Research to get you thinking
Davide de Sousa discusses a randomised trial exploring whether two weeks of intensive sit-to-stand training in addition to usual care will improve sit-to-stand in people who are unable to stand up independently after stroke.
You recently published a study of intensive sit-to-stand training in people who could not stand up independently after having a stroke. Is this something for which evidence was lacking?
Yes. There are five clinical trials that investigated the effects of additional repetitive sit-to-stand training after stroke. These trials either recruited people who could stand up without assistance or had methodological flaws that affected the validity of the results. Overall, these five trials do not provide clear evidence of the effectiveness of additional repetitive sit-to- stand training in people who are unable to stand up independently after stroke.
Was your study designed to overcome or avoid those same limitations?
Yes. We only recruited people who could not stand up independently and therefore, our results apply to people who are more disabled after stroke.
We also paid great attention to minimising bias. We did this by randomising people to a control or experimental group, concealing allocation, blinding assessors and attempting to conceal the intervention from participants and other therapists treating the control participants.
What about the measurement of improvement in the ability to stand? Presumably patients have very different starting abilities, so how did you find a measurement that was relevant to them all?
One of the challenges prior to the start of this trial was finding an outcome measure that would be appropriate for people with all levels of disability and particularly those who were very disabled. Most outcome measures of sit-to-stand ability are susceptible to floor effects in people who are too disabled to stand up. To overcome this problem, we used a novel method to assess sit-to-stand ability. That is, we used clinicians’ impressions of change of participants’ ability to move from sitting to standing from videos. We asked two blinded assessors to score the change in ability of participants to perform an independent sit-to-stand movement, taking into consideration the initial disability of the participant and the amount of change expected over a two-week period, assuming the participant received usual care. This way, small functional changes that are often missed by other outcome measures could be detected.
‘One common concern I hear from therapists is that there is not enough time in the day to provide this amount of physiotherapy.’
What were the findings of the study? The results of our trial indicate that intensive sit-to-stand training in addition to usual care improves sit-to-stand in people who are unable to stand up independently after stroke. The mean between-group difference (95% CI) for clinicians’ impressions of sit-to-stand change was 1.57/15 points (0.02 to 3.11). A secondary outcome (ranking of change in ability to move from sitting to standing) also demonstrated a treatment effect, with a mean between-group difference (95% CI) of –7 (–1 to –13) in favour of the experimental group, supporting the results of the primary outcome.
While we demonstrated a treatment effect of additional sit-to-stand training, there is uncertainty as to whether the size of this effect is clinically worthwhile. This is evident by the fact that the 95% CI spanned our minimally worthwhile treatment of 2/15 points. To overcome this uncertainty the study now needs to be repeated with a larger sample.
Did you have any concerns about doing this trial?
Prior to beginning the trial we were concerned that participants would not tolerate such an intensive intervention each day for more than two weeks, particularly in the early stages of stroke recovery. However, we found that the experimental participants were able to tolerate large amounts of sit-to-stand repetitions, suggesting that our concerns were unfounded. In fact, participants in our experimental and control groups performed a median (IQR) 89 (55 to 127) versus 37 (16 to 51) daily sit-to-stand repetitions, respectively. Overall, participants in our experimental group performed over three times more sit-to-stand repetitions than participants in our control group; median (IQR) 1252 repetitions (763 to 1773) versus 365 repetitions (164 to 514), respectively.
Do you think these results will help physiotherapists to prioritise what to include in rehabilitation?
Yes. There can be many tasks to train after stroke, and it can be difficult for physiotherapists to prioritise which tasks to train first. One possible implication of our results is that two weeks of intensive repetitive sit-to-stand training could be initially prioritised for people with difficulty standing up, allowing more time after this period to focus on other tasks requiring independent sit-to-stand, such as walking.
One common concern I hear from therapists is that there is not enough time in the day to provide this amount of physiotherapy. I acknowledge this issue and agree it is difficult; however, we successfully used strategies in our trial together with timetabling to increase the amount of sit-to-stand training for participants.
Davide de Sousa is a physiotherapist with a BSc (Hons) Physiotherapy. He is a PhD candidate investigating the effects of strengthening interventions after stroke, at the University of Sydney. He has more than 10 years’ experience in adult neurological, orthopaedic and older person rehabilitation. His current research is focused on dosage of functional training, and interventions that improve strength and function in people after stroke.
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