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

Objective: To investigate effect of initial severity of arm impairment on r esponse to additional physiotherapy for the arm after stroke. Design: In this controlled trial, patients were randomized into one of thre e groups: routine physiotherapy (RPT) patients received no additional physi otherapy; qualified physiotherapy (QPT) patients received additional treatm ent from a qualified physiotherapist; assistant physiotherapy (APT) patient s received additional treatment from a trained supervised assistant. Compar isons between the whole groups found no significant differences and have be en reported elsewhere. In a post hoc analysis, the groups were subdivided a ccording to severity of initial arm impairment. The subgroups were then com pared. Setting: A general hospital with acute and rehabilitation facilities for st roke patients. Subjects: Patients (n = 282) between one and five weeks after stroke. Interventions: Ten hours additional physiotherapy were given over a five-we ek 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 Researc h 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 considerabl e number of patients did not complete the additional treatment. The content of treatment differed between the QPT and APT groups. Treatment of less se vere APT patients emphasized repetitive supervised practice of movements an d functional tasks. No significant effects of additional treatment were fou nd in terms of shoulder pain or spasticity. Conclusions: Regardless of whether additional physiotherapy was given or no t, patients with severe arm impairment improved very little in arm function . Enabling adaptation to loss of arm function may be an appropriate rehabil itation 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 fo r guidance of repetitive practice of motor and functional tasks to be deleg ated to trained and closely supervised assistant staff.