doi: 10.1161/01.STR.0000164585.12776.ff
(Stroke. 2005;36:932.)
© 2005 American Heart Association, Inc.
Letters to the Editor |
Modern Therapeutic Approaches in the Rehabilitation of Walking Ability After Stroke
NRZ Leipzig, University Leipzig, Bennewitz, Germany
To the Editor:
Recently, the report by Yan et al1 about the impact of functional electrical stimulation (FES) on walking ability of stroke patients attracted our attention. The authors found that 15 sessions of FES (quadriceps, hamstring, tibialis anterior, and medial gastrocnemius muscle) applied to acute stroke patients combined with standard rehabilitation improved the walking ability. The study design meets the criteria of a high standard of scientific work.
Unfortunately, the authors chose as the standard rehabilitation approach the Bobath, or neurodevelopmental, facilitation approach. Particularly in the therapy of the lower extremities of stroke patients, this method has been shown to be less effective than other approaches. Hesse et al2 compared a treadmill training with the Bobath approach using an A-B-A study design. Both biomechanical parameters and functional assessment scores improved only during the treadmill training but not during the Bobath therapy. In a study by Pohl et al,3 the treadmill velocity was increased within each session, an approach that considerably enhances the therapeutic effect. Therefore, modern therapeutic strategies in the rehabilitation of stroke patients should include a task-specific training and shaping elements, ie, increasing the demand of performance in parallel with the improvement of performance. The neurodevelopmental facilitation approach widely ignores these standards. The study by Yan et al only shows that FES as a kind of repetitive movement training is superior to an approach that is known to be of minor effectiveness. It has not been shown that FES is more effective than modern task-specific approaches like the treadmill training. Considering the high technological expenditure, on the basis of these data it remains doubtful whether FES can be recommended as therapeutic tool.
References
1. Yan T, Hui-Chan CWY, Li LSW. Functional electrical stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke: a randomized placebo-controlled trial. Stroke. 2005; 36: 80–85.
2. Hesse S, Bertelt C, Jahnke MT, Schaffrin A, Baake P, Malezic M, Mauritz KH. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke. 1995; 26: 976–981.
3. Pohl M, Mehrholz J, Ritschel C, Ruckriem S. Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: a randomized controlled trial. Stroke. 2002; 33: 553–558.
Response:
Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hung Hum, Kowloon, Hong Kong (SAR), China
Dr H. Woldag questioned our choice of neurodevelopmental facilitation (Bobath) approach as the standard rehabilitation. He rightly noted that it has been shown to be less effective than treadmill training. The reality in Hong Kong is that neurodevelopmental approach is commonly used in hospitals. This is true also in Europe, where a survey showed that Bobath was the preferred approach by 67% of respondents.1 From an ethical standpoint, patients should not be withdrawn from their standard rehabilitation.
Another important point is that when patients cannot walk, treadmill training is not feasible. Our patients were studied during the acute stage, 9.2±4.1 days after stroke. In contrast, Hees et al2 and Pohl et al3 examined their patients 176.8 days and 114.6 days after stroke, respectively. They found that treadmill training with partial body weight support,2 or with treadmill speed progressively adjusted,3 was more effective than Bobath approach2 or conventional gait training.3 However, all the chronic stroke patients recruited by Pohl et al could walk 10 m with (35%) or without (65%) walking aid. In contrast, only 12% (or 5) of our 41 patients with acute stroke could walk with a quadruped. Hence, only passive modalities/approaches such as functional electrical stimulation (FES) would be feasible.
Quite aside from the reality of patients’ flaccid status during the acute stage that made neuromuscular stimulation rather than treadmill training feasible, there were 2 other considerations. The first one related to concept-driven treatment approach. As presented in our article, repetitive execution of similar movements of the limbs have been identified as crucial for motor recovery in stroke subjects.4 In fact, using positron emission tomography, similar brain activation patterns had been observed in these subjects during either active or passive movements.5,6 We hypothesized that FES, which generated gait-simulated leg movements plus related cutaneous and proprioceptive inputs, would be important in "reminding" subjects of how to walk during the acute stage. Therefore, we investigated whether FES plus standard rehabilitation (SR) was more effective than SR given with placebo stimulation or alone in promoting the recovery of motor function and functional mobility during acute stroke. That was what we found from week 2 or 3 onward during the 3-week treatment. Even at week 8 after stroke, 84.6% of the patients receiving FES plus SR were still able to walk when compared with 60.0% and 46.2% of those receiving, respectively, placebo stimulation with SR or SR alone. Given statistically significant between-group differences (P<0.05), Dr Woldag’s statement that "it remains doubtful whether FES can be recommended as therapeutic tool" is not substantiated, at least for the patients we studied during the acute stage.
The second consideration is cost-effectiveness. When patients cannot walk, helping them with passive walking movements requires expert knowledge and skill that could be quite expensive in many countries. The cost for 2 dual-channel Respond Select stimulators and program timer is US $2352 and $64, respectively. Including technician time, the total cost of our homemade FES unit comes to $2600. This unit could be used to treat 14 patients per day (at 30 minutes per patient) for 3 weeks, or 242.6 patients per year. Presuming a lifetime usage of 5 years, 1 unit could treat 1213 patients. Therefore, the cost per patient comes to only US $2.1, in addition to minimal therapist time for the 3-week treatment. When the outcome is that 84.6% of the patients could return home, which is almost double the 46.2% of those receiving SR alone, adding FES to the SR should be considered very cost-effective to the health care system.
References
1. Lennon S, Baxter D, Ashburn A. Physiotherapy based on the Bobath concept in stroke rehabilitation: a survey within the UK. Disability Rehab. 2001; 23: 254–262.
2. Hesse S, Bertelt C, Jahnke MT, Schaffrin A, Baake P, Malezic M, Mauritz KH. Treadmill training with partial body weight support compared with physiotherapy in noambulatory hemiparetic patients. Stroke. 1995; 26: 976–981.
3. Pohl M, Mehrholz J, Ritschel C, Ruckriem S. Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: a randomized controlled trial. Stroke. 2002; 33: 553–558.
4. Jones EG. Cortical and subcortical contributions to activity-dependent plasticity in primate somatosensory cortex. Annu Rev Neurosci. 2000; 23: 1–37.[CrossRef][Medline] [Order article via Infotrieve]
5. Nelles G, Spiekermann G, Jueptner M, Leonhardt G, Muller S, Gerhard H, Diener C. Reorganization of sensory and motor system in hemiplegic stroke patients: a positron emission tomography study. Stroke. 1999; 30: 1510–1516.
6. Weiller C, Juptner M, Fellows S, Rijntjes M, Leonhardt G, Kiebel S, Muller S, Diener HC, Thilmann AF. Brain representation of active and passive movements. Neuroimage. 1996; 4: 105–110.[CrossRef][Medline] [Order article via Infotrieve]
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