Lalin Fe Evangelista, PT, DPT
Utica University
With the modern era today, the use of evidence- based practice in physical therapy is non-detrimental to answer the vast clinical problems in our society. This paper discusses the use of evidence-based practice in managing gait instability in a post-CVA patient. “The case has been made that physical therapists should use evidence to inform their decision making during patient/client management process” (Jewell, 2015, p.21). Evangelista, 2016 argued that: “Evidence-based practice defines the future of physical therapy. Its significance in the physical therapy treatment provides the best possible outcomes and makes use of efficient time and energy to reach and maximize patient’s rehabilitation potential”.
Managing gait instability is a common problem, a physical therapist must address as instability caused by gait abnormalities might result to falls and increased dependency in caregivers, leading to patient to deteriorating effects of immobility and then non-weight bearing on our lower extremities which produces further complications such as muscle weakness, osteoporosis, and medical complications such as shortness of breathing, pneumonia and falls.
Gait training and early weight bearing activities therefore affect the most impact on providing patient’s maximum rehab potential in functional mobility. As a physical therapist, this has been the focus of my intervention with the objective of improving the quality of gait and promoting safe and effective adaptive and compensatory techniques for most patients especially those with neurologic cases such as cerebrovascular accident (CVA). [Thus,] “The recovery of walking ability is considered the most important objective of the lower limb rehabilitation of individuals after stroke” (Dickstein, 2008, 649-660).
Let us now discuss a previously presented and mentioned case, and use evidence based practice in attempt to provide an evidence-based physical therapy treatment approach.
Evangelista, 2016, para.2-6 had stated the following:“First, we generate a specific clinical question from a patient case. Patient X is a 65 year old, male, Caucasian patient who comes to the clinic with MD note: evaluate and treat as indicated. Patient presents with active medical history of hypertension, Type II DM, dementia, s/p (R) CVA, (L) hemiparesis, with complaints of (L)sided weakness and difficulty in walking; and PT diagnosis of (R)CVA affecting non-dominant (L) sided hemiparesis, gait abnormality and difficulty walking. In order to properly address patient’s condition, one of the goals of the intervention is managing gait instability for this patient for him to safely ambulate around living environment. Moreover, the clinical question: “How to manage gait instability in elderly post-stroke patients?” in attempt to provide an evidence based practice on physical therapy.
Now, using the databases offered by the Utica College Library, I then started my hunt for providing the treatment with best possible evidence. Using the “Important Links” button located in one of the toolbars in engage, I am able to go to Utica College Library. From there, I clicked on Medical, Health and Psychology from the categories listed below. This had then immediately brought me to the links for databases for collection of medical journals, articles and evidenced based treatments for various medical conditions. I then started my search engine using CINAHL, PEDRO and Academic search complete. Below is a chart which shows the number and availability of the articles which attempts to answer my clinical question regarding evidence based treatments with post-stroke patients.
| Categories | CINAHL | PEDRO |
Academic Search Complete (all databases) |
|---|---|---|---|
|
Keywords used |
Gait, Stroke, Elderly |
Gait Instability in Elderly Post-Stroke Patients |
Gait, Stroke, Elderly |
|
Initial search hits |
44 hits |
53 hits |
515 hits |
|
Advanced Search Words to Limit/Sort |
Publication, English, Peer Reviewed, Age 65+ |
Clinical Trial, Publication Date (5 yrs) |
Journals, Clinical Rehabilitation |
|
Advanced Search Hits |
35 hits |
8 hits |
8 hits |
|
Relevant articles |
7 |
8 |
3 |
|
Top 5 articles (No. of articles chosen) |
1 |
3 |
1 |
With regards to my topic, I started looking for databases and decided to use CINAHL, PEDRO and all databases and see the comparison. I started with CINAHL using the search words: gait, stroke and elderly from which had taken a lot of time cause documents load too slow. PEDRO on the other hand, displayed quick results and had given me a better advantage in searching: gait instability in elderly post-stroke patients displaying 53 hits. CINAHL later loaded which displayed 44 hits and the later, all data bases displaying the most hits which is 515. I then started to sort out using the advanced search toolbar, clicking peer-reviewed option for articles, filtering essential datum such as providing a publication date to make sure it is up to date and not later than five years, selecting age group which are 65+ and older, choosing peer reviewed and clinical rehabilitation topic. This then narrowed by search into getting 35 from CINAHL, 8 from PEDRO and 8 from all data bases. Looking into the articles, I then chose the best 5 among them from which 4 came from Pedro, 1 from CINAHL and 1 from all databases.
In searching for the best possible evidence based practice, I then compare and contrast. CINAHL gives me an advantage by providing a sufficient number of articles but it has less specificity most articles though refined using the advance search, aren’t relevant for me.. Next, choosing academic search complete made me feel I won’t miss out anything but since the advanced search options are very few, it then turned out to increase the percentage of my error. Lastly, PEDRO has vast number of articles available and had given me specific articles I’m looking for.
Below are the list of my top five articles in full APA formats, which are I found beneficial in my search for the evidence based-practice followed by a chart which summarizes the type of research and the results of the studies respectively:
1. Cho, H.Y, Kim, J.S., & Lee, G.C. (2013). Effects of motor imagery training on balance and gait abilities in post-stroke patients: a randomized controlled trial. Journal of Clinical Rehabilitation 27(8), 675-680. doi: 10.1177/0269215512464702.
2. Ferrante, S. et al. (2011). A biofeedback cycling training to improve locomotion: a case series study based on gait pattern classification of 153 chronic stroke patients. Journal of Neuroengineering and Rehabilitation 8(47). doi: 10.1186/1743-0003-8-47.
3. Kim, J.H., Lee, B.H. (2013). Action observation training for functional activities after stroke: a pilot randomized controlled trial. Journal of Neurorehabilitation, 33(4), 565-574. doi: 10.3233/NRE-130991
4. Mikolajewska, E. (2013). The value of the ndt-bobath method in post-stroke gait training. Advance in Clinical and Experimental Medicine 22(2), 261-271.
5. Ng, S. (2015). Parallel walk test: Its correlation with balance and motor functions in people with chronic stroke. Archives of Physical Medicine and Rehabilitation 95 (5), 877-884. doi:http://dx.doi.org.ezproxy.utica.edu/10.1016/j.apmr.2014.11.002.
| Article | Type of Research | Results |
|---|---|---|
|
Effects of motor imagery training on balance and gait abilities in post-stroke patients: a randomized controlled trial. |
An RCT with the used of both qualitative and quantitative measurements and provides results for the action observation training for functional activities after stroke.
|
Results revealed significant improvement of Functional Reach Test, Timed Up-and-Go Test, 10-m Walk Test) and Fugl-Meyer assessment and suggests that the use of motor imagery training significantly help post-stroke patients. |
|
A biofeedback cycling training to improve locomotion: a case series study based on gait pattern classification of 153 chronic stroke patients. |
The study used an intra-subject statistical analysis (ANOVA) which used both qualitative and quantitative measurements showing that all patients significantly decreased the pedaling unbalance after treatment and maintained significant improvements with respect to baseline at follow-up. |
Treatment reveals positive results and determines the effectiveness of the use of biofeedback cycling to improve locomotion and suggests in translating progresses from pedaling to locomotion. |
|
Action observation training for functional activities after stroke: a pilot randomized controlled trial. |
The study used RCT using quantitative measurements in comparing the effects of action observation training and motor imagery training on recovery from chronic stroke. |
Results showed significant improvement in Tined Up and Go test, gait speed, cadence and single limb support of the affected side. |
|
The value of the ndt-bobath method in post-stroke gait training. |
A systematic review research which used quantitative measurements in the study of post-stroke gait reeducation using the NeuroDevelopmental Treatment-Bobath (NDT-Bobath). |
The results revealed improvement in velocity, cadence, and stride length after NDT treatment. |
|
Parallel walk test: Its correlation with balance and motor functions in people with chronic stroke. |
A systematic review of cross sectional study (Level 1) that used intrarater, interrater, and test-retest reliability of the times and scores generated in the parallel walk test. |
PWT times and scores showed high intrarater, interrater and test-reliability in individuals with stroke. The study overall suggested effectiveness of using PWT in post-stroke patients. |
Among the articles above, the article entitled “A biofeedback cycling training to improve locomotion: a case series study based on gait pattern classification of 153 chronic stroke patients” best represents an evidence based article as this has high reliability, validity, with index clinical measure responsive. Moreover, it is clinically meaningful for my patient case as in our clinic; I could simulate the use of biofeedback cycling training and incorporate it in gait re-training to normalize patient’s quality of gait. Realistically, I could perform the intervention with my skills as a physical therapist. Most importantly, the patient himself is an exact fit for the intervention as the patient currently enjoys using the nautilus bike as part of treatment. I will definitely use the index clinical measure for this patient. “Furthermore, cycling avoids problems of balance and can be safely performed even from a wheelchair, without requiring expensive robotic devices or the constant supervision of a therapist which are, on the contrary, necessary to support body weight and to prevent falls during gait training. For all these reasons, leg cycling training is a safer and more economic intervention to supplement functional ambulation training after stroke and it is also becoming an interesting option for home rehabilitation of hemiparetic patients” (Ferrante, S. et al., 2011, para. 9).
As every study have its own strengths and weaknesses. The study used RCT to eliminate bias and presented a large quantity of subjects which decreases the margin of error. The evidence is highly appraised as the study. Though it has more bias control, it has its drawbacks as well. The research procedure is only performed three days a week for two weeks from which there is still room for improvement in upgrading the study into longitudinal design. I will definitely use the result of the study as an additional knowledge to my clinical practice not only for post-stroke patients but all of the patients that might benefit from the study.
Every search for evidence becomes exciting now. My quest for searching the best evidence in managing gait instability for post-stroke patients had allowed me to search for best possible evidence and together my clinical expertise as a physical therapist, I concluded that both are necessary in providing the highest quality of physical therapy treatment. I also learned how to be patient with searching, appraising and evaluating the best evidence based practice that will answer my clinical questions and provide the most appropriate treatment for my patients. The application of my knowledge in using the evidence-based practice in physical therapy had brought excitement for me. I am challenged by the way each patient presents differently and this is such an area for growth for my clinical expertise as a clinician.
In providing the best quality of care to patients, evidence based practice is now a necessity in attempt to address patient’s impairments. I must admit that an evidence-based practice takes a lot of hard work for now because I never thought that it will be this complex. Along with the complexity, it opened my eyes to vast number of solutions from which I believe boosts patient’s functional status leading to the fruit of hard work which is the patient most benefit. I always find the physical therapy profession as one of the best profession that helps humanity to restore back into function. Along with the evidence-based practice, I believe this will bring out the best among us.
Cho, H.Y, Kim, J.S.& Lee, G.C. (2013). Effects of motor imagery training on balance and gait abilities in post-stroke patients: a randomized controlled trial.
Journal of Clinical
Rehabilitation 27(8), 675-680. doi: 10.1177/0269215512464702. Retrieved March 2,2016 from: http://cre.sagepub.com/content/27/8/675.long
Dickstein R. (2008). Rehabilitation of gait speed after stroke: a critical review of intervention approaches.
Neurorehabilation Neural Repair, 22(6):649–660. doi:
10.1177/15459683080220060201.
Evangelista, L.P. (2016). The use of evidence-based practice in managing gait instability in elderly post-stroke patients, para.2-6. Retrieved March 7,2016 from:https://engage.utica.edu/learn/mod/forum/discuss.php?d=189411
Ferrante, S. et al. (2011). A biofeedback cycling training to improve locomotion: a case series
study based on gait pattern classification of 153 chronic stroke patients. Journal of Neuroengineering and Rehabilitation 8(47). doi: 10.1186/1743-0003-8-47. Retrieved March 2,2016 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200991/
Jewell, D.C. (2015). Guide to evidence-based physical therapist practice (3rd Ed.). Burlington,
MA: Jones and Bartlett Learning.
Kim, J.H., & Lee, B.H. (2013). Action observation training for functional activities after stroke: a pilot randomized controlled trial. Journal of Neurorehabilitation, 33(4), 565-574. doi:
10.3233/NRE-130991. Retrieved March 2,2016 from: http://content.iospress.com/articles/neurorehabilitation/nre991
Mikolajewska, E. (2013). The value of the ndt-bobath method in post-stroke gait training.
Advance in Clinical and Experimental Medicine 22(2), 261-271. Retrieved March 2,2016 from: http://www.advances.am.wroc.pl/pdf/2013/22/2/261.pdf
Ng, S. (2015). Parallel walk test: Its correlation with balance and motor functions in people with chronic stroke. Archives of Physical Medicine and Rehabilitation 95 (5), 877-884.
doi:http://dx.doi.org.ezproxy.utica.edu/10.1016/j.apmr.2014.11.002.