Effect of Integrated Cueing on Functional Transfers in Chronic Stroke Survivors
Condition: Hemiplegia and/or Hemiparesis Following Stroke
MeSH terms: Stroke; Hemiplegia; Paresis
Study type: Interventional

Summary: 
      Physical therapists frequently use manual cueing as a tool to improve movement quality in
      persons recovering from stroke but evidence to support its effectiveness is lacking.

      The purpose of this graduate student research study is to determine the immediate and
      carryover effects of an integrated verbal and manual facilitation approach used by physical
      therapists during sit to stand training on the midline alignment, muscle activation and
      quality of movement in chronic stroke survivors with hemiplegia.
    

Detailed description: 
      Over the last few decades, the profession of physical therapy has heavily relied on manual
      facilitation to improve motor control and functional movement in persons recovering from
      stroke or other neurological impairments. In the 1950's, Berta Bobath created
      Neuro-Developmental Treatment (NDT), a systematic problem-solving approach that is one of the
      most widely used methodologies in neurorehabilitation. NDT relies heavily on verbal and
      tactile facilitation as an integrated approach to improve motor control in persons with
      hemiplegia. However, current systematic reviews have stated that adequate evidence for the
      effectiveness of neuro facilitation is lacking. In the current climate of evidence-based
      practice, neurologic physical therapists no longer blindly accept the use of traditional
      interventions and instead rely on peer-reviewed research studies to support their clinical
      decision-making.

      However, the question remains for many physical therapists: are skilled manual cues really an
      essential ingredient in the post-stroke recipe? Most practicing neurologic physical
      therapists would claim that their hands are their most valuable tools and that the way in
      which they use their hands has a direct effect on movement patterns and functional outcomes
      with their patients. Ploughman and colleagues reported that manual tactile cues during gait
      had "robust but short-lived impacts on cadence and time in double support" during gait but
      their findings are merely a step in the right direction. An integrative approach of both
      manual and verbal cues have anecdotally shown to be effective to treat impairments from
      stroke but there continues to be a dearth of evidence to accurately support the pervasive use
      of manual facilitation by physical therapists. While support for manual tactile cueing is
      merely beginning to move in the right direction, strong evidence exists that task specific
      training can improve functional outcomes by focusing training on desired movements and
      activities. But what part does manual cueing truly play in task specific training? Sit to
      stand is an essential activity of daily living that is often impaired in stroke survivors and
      is commonly trained by physical therapists from both task specific training and NDT schools
      of thought. Physical therapists need further clarification as to which methods are most
      effective for facilitating maximum learning and recovery during this functional task in order
      to craft an ideal recipe.

      Training correct movement patterns in order to improve functional independence is important
      at every stage of recovery after stroke. Kerr et al. suggested that successful sit to stand
      movements require proper training of the critical timing of events as well as improving
      synergistic activation of the appropriate lower limb musculature. Ultimately, asymmetry can
      lead to a conditioned suppression of available movement termed "learned non-use". Continual
      reinforcement of poor movement strategies thus leads to passive suppression of maximally
      efficient normal movements unless the stroke survivor is actively retrained to unlock masked
      abilities over time. Teasell and colleagues confirmed the importance of skilled
      rehabilitation throughout all phases of recovery including the chronic stroke phase, though
      this important population regularly experiences fewer opportunities to participate in therapy
      as time progresses. Measurable gains may be slower at this stage but the ability to perform
      essential mobility tasks remains just as important to the individual.

      Thus, the purpose of this graduate student research study is to determine the immediate and
      carryover effects of an integrated verbal and manual facilitation approach during sit to
      stand training on the midline alignment, muscle activation and quality of movement in chronic
      stroke survivors with hemiplegia. By determining the essential ingredients that lead to an
      ideal recipe for success, physical therapists may have more evidence-based tools available to
      maximize the independence, quality of life and confidence of their patients.

      Procedures: Session 1: All participants will complete the initial paperwork and then be
      randomized into Verbal Cueing Group or Verbal + Manual Cueing Group using envelopes that are
      predetermined from a random number table. Height will be assessed using a stadiometer and
      weight using a scale. Subjects will then have trajectory markers and surface
      electromyographic (EMG) sensors placed according to the chart. This includes 24 individual
      marker trajectories, two thigh clusters and two shank clusters of four trajectories each for
      a total of 40 markers and 6 surface EMG sensors that will be placed on major muscle groups of
      the lower extremities. Once the setup has been completed and verified, the subject will
      perform two static standing trials, followed by two initial sit to stand (STS) trials to
      determine their baseline variables. This format will be followed by both the Verbal Cueing
      and the Verbal + Manual Cueing throughout the treatment session. The first 5 repetitions of
      both groups will include part to whole task practice of partial sit to stand using scripted
      verbal cueing to facilitate understanding of the task. The goal of both groups is to improve
      midline orientation and alignment during the task of moving from sitting to standing.

      After the first 5 repetitions, the subject will perform two sit to stand trials on their own
      following the clinician's scripted verbal commands. Next, five Manual + Verbal Cueing or
      Verbal Cueing trials will commence followed by another two PostCue trials. This repeated
      sequence of 5 cued trials followed by 2 assessment trials will continue for a total of 40 sit
      to stand trials. After a 5-minute rest period the subject will then be asked to perform two
      additional STS to determine retention of learning over that interval. Next, two isometrically
      resisted sit to stand trials will be performed for EMG normalization. Once the EMG
      normalization is completed, the subject will then be told they are done and may get up to
      leave. When they get up to leave, their sit to stand activity will also be discretely
      recorded for comparison to their last knowingly observed trial. This is based on the Actual
      Amount of Use Test (AAOUT) in which subjects are observed under normal circumstances to
      assess whether the learning was integrated into functional use when the subject doesn't think
      they are being observed.

      At the end of session #1, the investigator will ask the subject what strategy most helped
      them achieve midline. Based on their feedback, the investigator will create and issue a home
      exercise program (HEP) handout that incorporates that subjective report. Examples include
      statements such as, "Feeling the pressure through my left leg" or "Leaning to my left". This
      cue will be placed on a brightly colored card that will be placed near where the subject
      practices sitting to standing most often in their home environment. The card will also
      contain an easy to mark log to encourage practice of the STS task over the next 3-5 days. The
      subject will be instructed to perform the exercises at the times specified on the card using
      the subject's subjective to help encourage maximal midline orientation. Permission will be
      obtained to text the subject on a regular basis to remind them to perform the exercises.

      Session 2: Participants who choose to return will come back within 3 to 5 days of Session #1.
      Subjects will be asked to bring their HEP card to verify compliance via the practice log.
      After placement of the trajectory markers (but not the EMG), subjects will be asked to
      perform two trials of sit to stand, regardless of their original group. They will then be
      assessed with the AAOUT test in the same manner as the end of session #1. Afterward,
      participants in the Verbal Cueing group will be offered the Integrated Cueing approach if
      they so choose.
    

Intervention name(s): Integrated Cueing Protocol; Verbal Cueing Protocol
Intervention type(s): Other; Other
Intervention description(s): The first 5 repetitions will include part to whole task practice of partial sit to stand using scripted verbal cueing to facilitate understanding of the task. The goal is to improve midline orientation and alignment during the task of moving from sitting to standing. In addition to verbal cueing, the manual cueing group will receive hands-on tactile facilitation from a trained physical therapist to facilitate appropriate midline weight shift during the sit to stand activity for the series of 40 training repetitions.; The first 5 repetitions will include part to whole task practice of partial sit to stand using scripted verbal cueing to facilitate understanding of the task. The goal is to improve midline orientation and alignment during the task of moving from sitting to standing. The verbal cueing protocol consists of verbal cueing from a trained physical therapist to facilitate appropriate midline weight shift during the sit to stand activity for the series of 40 training repetitions.
Other intervention name(s): Manual Cueing Protocol
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Facilitation; Sit-to-Stand; Manual Cueing; Verbal Cueing