has the same weight. The student has to pass 60% of all stations or more, otherwise the
maximum final score a student can obtain for this course is 8 out of 20.
