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Physiotherapy for Stroke Rehabilitation: A need for evidence-based handling techniques
Key Words Manual handling, back pain, physiotherapy, stroke rehabilitation. by Victoria Sparkes
Literature review
Summary This paper seeks to identify, through reviewing the literature, a focus for future research on manual handling practices in neurological physiotherapy. The lack of evidence to support neurological rehabilitation in general places some treatment modalities in question. One of these is the use of the ‘pivot’ assisted transfer. The introduction of the EC Manual Handling Operations Regulations (1992) prompted the scrutiny of lifting and handling methods within the health sector. Some manoeuvres, such as the pivot transfer, were then condemned by various professional bodies who considered it to be physically dangerous to the handler. However, anecdotal evidence still suggests that the pivot transfer is widely used by neurological physiotherapists practising the Bobath technique. Neither the effectiveness nor outcome of this method of neurological handling has been adequately researched in light of these regulations. Similarly, there is little research on the incidence of musculoskeletal disorders among neurological physiotherapists as a result of their handling methods. This literature review indicates an immediate need for further investigation of these subjects.
Introduction
Sparkes, V (2000). ‘Physiotherapy for stroke rehabilitation: A need for evidence-based handling techniques: Literature review’, Physiotherapy, 86, 7, 348-356. Physiotherapy July 2000/vol 86/no 7
The EC Manual Handling Operations Regulations (MHOR) were introduced primarily in response to the high incidence of occupational injuries caused by faulty lifting practices, and subsequent loss of industrial working days (HSE, 1992a). Within the health sector, injuries to nursing personnel caused by incorrect patient handling have been the subject of both ergonomic and occupational health research (Stubbs et al, 1983; Seccombe and Ball, 1992; Arad and Ryan, 1986). Nursing has subsequently been highlighted as a vulnerable profession, predisposed to a high incidence of low back pain (LBP), largely due to the nature of patient handling tasks. As a protective strategy and in response to the MHOR, the Royal College of Nursing issued prescriptive manual handling guide-
lines for nurses, with an aim of working towards a ‘no lift’ policy (RCN, 1996a,b). Physiotherapy involves extensive handling of patients (Hignett, 1995) and it is surprising that both manual handling techniques and prevalence of LBP have been poorly researched within this field, particularly when compared to the many published studies investigating handling by nurses. A specialism within physiotherapy which can be considered most vulnerable is that of neurological rehabilitation, in which therapists are required to offer extensive physical support to patients during treatment (Davies, 1995). Working posture analyses have categorised neurological physiotherapy as high risk for musculoskeletal disorders (Jackson and Liles, 1994). Nonetheless, from experience, the author knows that particular transfers recently ‘condemned’ by the RCN are still being used by neurological physiotherapists as a method of rehabilitation. The treatment technique practised by physiotherapists depends largely upon which theory they espouse (Davidson and Waters, 2000). Treatment techniques are not adequately researched in the United Kingdom, and as a result the manual handling practices of neurological physiotherapists have not been placed under scrutiny. Many issues within neurological physiotherapy practice regarding manual handling and its possible consequences need to be defined. Before considering various areas for future research it is necessary to review the literature about many aspects of neurological handling. Historical Perspective There have been many philosophies of neurological rehabilitation which have been outdated through continual developments
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within neurophysiology. Contemporary concepts use the theory of neuroplasticity to explain changes in brain functioning and subsequent recovery of motor control (Lowrie, 1998). The two models described most frequently within physiotherapy are rehabilitation through facilitation (Bobath) (Davies, 1985, 1990, 1995) and the motor re-learning model (MRM) (Carr and Shepherd, 1982, 1989, 1998). Rehabilitation through Facilitation: The Bobath concept uses techniques to help stroke patients to regain normal movement in both their affected and unaffected sides. A core principle of the Bobath concept is the alignment of body segments, through manual facilitation, with an emphasis on achieving functional symmetry (Davis, 1996). The sessions are predominantly therapist-led, with an emphasis upon suppressing patient-generated incorrect movements until a normal movement pattern is achieved (Lennon, 1996) -- a concept negatively described by Sackley and Lincoln (1996, page 92) as ‘enforced immobility’. Unsupervised patient practice is strongly discouraged as the adoption of an incorrect pattern of movement is deemed detrimental to rehabilitation (Davies, 1990), although treatment is still considered to be a 24-hour process, with carers or healthcare workers supplementing therapy sessions. Transfers Within the Bobath paradigm, the most common initial functional goal for a patient is to achieve independent transfers, from wheelchair to toilet, bed, chair or car, since weight-bearing through the affected limb is believed to ‘normalise’ tone (Sackley and Lincoln, 1996). Independent transfers are considered to be a large functional milestone within a patient’s rehabilitation, and Bobath therapists practise transfers with patients long before they are able to achieve independent sitting to standing. Transfers are facilitated through a ‘pivot’ assisted transfer, until the patient has enough control to perform the movement independently and correctly. The practice of the ‘pivot’ transfer has been strongly discouraged in the collaborative guidelines devised by the National Back Pain Association (NBPA) in conjunction with the Royal College of Nursing (RCN), due to the excessive biomechanical loading of the therapist’s spine (NBPA and RCN, 1997).
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Bobath tutors continue to run practical postgraduate courses teaching this transfer. Davies, an advocate of the Bobath concept, states that if a patient cannot bear weight sufficiently through his affected side, the therapist should offer complete support during a transfer in order to ensure a normal movement pattern (Davies, 1990). Lynch and Grisogono (1991) and Johnstone (1995) both consider the transfer to be ‘learned’ through repetition during therapy sessions. The concept of repeatedly allowing patients the complete physical support of one therapist throughout their hospital stay has contentious manual handling implications, especially as neurological physiotherapists often have large caseloads of patients requiring similar physical support. In the Bobath literature, there is no mention of using mechanically assisted transfers to facilitate a ‘normal movement’. Use of adaptive equipment is considered as a last resort, not part of the rehabilitative process (Davis, 1996). Although there is no recent literature supporting the Bobath concept and transfer methods, anecdotal evidence suggests that they are still practised, and pre-manual handling regulation literature from the early 1990s is still used to outline many of the principles of treatment (Davies, 1985, 1990). Davies more recently (1995) offered practical strategies for handling using the Bobath technique, although she did not apparently consider the MHOR when she was suggesting such manoeuvres.
Author and Address for Correspondence Victoria Sparkes MSc MCSP PGCert is a lecturer in the Department of Physiotherapy, University of Hertfordshire, Hatfield Campus, College Lane, Hatfield, Herts AL10 9AB This article was received on February 17, 2000, and accepted on March 7, 2000.
The Motor Re-learning Model The motor re-learning model of stroke rehabilitation, developed by Carr and Shepherd (1982), focuses on accessing existing ‘motor programmes’, or preplanned patterns of movement, to relearn muscle activity functionally through ‘taskoriented’ goals. The emphasis is placed upon active patient participation, with guidance, instruction and various forms of feedback, until the correct movement is performed to solve the motor problem. The concept is all-encompassing, with an emphasis upon analysing not only biomechanics, but behaviour (Ostrosky, 1990), and lends itself to functionally meaningful environments in which re-learning takes place (Carr and Shepherd, 1982). Three main strategies underlying the MRM are: ‘[1] the elimination of unnecessary muscle activity. ... [2] feedback of Physiotherapy July 2000/vol 86/no 7
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information about per formance. ... [3] practice’ (Partridge, 1996, page 6). Initial therapist guidance is later superseded by patient-initiated active movements, which encourage the patient’s volitional movement control (Ostrosky, 1990). Sit to Stand When considering the transfer of a patient, Carr and Shepherd (1982) advise that the patient must first achieve the more defined tasks of moving from sitting to standing, and standing to sitting. They propose that the therapist should provide minimal help, and pivot transfers are not practised as they are believed to constrain patient performance, while failing to replicate a normal activity (Carr and Shepherd, 1998). The authors also advocate recruiting more than one therapist in the initial stages of helping a patient to stand. Carr and Shepherd acknowledge the relatively slow uptake of their concept into practice (Carr et al, 1994) and voice general concern over physiotherapists’ lack of initiative to embrace new theoretical concepts. Clinical Uptake of Neurological Concepts The clinical use of neurological concepts within the UK has not yet been established. Studies have, however, been performed in Sweden (Nilsson and Nordholm, 1992), Australia (Carr et al, 1994), and the Trent Region (Sackley and Lincoln, 1996). Collectively, they found that the Bobath concept was the most commonly practised treatment technique and that theoretical bases of treatment were not deemed important to treatment choice. All authors reiterated the problem of a lack of published theoretical evidence to support the Bobath concept. Evidence-based Practice The core of evidence-based practice is to integrate expertise derived from practice, with research evidence when making clinical decisions, as successful practice cannot occur with one of these factors in isolation (Sackett et al, 1996). Best practice for one patient may not be appropriate for another, and it is clinical expertise which allows practitioners to make these discriminations. Difficulties have been identified in clinically applying evidence-based practice since patients rarely present with a one-dimensional problem (Greenhalgh, 1996), and this is amplified in the case of stroke patients Physiotherapy July 2000/vol 86/no 7
who may present with a multitude of signs and symptoms. Evidence-based treatments are most likely to be clinically effective. Appropriately peerreviewed research which shows the efficacy of a form of therapy may warrant its integration into practice, and subsequently improve clinical effectiveness. However the recorded outcomes of neurological physiotherapy interventions are not made known widely enough. Stroke Rehabilitation There is a lack of published clinical evidence to support the assumption that neurological physiotherapy as a whole is effective in the treatment of brain injured adults (Partridge, 1996). Partridge elaborates by stating that authors of neurological physiotherapy literature largely rely upon clinical evidence as opposed to research findings upon which to ground their theories. Riddoch et al (1995) state that the lack of published neurological case studies inhibits the development of a formal empirical evidence base and consequent evidence of clinical effectiveness. Riddoch et al (1995) and Ashburn et al (1993) reviewed trials investigating the efficacy of rehabilitation after stroke, and found that most trials had inconclusive results, and no single treatment modality was found to be more effective than another. The former authors, in addition to Partridge (1996) and Sackley and Lincoln (1996) strongly suggest that literature reviewers have had difficulty interpreting study results, as research comparing two or more treatment modalities has been found to use inappropriate methodology. Lennon (1996) offered another reason for inadequate comparison studies, by highlighting that stroke patients are too individual to compare or standardise. Comparisons aside, to establish clinical effectiveness in a stand-alone model of rehabilitation would require a control group to be excluded from physiotherapy. Ethically, this cannot be considered an acceptable option. Bobath Reviewed Clinical effectiveness within neurological physiotherapy can therefore be strongly questioned. Within the Bobath technique for rehabilitation, the incongruity between theoretical underpinnings and practice is explored. Lennon (1996) reviewed
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the literature surrounding this and surmised the following problems: ■ Failure of adherents of the Bobath concept to update their theoretical support, in response to recent advances of motor control and motor learning models. ■ Inability to holistically consider biomechanical and psychosocial influences within neurological rehabilitation. ■ Subjective and regionally variable oral communication of Bobath teachings. ■ Absence of published literature by Bobath tutors. Edwards (1996) also identified the need for evidence-based practice, yet believes that a lack of research should not prevent an ‘assertion’ regarding treatment procedures. Perhaps this is the area where Bobath encounters its main criticism. Carr and Shepherd (1982) believe that too much emphasis is placed upon on attempting to justify current techniques, rather than looking at how therapists can make best clinical use of theoretical models arising from research. Best practice must therefore be a reciprocal relationship between clinical practice informing research, and scrutinised research informing theory. Expense or Quality? Current research into neurological rehabilitation is preoccupied with establishing the financial implications of therapy, this arising from the advent of NHS trust hospitals, primary care groups and local budget control. Riddoch et al (1995) identified the need for increased evidence surrounding the efficacy of physiotherapy in stroke rehabilitation, but emphasised the changeover from evaluating patients’ improvement to calculating financial gain. The core of rehabilitation is to improve patients’ quality of life, but unfortunately there remains little interest in researching quality of life gains as a direct result of rehabilitation. This need for rehabilitative justification has been more recently echoed at national level as the NHS White Paper The New NHS: Modern, dependable (DoH, 1998) seeks to identify ‘quality of care’ through clinical governance.
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Lifting and Moving Regulations The MHOR (1992) were applied to all working environments from January 1, 1993, and replaced all pre-existing health and safety regulations specific to handling. Their objective was to reduce the high incidence of injury resulting from manual handling which then accounted for more than a quarter of total occupational accidents (HSE, 1992). Within the regulations, the duties of the employer are to ‘reduce the risk so far as is reasonably practicable’ (HSE, 1992, page 8), and emphasis is placed upon the elimination of all manual lifting and moving wherever possible. However, this particular rule can be open to a variety of interpretation, since its description is somewhat imprecise (Tracey, 1997). Employees’ duties are similarly included within the regulations. Emphasis is placed upon adhering to ‘the systems of work laid down by their employers’ (HSE, 1992a, page 37). The regulations therefore openly place the greatest responsibility upon the employers, and within the healthcare setting this means the individual trusts within which practitioners are employed, since the NHS Executive no longer has the authority to endorse such policies (White, 1997). The implication of this is that there is scope for regional variation in interpretation of the regulations, and therefore no definitive national framework by which moving and lifting practices may be shaped. In response to the MHOR, many institutions have formulated lifting policies to protect themselves in the event of litigation following injury. This is a trust disclaimer, rather than a protective approach to staff, and many trusts are adopting a strict ‘no lift’ policy, whereby all hospital staff must use a hoist or transfer aid to move patients (Hodges, 1997). Although restrictive within a rehabilitation setting, ‘no lift’ policies do fall in line with the guidelines issued by the RCN (1996a,b) which reflect the MHOR (HSE, 1992a). Since the issues surrounding manual handling within nursing have been well researched, it seems appropriate to use this as a model for comparison with that of physiotherapy. Nursing Policy The consequences of incorrect patient lifting to the nursing profession have been well documented (Stubbs et al, 1983; Seccombe and Ball, 1992; Hollingdale, Physiotherapy July 2000/vol 86/no 7
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1997), and many of these studies focus upon the incidence of LBP within nursing. Other studies have examined the economic costs of lost working days through sickness absence (Davies and Teasdale, 1994). Nurses are well represented by an active governing professional body, the RCN, responding rapidly to practice issues requiring national frameworks or guidance (Hodges, 1997). In an effort to reduce the incidence of LBP in nurses, the RCN published specific weight restriction recommendations, advising that when transferring patients weighing more than eight stones, nurses should use mechanical hoists (Tracey, 1997). The RCN clearly states that manual lifting should be eliminated in all circumstances except lifethreatening situations (RCN, 1996a,b). Physiotherapy Policy The Chartered Society of Physiotherapy (CSP) offered guidelines (CSP, 1993a,b) in response to the MHOR (HSE, 1992a), stating that before applying a manoeuvre, therapists should calculate the risks to the patient, other healthcare workers, and themselves. Similarly, lifting tasks delegated to others must be assessed for risk before they are carried out. The guidelines are vague, and can be interpreted subjectively -what is deemed wholly appropriate by one therapist may be considered high risk by another. However, for the CSP to offer prescriptive advice might have negative repercussions among therapists in neurological rehabilitation, and impact upon professional autonomy. The lack of published concern regarding guidance signifies a general acceptance of these non-specific guidelines. Risk Assessment The CSP has proffered risk assessment as a way of enabling physiotherapists to continue to practise lifting and moving, but this may not be permissible within the regulations of their individual trusts, owing to the popular implementation of the ‘no lift’ strategy. Little has been published about effectiveness of risk assessment in physiotherapy, but what is accepted is that risk assessments should be a continuous process, incorporated into the daily physiotherapeutic assessment of patients. To assess the risks of lifting and handling procedures is now a legal requirement (Carlowe, 1998). How this can ensure the safety of physiotherapists practising therapeutic transfers is not clear, due to the relative subjectivity of the Physiotherapy July 2000/vol 86/no 7
procedure. Similarly, whether risk assessment is adequately translated into risk management is also questionable (Hignett, 1994a). Hignett also believes that within a healthcare setting, the concept of a generic task assessment is not viable, due to both the diverse nature of different professionals’ remit, and the unpredictability of the animate load being manipulated. Collaboration There is a need for more effective collaboration in the handling of rehabilitation patients. Although nurses are not now expected to ‘lift’ patients, the handling role of physiotherapists is less easily defined. Within neurological rehabilitation, these precise guidelines could be deemed restrictive to the rehabilitation process. Transfers outside therapy sessions used to be practised with nurses, to improve ‘carry-over’ from therapy sessions. The emphasis currently falls upon therapy, as patients now practise assisted transfers only during treatment sessions. If independence is consequently achieved more slowly, then the period of assisted transfers is extended, thus potentially increasing the physical demands placed on therapists. Thus the burden of a heavy workload, instead of being spread over the caring professions responsible for rehabilitation, has now been confined to only one professional group. The argument for this has been that physiotherapists, with their underlying knowledge of biomechanics, are expected to use this expertise to handle patients correctly (Fenety and Kumar, 1992; Ellis, 1993; Hignett, 1995). Similarly, it should not be expected that other professionals who do not possess this knowledge should be required to carry out the same task (Fletcher, 1997; CSP et al, 1997). However, Hignett (1995) deduced that it has been assumed that physiotherapists would use their ‘kinaesthetic’ knowledge. This conflicts with physiotherapists’ professional commitment to minimise the use of mechanised equipment to help in rehabilitating patients. If physiotherapists do have extensive knowledge of biomechanics and ergonomics, it seems contradictory that they are reluctant to employ this wisdom when considering their own health and safety. Back Pain Physiotherapists have been highlighted as biomechanical experts, and as such, there
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has been a lack of research illustrating the prevalence of LBP or focusing on their lifting practices (Ellis, 1993; Fenety and Kumar, 1992). Before the advent of the manual handling regulations (MHOR) certain studies undertaken show alarming results. Scholey and Hair (1989) compared the incidence of LBP between physiotherapists and non-medical personnel. A total of 96% of respondents blamed heavy lifting, while 100% identified frequent lifting as their main risk factor for LBP. This is supported by Hignett (1994b) who demonstrated that physiotherapists are susceptible to LBP due to their physical workload and the repetitive nature of their tasks. This evidence therefore invalidates the premise that specialist ergonomic knowledge reduces the incidence of LBP in a physically demanding occupation. Hignett (1994b) also highlighted the vulnerability of newly qualified physiotherapists compared with their more experienced colleagues. Physical stress encountered by neurological physiotherapists was identified in a study conducted by Broom and Williams (1996). They interviewed 10 neurological physiotherapists over a cross-section of grades within one health district to identify their causes of stress, which were work overload, under-staffing and large patient numbers. Manifestations of stress within this group included back pain and anxiety. One stressful issue identified was when attempting to fit the varied nature of physiotherapy into standards and policies – this is especially relevant with the current adoption of trust manual handling protocols. Although this study represents only the population and health district studied, the climate of physiotherapy understaffing caused by recruitment and retention problems throughout the UK is well documented (Chadda, 1999). Hignett (1994b, page 447) declared in her closing statement: ‘The cost of treatment handling may be the loss of physiotherapists’, which enforces a longer-term cause for concern. Nonetheless, the underlying perceived biomechanical knowledge inherent within physiotherapy has so far prevented research into the potential handling risks encountered by physiotherapists. Ergonomics: Practising what we preach? The practice of ergonomics has two main objectives: to improve quality of output, while reducing the incidence of occupational musculoskeletal disorders, by using
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the principles of kinesiology, anatomy, physiology, anthropometry, psychology, engineering and physics (Kerk, 1998). Although physiotherapists teach patients ergonomically sound techniques, whether they are practised by therapists themselves is debatable. Fenety and Kumar (1992) conducted an ergonomic survey of a hospital physiotherapy department. They found numerous unsafe handling manoeuvres, in spite of the therapists having received extensive training. The highest risk manoeuvres identified were pulling, pushing, lifting, twisting, working with patients in kneeling, and frequent handling. These postures are adopted regularly within neurological rehabilitation, particularly when using Bobath techniques. A pilot study was conducted by Hignett (1995) to investigate the working posture of physiotherapists during a care of the elderly treatment session. Her findings showed that physiotherapists work at a biomechanical disadvantage since patients cannot be anthropometrically fitted to their therapists – instead, therapists need to adapt to patients. Hignett (1995) also recognised the dangerously misplaced theory that physiotherapists can counteract the effects of their occupation by being able to treat their own LBP. This was reinforced by a study to examine the vulnerability of inexperienced physiotherapists. Jackson and Liles (1994) assessed the working postures of two separate years of physiotherapy students, using the Ovako Working Posture Analysis System. They found that within neurology ‘the optimum positions for patients’ management were achieved largely at the expense of the therapists’ posture’ (page 436), and identified prolonged poor working posture as hazardous. From this study, they recommended that attention should focus upon the physical effect of practice on physiotherapists. Stroke Patients Neurological patients themselves can be considered an added risk within neurology, as they tend to present with a plethora of physical, cognitive or behavioural problems. Garg et al (1991) studied patient transferring tasks. They identified that transfers involving human bodies are not amenable to handling, as the load is usually awkwardly shaped and difficult to hold, and patients are often unpredictable, combative or contracted. Their study involved collating Physiotherapy July 2000/vol 86/no 7
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both subjective and objective data surrounding transfers, and their recommendation was that totally dependent patients (who were not able to bear weight fully) should be transferred only by hoist. This recommendation is reinforced by outcomes of another transfer methods study by Ulin et al (1997), who recommend the use of mechanical aids for all patients who need transfer help. Studies directly considering functional ability of stroke patients have identified the reduction of balance, reaction time, and muscle activation during functional tasks as commom physical impairments encountered by patients (Yaretzky et al, 1994; Dickstein et al, 1994; Lee et al, 1997). The inherent question as to whether stroke patients themselves are a direct risk to therapists during manual handling practices needs to
be further explored in light of these established physical impairments. Conclusion The physical risks taken by neurological physiotherapists have been made explicit within this paper but are not at present adequately researched, particularly in conjunction with the MHOR (HSE, 1992a). Although LBP should not be accepted as an occupational hazard (Ellis, 1993), alternative options for neurology treatment have not been explored -- extensive (and often inappropriate) handling still dominates practice within this area. Discrepancies between policy and practice have arisen and have been discussed. From this, a number of factors need to be considered for future research. These are listed in the table below.
Issues within neurological physiotherapy and manual handling practices prompting future research ■ There is a lack of theoretical and clinical evidence supporting the Bobath technique as part of stroke rehabilitation, yet it continues to dominate contemporary neurological rehabilitation (Riddoch et al, 1995; Lennon, 1996). ■ Certain manoeuvres involved in practising the Bobath technique directly oppose what is deemed safe by the MHOR, yet evidence suggests that physiotherapists still support and practice this (Davies, 1995). ■ There has been no published evidence suggesting that supportive handling equipment is an effective rehabilitative tool for neurological physiotherapy, therefore alternatives to manual handling have not been explored within this specialism. ■ Professional remit and expectations of service provision within neurological rehabilitation apparently conflict with manual handling policies laid down by individual hospitals. ■ The incidence of LBP in physiotherapists has been poorly researched, especially in light of the MHOR (1992). These factors, although listed separately, all impact upon one another, and no single point can be addressed without considering the remaining issues. It was the purpose of this review to discuss in depth the issues which surround current handling techniques in neurological physiotherapy, and to outline areas requiring thorough investigation. It has become apparent that neurological physiotherapy and handling techniques have not been adequately considered in light of the MHOR (HSE, 1992a). In order to protect the future of physiotherapists employed within neurology, further research is imperative. Equally pressing is the need to encourage physiotherapists as a profession to consider recent legislation and to offer, alongside other professional bodies, practical and definitive solutions to conflicts arising between policy and practice.
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Key Messages
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■ The clinical use of manual handling techniques as a method of neurological rehabilitation conflict with the Manual Handling Operations Regulations (1992).
■ A lack of research in this area has not yet legitimised the use of mechanical aids as a treatment technique in neurological rehabilitation.
■ Some studies have identified the physical vulnerability of physiotherapists working in rehabilitation, due to the extensive handling performed repetitively every day.
■ Professional remit and expectations of service provision within neurological rehabilitation apparently conflict with manual handling policies laid down by individual trusts.