Effect of severity of arm impairment on response to additional physiotherapy early after stroke

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Abstract
Objective: To investigate effect of initial severity of arm impairment on response to additional physiotherapy for the arm after stroke. Design: In this controlled trial, patients were randomized into one of three groups: routine physiotherapy (RPT) patients received no additional physiotherapy; qualified physiotherapy (QPT) patients received additional treatment from a qualified physiotherapist; assistant physiotherapy (APT) patients received additional treatment from a trained supervised assistant. Comparisons between the whole groups found no significant differences and have been reported elsewhere. In a post hoc analysis, the groups were subdivided according to severity of initial arm impairment. The subgroups were then compared. Setting: A general hospital with acute and rehabilitation facilities for stroke patients. Subjects: Patients (n= 282) between one and five weeks after stroke. Interventions: Ten hours additional physiotherapy were given over a five-week period. The treatment approach reflected current usual British practice. ‘Blind’ outcome assessment was performed after intervention, and at three and six months after stroke. Main outcome measures: Rivermead Motor Assessment Arm Scale, Action Research Arm Test. Results: In more severe patients, no benefits of additional treatment were detected. In less severe patients, significant benefits were found in those who completed treatment with the trained assistant. However, a considerable number of patients did not complete the additional treatment. The content of treatment differed between the QPT and APT groups. Treatment of less severe APT patients emphasized repetitive supervised practice of movements and functional tasks. No significant effects of additional treatment were found in terms of shoulder pain or spasticity. Conclusions: Regardless of whether additional physiotherapy was given or not, patients with severe arm impairment improved very little in arm function. Enabling adaptation to loss of arm function may be an appropriate rehabilitation strategy for some patients. Trends in the data confirm findings of some previous studies that intensive treatment for patients with some motor recovery of the upper limb is effective. Following patient assessment and treatment planning by a qualified physiotherapist, it may be appropriate for guidance of repetitive practice of motor and functional tasks to be delegated to trained and closely supervised assistant staff.