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Section 5.5.1

Mobility and Transfer Skills

Therapeutic Goal: Improve Basic Mobility and Transfer Skills

  1. Task-oriented Training (i.e. Training that is progressively adapted, salient, and involves active participation) is recommended to improve transfer skills and mobility [Evidence Levels: Early-Level C; Late-Level C].
  2. Task-oriented training consisting of an extra 11 to13 reps/days of sit-to-stand practice with eyes open and minimal use of arm support should be included in the patient’s therapy program [Evidence Levels: Early-Level A; Late-Level C].
  3. Spasticity should not limit the use of strength training in the leg [Evidence Levels: Early-Level C; Late-Level C].
  4. Assess the need for special equipment on an individual basis. Once provided, equipment should be evaluated on a regular basis [Evidence Levels: Early-Level C; Late-Level C].
  5. Ankle foot orthoses may help some patients with foot drop; they should not be used routinely without proper assessment prior to prescription and follow-up to establish their effectiveness in the individual [Evidence Levels: Early-Level A; Late-Level A].
  6. Lower extremity orthotic devices may be helpful if ankle or knee stabilization is needed to help the patient walk. Prefabricated bracing can be used initially, and more expensive customized bracing reserved for patients who demonstrate a long-term need [Evidence Levels: Early-Level C; Late-Level C].
  7. Functional electrical stimulation (FES) should be considered for use in improving muscle force, strength and function (gait) in selected patients. Functional electrical stimulation must not be assumed to have sustained effects [Evidence Levels: Early-Level A; Late-Level A].
  8. There is insufficient evidence to recommend for or against neurodevelopmental therapy (NDT) in comparison to other treatment approaches for motor retraining following an acute stroke [Evidence Levels: Early-Level B; Late-Level B].
  9. Recommend that wheelchair prescriptions and be based on careful assessment of the patient and the environment in which the wheelchair will be used [Evidence Levels: Early-Level C; Late-Level C].
    Rationale

    Stroke frequently affects balance and the use of the legs. Before being able to walk stroke survivors must develop basic abilities to stand and transfer safely. Sit to stand training is a feasible strategy that any member of the team on a daily basis. Some individuals may not achieve independence in walking and will require a wheelchair.

    System Implications

    To achieve timely and appropriate assessment and management of basic mobility, postural control and transfer skills the organization requires

    • Organized stroke care available, including stroke units with critical mass of trained staff and interprofessional team during the rehabilitation period following stroke.
    • Initial assessment performed by clinicians trained and experienced in stroke rehabilitation.
    • Timely access to specialized, interprofessional stroke rehabilitation services.
    • Timely access to appropriate intensity of rehabilitation for stroke survivors, including sit to stand training.
    Performance Measures
    1. Change (improvement) in functional status scores (FIM® Instrument sub scores transfers and locomotion) from admission to an inpatient rehabilitation program to discharge.
    2. Change (improvement) in functional status score (Berg balance) from admission to an inpatient rehabilitation program to discharge.
    3. Average hours per day (minimum of three) of direct task-specific therapy provided by the interprofessional stroke team.
    4. Average days per week (minimum of five) of direct task specific therapy provided by the interprofessional stroke team.
    5. Number/percentage of organizations using sit-to-stand as a standard treatment modality for post-stroke functional gain.

    Measurement Notes

    • Therapy time may be extracted from rehabilitation professional workload measurement systems where available
    Summary of the Evidence

    A Cochrane review on physical therapy treatment approaches for the recovery of postural control and lower limb function following stroke included 21 trials. 440 Eight trials compared a neurophysiological approach with another approach, eight compared a motor learning approach with another approach, and eight compared a mixed approach with another approach.  A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardized mean difference 0.94, 95% confidence intervals [CI] 0.08 – 1.80).  There was no significant evidence that any single approach had a better outcome than any other single approach or no treatment control.

    Strength training should not be avoided in those with spasticity as spasticity has not been shown to be a contraindication to the use of strengthening .441

    Task oriented sit to stand training consisting of an extra 11 to13 reps/daily of sit-to-stand practice with eyes open and minimal use of arm support should be included in the patient’s therapy program for patients with difficulty rising from a chair and who have difficulty with postural control. 442,443 Both studies found significantly greater improvement in sit-to-stand compared to controls. Specifically, Barreca’s study found a significant between-group difference in the number of patients who were successful in standing up twice from a 16-inch high surface without the use of their hands following sit-to-stand training from various heights three times weekly for 45 minutes until the task was achieved or discharge.442Dean and colleagues (2000) found greater force production through the affected limb during sit to stand). 443

    Task oriented training In a high quality RCT Salbach and colleagues found that balance self-efficacy was better in those who received a task-oriented targeted walking intervention versus a control group.444 Cheng and colleagues assigned individuals to repetitive sit to stand and symmetrical standing training with a biofeedback trainer versus conventional therapy.445 There was no short term benefit in sit to stand but at six months the task oriented group had significant improvements and less mediolateral sway than the control group.

    For additional information and more extensive reviews of the literature, please refer to:

    StrokEnginewww.strokengine.ca/

    Evidence Based Review of Stroke Rehabilitation www.ebrsr.ca