DEPARTMENTS: Clinical Point of View
The ability to translate research to the clinic is a critical step in evidence-based practice to provide optimum care for our clients.1 The translation of research intervention protocols to the clinic is often challenging for many reasons. Results of research studies with narrow inclusion criteria may not generalize to results observed in the wider range of clinical presentation among clients with whom physical therapists work. The intervention protocol may not be feasible in the clinical setting (eg, expensive equipment, number of treatment hours, duration of sessions). Often times, the research article does not provide sufficient detail for the therapist to duplicate the intervention protocol in the clinic. The later is the unique contribution of this case study by Hui-Chan and Ng,2 in this issue—it serves to provide details of a research treatment protocol to facilitate translation to the clinic.
In a series of experiments, these authors have studied the effects of transcutaneous electrical stimulation (TES) on spasticity and function. Their findings have spanned the range from physiology3 to function, with two recent randomized control trials (RCT) showing the effects of TES in combination with task-related training (TRT) in persons with chronic stroke.4,5 These RCTs used an intervention protocol similar to that used in the case study reported in this issue. The intervention consisted of home-based program of 60 minutes of TES to 4 acupuncture points followed by 60 minutes of TRT 5 d/wk for 4 weeks, in addition to 8 clinic-based physical therapy sessions that focused on instruction to ensure adherence to the protocol and progression of the program. These RCTs involved 884 and 1095 persons who were at least 1 year poststroke (average 5.3 years) and an average of 57 years old, with moderate to severe spasticity. Results showed significantly greater changes compared with control groups including a decrease in plantarflexion spasticity, increased peak torque of ankle dorsiflexion and plantarflexion, increased gait speed, and decreased time to complete the Timed Up and Go.4,5
This TES+TRT intervention protocol has strong foundations. The authors refer to 2 articles that have shown TRT to increase motor function in persons poststroke.6,7 Therefore, the theory is that adding TES to TRT may result in outcomes greater than those provided by TRT alone. Furthermore, after stroke, neuroplasticity and function are maximized by practice and repetition. Unfortunately, current health care economics in the United States (and internationally in many instances) allows only a limited number of treatment sessions, increasing the importance of effective, evidence-based home programs.
Sensory stimulation through TES provides a relatively accessible, inexpensive method of increased cortical activation that could be used as an adjunct to a home exercise and/or physical therapy program. Portable electrical stimulation units (eg, TENS units) are fairly inexpensive and also could be rented for a month to follow this protocol. The use of acupuncture points is intriguing. It is not known whether sensory stimulation of acupuncture points would be more or less effective compared with sensory stimulation of the peripheral nerves (such as that employed for improving hand function of individuals with spinal cord injury in the study by Hoffman and Field-Fote8 in this issue). The authors state that the acupuncture TES may have resulted in exciting the areas innervated by the peroneal nerve, and there is a high correspondence between acupuncture points and motor points. It may be interesting for future studies to investigate the unique contribution of using acupuncture points versus peripheral nerve sensory stimulation.
From a functional perspective, the improvement in gait velocity observed in the client in this case study is the most meaningful outcome. Gait velocity increased from 51.2 cm/s at baseline to 66.6 cm/s immediately after the 4-week intervention, and a gait speed of 73.4 cm/s was achieved by the 4-week follow-up assessment. While the client, whose walking capacity at the start of the intervention was classified as limited community ambulation (50-80 cm/s), did not progress to unlimited community ambulation (>80 cm/s),9 the changes in outcome measures were clinically meaningful in other ways. Improvements in gait velocity (30%) and 6-minute walk test (25.8%) were greater than measurement error, standard error of the mean (SEM%) of 7.9% and 4.8%, respectively.10 The Timed Up and Go change (24.5–18.7 s) was greater than the minimal detectable change of 3.7 seconds for persons with chronic stroke.11 Future studies may wish to follow up for a longer period to determine whether gait velocity would increase further as the client continued to practice their newly developed walking skills.
In their case study, Hui-Chan and Ng provided details of a research intervention protocol to facilitate translation to the clinic. However, as noted previously, one of the limitations of any study is the generalizability of the participants to typical patients in the clinic. In this case, the client was highly motivated as indicated by performing a 2-hour home exercise program 5 days per week in addition to walking 1 hour every morning. Furthermore, although important for research validity, in the real-world clinical setting it may not be feasible to for a therapist to verify adherence by calling a client 3 times per week. Therefore, even the application of a protocol used in a case study to actual clinical practice has its challenges.
Research intervention protocols may be difficult to include in an original research article (eg, page limitations, distraction from the main focus of the article), but the details are critical for translation to the clinic. Fortunately, it has become more common for research studies to publish their intervention protocols (eg, Locomotor Experience Applied Post-stroke [LEAPS]11). More researchers and journals should encourage publication of intervention protocols employed as part of clinical trials, to facilitate translation from “bench to bedside.”
1. Sullivan KJ. Translational rehabilitation research: from science to practice and practice to science. J Neurol Phys Ther. 2010; 34(2):119–121.
2. Hui-Chan WY, Ng SSM. Transcutaneous electrical stimulation on acupoints combined with task-related training to improve motor function and walking performance in an individual seven years poststroke: a case study. J Neurol Phys Ther. 2010; 34(4):2087–2112.
3. Levin MF, Hui-Chan CWY. Relief of hemiparetic spasticity by TENS is associated with improvement in reflex and voluntary motor functions. Electroencephalogr Clin Neurophysiol. 1992; 85:131–142.
4. Ng SS, Hui-Chan CW. Transcutaneous electrical nerve stimulation combined with task-related training improves lower limb functions in subjects with chronic stroke. Stroke. 2007; 38(11):2953–2959.
5. Ng SS, Hui-Chan CW. Does the use of TENS increase the effectiveness of exercise for improving walking after stroke? A randomized controlled clinical trial. Clin Rehabil. 2009; 23(12):1093–1103.
6. Dean CM, Richards CL, Malouin F. Task related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000; 81:409–417.
7. Richards CL, Malouin F, Wood-Dauphinee S, Williams JI, Bouchard JP, Brunet D. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil. 1993; 74:612–620.
8. Hoffman LR, Field-Fote EC. Functional and corticomotor changes in individuals with tetraplegia following unimanual or bimanual massed practice training with somatosensory stimulation: a pilot study. J Neurol Phys Ther. 2010; 34(4):193–201.
9. Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke. 1995; 26(6):982–989.
10. Flansbjer U, Holmbäck AM, Downham D, Patten C, Lexell J. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005; 37:75–82.
11. Duncan PW, Sullivan KJ, Behrman AL, et al. LEAPS Investigative Team. Protocol for the Locomotor Experience Applied Post-stroke (LEAPS) trial: a randomized controlled trial. BMC Neurol. 20078; 7:39.