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Observation of Meaningful Activities: A Case Study of a Personalized Intervention on Poststroke Functional State

Chatterton, Hilary PhD; Ewan, Louise MSc; Kinmond, Kathryn PhD; Haire, Antonita PhD; Smith, Nickolas PhD; Holmes, Paul S. PhD

Journal of Neurologic Physical Therapy: June 2008 - Volume 32 - Issue 2 - p 97-102
doi: 10.1097/NPT.0b013e31817323dc
Case Report
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SDC

Background and Purpose: Stroke rehabilitation coordinated by specialist teams and oriented toward functional activities is now common. However, the potential remains for improved outcome, and new methods for improving rehabilitation are being developed. Observation of functional, meaningful activities, via DVD, has been suggested as a technique that may be effective. This case study aimed to investigate the effect of an individualized program of observation for functional status after stroke.

Case Description: The case study participant was a 44-year-old man, 12 months after a right intracerebral hemorrhage, with a Scandinavian Stroke Scale (SSS) score of 42. He was independently mobile using a cane. He viewed, with the instructions to understand and imitate, four DVDs of meaningful daily activities filmed from first- and third-person visual perspectives. Pre- and postintervention measures administered in the participant’s home were the SSS, Postural Assessment Scale (PASS), Timed Up and Go test (TUG) with manual and cognitive components, a fluidity scale, and the Stroke-Specific Quality of Life Scale.

Outcomes: Improvements were observed in the TUG and the fluidity scale. Small but clinically insignificant changes were observed in the PASS. The patient also felt confident to progress to walking without his cane.

Discussion: The findings suggest that, for this relatively young and motivated individual, observation of meaningful activities was an important part of his stroke rehabilitation.

Research Institute for Health and Social Change, Manchester Metropolitan University, Manchester, UK.

Address correspondence to: Paul S. Holmes, E-mail: p.s.holmes@mmu.ac.uk

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INTRODUCTION

Stroke remains a major cause of disability. The UK incidence of stroke is reported as 3.75 per 1000 head of population, with a prevalence rate of 15 in every 1000.1 An estimated 130,000 individuals are treated in hospital each year, with 35% of them with new strokes having significant residual disability requiring rehabilitation.1 More than 300,000 people in the United Kingdom are living with moderate to severe disabilities resulting from stroke.2

Coordinated specialist stroke rehabilitation involving stroke unit care is known to produce improved therapeutic outcomes. These include increased survival rates, regaining functional independence, and returning home.3 It is advised that rehabilitation be oriented toward functional activities.4 Potentially important contributors to improved outcome are early goal setting and career involvement.5 While delivery of stroke care continues to improve,4 only weak relationships have been found between processes in stroke care and outcome.6 Despite this positive contribution to outcome, the amount of therapy being received is small; in many studies, a median treatment time of only 45 minutes of physical therapy and 40 minutes of occupational therapy were received on weekdays,5 and residual levels of disability remained high.

One method of overcoming the problem of limited patient-therapist contact time is to find ways in which patients can perform valid rehabilitation activities on their own. Unsupervised practice has in the past concerned therapists as patient performance on therapeutic activities may deviate from the prescribed optimal movement quality. Current interpretation of the Bobath concept encourages goal-directed self-practice with the aim of optimizing postural and movement strategies to increase movement efficiency to the individual patient’s maximum potential. The repetitive use of compensatory and maladaptive movement strategies, as opposed to more efficient movement patterns, raises some concerns as these may result in plastic changes in the neural and musculoskeletal systems, which, it is hypothesized, may ultimately limit recovery.7 In addition, some activities may be associated with the risk of falling. What is clear, however, is that the frequency and quality of motor rehabilitation activities are fundamental to effective reacquisition of skilled movement.8

Based on current evidence, it is unclear whether more frequent or intensive periods of rehabilitation produce significant therapeutic benefits. There is some evidence that increased intensity of therapy may improve outcome, but effect sizes are small and the clinical significance of the differences is debatable.9 Similarly, the dose-response relationship between therapy frequency and meaningful clinical or behavioral outcomes is not known. Further, whether individual variations exist in the response to more intensive treatment regimens and at what stage post-stroke they are best implemented remain important, unanswered questions. It may be that innovative interventions offer more effective opportunities for recovery.

Neuroplastic changes may be facilitated by repeated practice of movements, but also by motor imagery10 and action observation.11 Thus, there is a potential for increasing the amount of neural stimulation through more covert interventions, beyond that achieved through physical practice, to reach the thresholds necessary for permanent plastic change. These interventions may be initiated early after stroke and used throughout the rehabilitation process. They can incorporate the early goal setting identified above6 as potentially important contributors to improved outcomes and can be used in conjunction with conventional rehabilitation activities to support the achievement of short- and long-term goals. In addition, increasing the variety of rehabilitation activities available may assist in engaging patients in extended practice and may contribute to overcoming plateaus in recovery.12

Motor imagery, the covert mental simulation of movement, has received attention and has been investigated recently as an adjunct to conventional treatment with encouraging results.13–16 However, some stroke patients have problems with image generation, content, and control.17 In addition, when used as a therapeutic intervention, motor imagery depends on the individual’s ability to initiate and sustain valid, meaningful practice for sufficient periods of time for benefit to accrue. When these and other procedural characteristics are controlled, imagery may be a useful addition to more conventional physical therapies.13

In response to some of these concerns, Holmes18 suggested that action observation may provide a more useful intervention since it seems to address many of the fundamental problems associated with the use of motor imagery in a stroke context. In contrast to motor imagery, during structured observation, the visual percepts are provided for the observer, and the social context, visual perspective, and movement agency are more easily controlled. In addition, there is strong evidence from the modeling literature to support the inclusion of action observation in a motor (re)learning context poststroke. While a full review is beyond the scope of this article, the reader is referred to the chapter by McCullagh and Weiss19 on modeling and the excellent meta-analysis by Ashford et al,20 who were able to demonstrate a significant advantage of observational modeling over practice-only conditions.

Recent neuroscience research has provided a mechanism to support the use of action observation as a valid intervention; the mirror neuron system (MNS)21,22 and cortical midline structures (CMSs).3 These visuomotor mirror neurons show special characteristics. For example, they fire when a participant executes a goal-directed hand movement22 and also then the participant observes the execution of the same action. The MNS has been shown to be important for action and intention understanding, imitation, empathy, and motor learning,23,24 and similar changes in motor and sensory cortical activity have been reported in action observation and performance conditions.25–27 However, these behaviors interact with self-related processing and the social context of the observed condition modifying neural activity in right CMSs during the observation process.28 Therefore, providing social meaning for any observation intervention would seem important. However, little is known about how stroke patients respond to viewing observation activities performed by themselves, an actor representing them, or a neutral third party. There may be differences in psychological and physical responses to these different conditions.

While action observation has been shown to lead to cortical reorganization in young adults,29 there has been little investigation of the use of meaningful action observation for recovery after stroke. We describe here the use of action observation in stroke rehabilitation. This case study was a preliminary investigation, in a funded research program, with the aim of describing the effect of an individually meaningful program of observation on functional and psychological status after stroke.

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METHOD

Case Description

The case participant was a 44-year-old man, 12 months post-stroke with a right temporoparietal intracerebral hemorrhage. Initial poststroke assessments during the participant’s hospitalization indicated complete left-sided hemianesthesia and hemiplegia with left hemianopia. Immediately after his stroke, the participant received three months in-patient physical and occupational therapy. The participant had received physical therapy for one hour per week from a National Health Service (NHS) practitioner after his discharge from hospital. This physical therapy continued throughout the duration of the intervention.

At the time of the study, the participant required assistance with activities of daily living, but was able to walk short distances with the aid of a cane and slowly climb the stairs one step at a time using the handrail for support and to pull on. Increased tone in an antigravity pattern was present in both upper and lower limb, being more marked in the upper limb. There was no functional recovery in the upper limb, and associated reactions in a flexor pattern were present. Impairment measured on the Scandinavian Stroke Scale (SSS) was 42 pre-intervention. The participant was a member of a stroke support group working with the research team.

Before the stroke, the participant had worked as a carpenter and led a physically active lifestyle. His hobbies included coaching a junior soccer team, attending a local gymnasium, road running, and attending soccer games. After his stroke, the participant reported spending much of his time watching television, feeling confined to the house, and unable to play an active role in his young family’s life, for example, playing soccer in the yard with his two sons.

Written informed consent to participate was obtained after written and verbal explanation of the study. The study was approved by both the NHS Regional Ethics Committee and the local institutional ethics committee.

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Interventions

The participant was interviewed in his home for approximately one hour to explore his meaningful prestroke life events and behaviors. The PETTLEP model30 was adopted to guide the observation content. The model identifies seven behavioral factors (physical, environment, task, timing, learning, emotion, and perspective) argued to represent the key contributors to matching shared neural circuitry under related behavioral conditions (eg, physical activity, imagery, and observation). Originally developed for use in sports psychology for imagery interventions and demonstrating encouraging effects,31,32 the PETTLEP model may have potential to be applied to related visuomotor interventions in stroke rehabilitation. Therefore, in the current observation case study, the interview questions were based on the PETTLEP factors. For example, the participant was asked to describe the environment of his favorite road run, how it made him feel during the run, which physical senses he focused on while running, and how he would dress for the activity. Personal significance was important as functional magnetic resonance imaging studies have shown greater mirror neuron activity when viewing actions from personal motor repertoires.33

The interview content emerging from the PETTELP-directed interviews was developed into film storyboards. The identified activities were a soccer-coaching environment, a training run, a country drive, and a weights and cardiovascular gym training session (which included ergometer rowing). All experiences were filmed from a first-person (as if looking through one’s own eyes) and a third-person (watching oneself as if on TV) visual perspective. Films were edited to create 15- to 20-minute DVDs. Where physically possible, the participant was filmed from camera angles to display him as able-bodied for the entire DVD script. In situations where this was not possible (eg, for parts of the running and ergometer rowing DVDs), an actor of age and anatomical features similar to those of the participant and dressed in the participant’s clothes, modeled the meaningful experiences to produce a physically coordinated, errorless performance. However, since these modeled additions were primarily from a first-person visual perspective, the illusion that the participant was the agent of the action was maintained. To further facilitate this illusion, video clips of the participant were edited into the DVDs. For the majority of the third-person perspective footage, the participant was the main actor, and for first-person perspective DVDs, the action was modeled by the actor.

The participant was provided with the edited DVDs and asked to observe his choice with the intention to understand the movement patterns for future imitation of the behaviors. No other instructions were provided in order not to direct or bias viewing behaviors. He was asked to select and observe one of the DVDs for 15 to 20 minutes, twice each day over a period of 12 weeks. The participant kept a daily viewing diary to record which DVD he chose to watch, thus informing the study team of his preferred DVDs and any other relevant experiences or behaviors. The participant was contacted on a weekly basis.

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Outcome Measures

The participant was assessed before the interview and after three months of the observation intervention. The measures employed demonstrate reliability and validity in the stroke population. Completion took place at the same time of day and at the same venue on each testing occasion. The measures included the Scandinavian Stroke Scale (SSS),34 Postural Assessment Scale (PASS),35,36 Timed Up and Go test (TUG)37–39 with manual and cognitive components,40 fluidity scale,41 and Stroke-Specific Quality of Life Scale (SS-QoL).42 All tests were administered by an experienced neurophysical therapist in the participant’s home. These measures were selected to capture changes in motor control, balance, and gait that may have been expected from the activities observed in the DVDs. The NHS Ethics Panel requested that the team monitor the participant’s psychological state to consider possible negative effects associated with the participant’s viewing of himself as able-bodied. Therefore, the Rosenberg Self-Esteem Scale43 and the Positive and Negative Affect Scale (PANAS)44 were also administered in the participant’s home before and after the intervention by an experienced psychologist. These scales have been used extensively in psychological research to evaluate the self-esteem and affective consequences of therapeutic interventions and show acceptable psychometric properties.

The SSS has been used frequently in research studies to evaluate neurological impairment and monitor progress. The current research used the SSS to determine the severity of the participant’s stroke. The scale consists of nine items (consciousness, eye movement, arm motor power, hand motor power, leg motor power, orientation, speech, facial palsy, and gait) scored on two to five possible grades of deficit that are ranked so that a low score indicates greater deficit (0–48). SSS items are reported to have good to excellent interrater reliability (κ = 0.688–0.912)34 and to correlate significantly with measures of lesion volume at different time points after stroke.

The PASS is a reliable and valid method of assessing balance after stroke. It demonstrates fewer floor and ceiling effects and is more responsive to change than the Berg Balance Scale and the Fugl Meyer Balance subscale.35,36 It contains 12 four-level items of varying difficulty that require the maintenance of either a given posture or equilibrium during position change. Normative data are available. This scale is scored from zero to 36, with a score of zero if the participant cannot perform any activity and 36 if the participant is able to perform all activities. Interrater reliability has been shown to be κ = 0.88 for the 12 items and limits of agreement are −0.5 (range, −2 to + 2).35

The TUG has demonstrated validity and excellent test-retest reliability in stroke patients and is sensitive to change.38,39 Relevant, normative data for this test are also available.

The fluidity scale is a four-point, ordinal scale (zero to three, where three indicates best performance) assessing the quality of movement during the task of rising from a seated position to walk. Interrater agreement across three raters has been shown to be κw = 0.78. Concurrent validity has also been demonstrated against a laboratory measure of forward body momentum and clinical measures including TUG and the Berg Balance Scale.41

SS-QoL is a 12-domain, 49-item scale. Items are rated with reference to the past week on a five-point Likert scale with one of three response sets: (1) amount of help required to do specific tasks, ranging from no help to total help; (2) amount of trouble experienced when attempting tasks, ranging from unable to do it to no trouble at all; and (3) degree of agreement with statements regarding their functioning, ranging from strongly agree to strongly disagree. Higher scores indicate better QoL. This scale was developed to assess QoL specifically in the stroke population.42

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Outcomes

Analysis of the participant’s daily viewing diaries revealed that he chose to watch the soccer coaching DVD most frequently (36%) and the driving DVD least frequently (2%). In addition, the participant chose to watch the running DVD in 31% of the viewing sessions, the complete gym DVD in 11% of the viewing sessions, and the rowing ergometer gym session DVD 20% of the time.

After the intervention, improvements were observed in the three elements of the TUG and the PASS (Fig. 1). The fluidity scale score increased from 1 pre-intervention to 2 post-intervention. The SS-QoL showed some reduction in the participant’s rating of his physical performance, mobility, and upper limb domains, but improvements in energy, family roles, personality, and vision (Fig. 2). Scores on the Rosenberg Self-Esteem Scale and PANAS showed no significant difference in psychological affect from before to after intervention.

FIGURE 1.

FIGURE 1.

FIGURE 2.

FIGURE 2.

The participant reported that after the intervention, he no longer required his walking cane and that he was able to kick a football. He also reported being able to participate in his children’s soccer games and that he had increased his participation in kitchen-based tasks. He had also taken a holiday with the stroke support group and enjoyed walking on the beach with his family.

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DISCUSSION

To our knowledge, this is the first description of personalized action observation in stroke rehabilitation.

Postintervention assessment demonstrated improvements in physical function. Performance on the TUG showed marked improvement to a degree that, in our opinion and supported by others,45 was clinically worthwhile. The increase of one point on the four-point fluidity scale represents an improvement in the quality of rising to walk from sitting, that is, from pausing between achieving an upright standing posture and stepping forward to being able to step forward immediately and achieving the upright stance. Improvement on the PASS was also recorded for the item standing on the hemiparetic leg. The participant reported practicing raising the good foot to place on the seat of a low chair. These improvements seem linked to the participant’s self-reported behavioral changes. For example, the participant reported single leg balance behavior while dribbling a soccer ball. He was able to demonstrate alternate-leg balance with the contralateral foot on the soccer ball.

There is a potential conflict between the objective measures and the participant’s rating of physical domains of the SS-QoL. It may be that the observation intervention caused the participant to change his movement goals. The mobility rating on the SS-QoL shows a marked decrease after the intervention. Given the ability of the participant to walk unaided and with better scores on the TUG, this was surprising. Following investigation with the participant, he revealed that pre-intervention, he spent much of his time comfortably seated in front of his television. After 12 weeks of the intervention, he reported a far more active lifestyle. However, as a consequence of this greater activity, he experienced more trips, stumbles, and falls and therefore reported on the SS-QoL that he perceived that he was less mobile. Asked whether he had concerns about the reduced mobility, he replied that this was the best that he had felt since his stroke. There was also some evidence that the involvement with the intervention had allowed the participant to reappraise his longer term goals, setting higher mobility and activity goals for himself. Therefore, at post-test, he was rating his mobility against the new goals, despite evidence of objective functional improvement.

The stroke rehabilitation literature suggests that the first three months are typically when most spontaneous functional recovery will occur.46 Therefore, if the results are considered within the time frame of the participant’s poststroke recovery, differences in physical functioning during the intervention period are likely to be attributable to the therapeutic intervention. The patient also reported that he had improved more during the intervention than at any previous time after his discharge from hospital. These statements were supported by similar evidenced claims from his physical therapist, stroke support group members, and family members. In addition, the improvements in motor function were for behaviors that the participant reported as being meaningful to him. The participant had received traditional stroke rehabilitation physical therapy since his stroke and continued to have one hour of physical therapy each week during the intervention period. This therapy had focused on managing the increased muscle tone, increasing the range of movement of his paretic arm, and improving walking. However, up to the time of the intervention, the participant continued aided walking with a cane and showed no change in arm/hand function. After five weeks of the intervention, he had discarded his walking cane and was involved in daily viewing of, and unprompted physical imitation of, a rowing task that was part of the gym training session on the DVD. Additionally, the participant reported being more able to participate in family life, for example, kicking a soccer ball with his children and walking on the beach. These are examples of activities that he had not been able to do since his stroke.

As a consequence of these behavioral differences, the participant’s physical therapist encouraged behaviors being employed as part of the viewing experience. Specifically, these included the introduction of a soccer ball while standing and balancing. Therefore, while attending the participant, she included some of the activities and behaviors in her therapy session to replace more traditional activities previously employed. Additionally, the physical therapist supported more frequent activity based leisure activities such as swimming and gym attendance, where the participant undertook rowing, cycling, and light weight exercises, which the participant described as wanting to re-engage in after the observation experiences. This was an important procedural and behavioral change for the participant. It is clear that these behaviors may have had a greater influence on the dependent variable scores compared to the predicted neural consequences of observation. However, the self-action observation seems to have provided the participant with the motor understanding of the actions and the confidence to physically execute the movements. The observation sessions may have reactivated shared circuitry that had been less active since his stroke. The observation intervention directly encouraged movement associated with the observed actions and was an integral part of the intervention. Therefore, while a single, manipulated intervention may be the best method of demonstrating a treatment effect in research studies, in the clinical application, it is unlikely that a single intervention would be administered in isolation. The use of observation as a therapeutic tool is, therefore, likely to be used as part of a stroke rehabilitation package, supporting manual therapies. Its effects may be multifarious. These include information about the goal of an action; strategies to achieve the goal such as movement kinematics, body position, placement, and timing; and motivated behavior change associated with the meaningful viewing. Since we measured the participant’s psychological state as part of the ethical precautions linked to the study, we can report that there was no evidence of reduced effect linked to the viewing experience. In contrast, there is now strong evidence to support confidence and motivational influences of observation that would also seem to have been evident here.47

One of the main aims of the study was to explore the provision of a valid intervention that would not require therapist delivery and that could address the time and resource pressures experienced by physical therapists. The interview with the patient took approximately one hour. However, therapists could adapt or expand conversations made during therapy sessions to discuss ideas. Given their privileged access and contact with stroke patients, therapists may be best placed to support observation-based interventions alongside more traditional therapies.48 The DVDs were created using a basic digital video camera and video editing software included in typical PC media packages. After careful planning and filming, each DVD was edited and produced in less than a day. It is also possible that rehabilitation benefit could be obtained from a pool of more generic action DVDs for more fundamental limb actions such as reaching and grasping. The cost of implementing the intervention was less than $400. Investing time in developing the DVDs may allow therapists to use their direct contact time more effectively and efficiently; engaging stroke-affected individuals in therapy without the need for one-to-one contact. In addition, the increased central neural drive that occurs as a consequence of the observation may support more physical therapy activities.

The study suggests that the use of personalized and meaningful systematic observation experiences can support functional improvements post-stroke. The intervention also appears to motivate active patient engagement in the observed activities. For example, in the interviews, the participant discusses how he re-engaged in activities that he has not tried to participate in since his stroke, such as going to the gym. In addition, physical therapy practice was able to be modified to take account of the observation intervention procedures to create an improved, meaningful therapy with increased functional outcome for the patient. The participant described in the interviews that these changes in physical therapy sessions increased his motivation to follow the therapist’s guidance and take an active role in therapy.

Without a control phase, it was not possible to attribute the changes unequivocally to the intervention, and the desire to provide a socially acceptable response will always remain a confounding factor. The modified content of the physical therapy sessions, delivered with the same frequency and duration as the preintervention therapy, may also have enhanced the therapeutic benefits attributable to the intervention. However, it is important to note that the participant’s behavioral changes preceded the modification of the therapy session content.

The extent to which observation interventions in stroke actively recruit neural systems linked to the MNS and CMSs is unknown at this point. Future work should explore this proposition through detailed brain imaging techniques. Similarly, the impact of such interventions on participant self-esteem and affect requires further study. It is likely that stroke-specific tools will be required for this research. We are currently undertaking randomized, controlled trials with the support of stroke groups, regional stroke research networks, and multitherapy support teams.

In conclusion, the current findings support the use of observation as an intervention for stroke rehabilitation and highlight the importance of integrating meaningful support systems for the individual. This observation-based intervention provided a method of allowing the patient and caregivers an active role in rehabilitation alongside the physical therapist. This is in accordance with the good practice outlined by Langhorne and Pollock5 and with growing understanding of the importance of self-efficacy in rehabilitation.49

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Keywords:

stroke; rehabilitation; observation

© 2008 Neurology Section, APTA