Research discoveries

MOTOR RECOVERY AND REHABILITATION AFTER STROKE 

Researchers from Australia, the USA and the Netherlands summarised five years of research into motor recovery and rehabilitation after stroke. Two of the authors, Dr Emily Dalton and Associate Professor Natalie Fini, agreed to answer some questions. 

You have authored a Recent Highlight contribution that summarises what the past five years of research tells us about motor recovery and rehabilitation after stroke. What a mammoth effort. How did you tackle that? 

Dr Emily Dalton

It was important to bring together stroke recovery researchers who are global leaders with diverse expertise. 

Not only did we conduct a systematic review to identify published literature, but we also searched for late-breaking conference abstracts to identify recently completed trials and looked to the future by including published protocols to ensure we presented a thorough review of the evidence. 

Practically, it was lots of screening on Covidence, lengthy discussions over Zoom with the team and coffee and tea to keep us going. 

It is known that motor training enhances recovery after stroke but one theme you observed in the literature is that motor training may be improved with adjuvants. What sort of adjuvants were shown to do that? 

We still have a long way to go to identify which adjuvants may enhance motor outcomes after stroke. 

What is important is that an adjuvant is paired with high quality motor training. 

One example that did this well was vagus nerve stimulation. 

Showing that adjuvants paired with high quality motor training do more than high quality motor training alone is essential if we are to change clinical practice.

Associate Professor Natalie Fini

Another theme you drew out of the research was ‘mode is a tool to support the delivery of motor training’. What did the evidence say about that? 

Delivery mode encompasses method, personnel and mechanism of delivery. 

There has been a lot of research on robotics and virtual reality (mechanisms of delivery) but there is still no definitive evidence that they outperform usual care. 

For those with mild to moderate impairment, changing the personnel (eg, self-practice versus therapist-delivered) or method (eg, telerehab versus in-person) yielded similar benefits, meaning that one was not necessarily better than the other. 

Changing personnel or method could be a useful tool in supporting increased therapy doses alongside standard care. 

You also emphasised that trials of motor training need a defined measurement strategy. What do you mean by that and why does the evidence dictate that? 

Before you run a trial, you need to decide exactly what you need to measure (the hypothesised target of the intervention) and how best to do it. 

Too often in stroke recovery and rehabilitation trials, we see measurement strategies that do not align with the research question or are not appropriate for the target population. 

We propose in our paper that a measurement strategy should encompass not only the effect of the intervention but also how the intervention was delivered (eg, a fidelity plan to ensure that participants are receiving the intended trial intervention). 

What recommendations for researchers did you draw from your review of the recent highlights in stroke recovery and rehabilitation research? 

One recommendation is that motor training delivered in clinical trials adhere to evidence-informed parameters. 

This means that motor training should be goal-oriented (tied to what the patient wants to achieve), task-specific (practising real-world movements), contextspecific (training in realistic environments), repetitive (practising similar tasks over and over), progressive (graded appropriately for the individual patient) and appropriately dosed (to the individual participant or intervention). 

It is essential that future stroke recovery trials compare new treatment approaches to high quality motor training so we can continue to progress the stroke recovery and rehabilitation field. 

Check out the paper here for our other recommendations. 

>>>Dr Emily Dalton is a research fellow at the University of Melbourne and a senior occupational therapist at the Royal Melbourne Hospital. Emily has over 10 years of clinical experience in stroke. Her research interests are in stroke rehabilitation, upper limb motor training and early phase trials. 

>>>Associate Professor Natalie Fini MACP is an associate professor in physiotherapy at the University of Melbourne. Natalie is an APA Titled Neurological Physiotherapist with more than 20 years of experience in neurological rehabilitation. Her research interests are stroke rehabilitation, physical activity, co-design and early phase trials. 

 

PHYSIOTHERAPY MANAGEMENT OF PLANTAR HEEL PAIN 

A comprehensive Invited Topical Review from Australian and English researchers provides an in-depth overview of physiotherapy management of plantar heel pain – a complex condition affecting millions of people worldwide. First author Dr Matthew Cotchett agreed to answer some questions on the review. 

Your Invited Topical Review recognises a diverse array of treatment options for plantar heel pain. What makes this condition challenging for physiotherapists to manage? 

Plantar heel pain is challenging for two reasons. 

The first is the simple fact that weight-bearing perpetuates the problem once it is present and the condition typically occurs in people who spend a lot of time on their feet. 

Secondly, it is rarely associated with a single factor. While mechanical loading of the plantar heel is important, many patients also present with lifestyle, behavioural, psychosocial and systemic factors that influence their symptoms and recovery. 

The condition can have a significant impact on function, work participation and health-related quality of life, and symptoms may persist for months or even years. 

As a result, physiotherapists may need to look beyond the foot itself and consider the broader factors that might influence a patient’s presentation including their health status, beliefs, behaviours and goals when developing a management plan. 

Dr Matthew Cotchett

What should be covered in diagnosis? Are there many differential diagnoses to be considered? 

Diagnosis is primarily based on clinical assessment rather than imaging. 

Patients typically report inferior heel pain that is worse upon weight-bearing after periods of rest and aggravated by weight-bearing activities. 

However, physiotherapists should also consider a range of differential diagnoses including heel fat pad syndrome, calcaneal stress fracture, plantar fibroma, nerve entrapment (eg, Baxter’s neuritis), lumbar referral and inflammatory arthropathies. 

Imaging is usually not required unless symptoms are persistent, are atypical or suggest an alternative diagnosis. 

What should physiotherapists include in their assessment of a patient with plantar heel pain? 

Assessment should include a detailed subjective history and a comprehensive physical examination using a biopsychosocial approach. 

This may include active and passive range of motion testing, muscle strength testing, balance assessment, gait analysis, foot posture assessment and palpation. 

Physiotherapists should also explore factors such as activity levels; footwear; body composition; lifestyle factors; patient beliefs, knowledge and expectations; and any relevant medical conditions. 

Your review recommends beginning with a core management approach. What interventions are included in that core approach?

Do – the core approach includes three key evidence-based interventions: foot taping, plantar fascia stretching and individualised education. 

The key challenge is to teach and support the patient to tape effectively and stretch regularly, as both need to happen daily over a four- to six-week period. 

These interventions should typically be implemented for four to six weeks before considering a stepped approach or additional treatments. 

Decide – education should be tailored to the patient and include discussions about load management, pain, relevant health factors and footwear. 

Develop – advice regarding nutrition, cardiovascular fitness and sleep may also play a role in recovery. 

Depending on the response of the patient, you recommend a model of stepped care where other interventions are added to the core approach. What is added and when? 

If a clinically meaningful improvement is not achieved after four to six weeks of the core approach, shock wave therapy is recommended as the next step based on the strength of the supporting evidence. 

If symptoms remain unresolved or improvement plateaus after approximately 12 weeks, custom foot orthoses may be considered. 

The core approach should continue throughout this process. 

When patients do not respond to the core approach or these adjunct treatments, more experimental interventions (eg, injection therapies) may be considered for selected patients although the evidence supporting injections remains limited. 

Varying the order of stepped care according to intervention availability within your local context is entirely reasonable. 

Where should research for this condition head next? 

Innovation in the prevention space would be a major step forward. 

There is a need for high-quality trials that evaluate stepped-care models. Importantly, future research should continue to incorporate the perspectives of people with lived experience of plantar heel pain so that management strategies better reflect patient needs and priorities. 

Further research is also needed to explore how lifestyle and psychosocial factors such as sleep, physical activity, nutrition and mental wellbeing affect the experience of and recovery from plantar heel pain and potentially its prevention. 

>>>Dr Matthew Cotchett is an advanced practice podiatrist and a senior lecturer in the Department of Physiotherapy, Podiatry, Prosthetics and Orthotics at La Trobe University. His research focuses on developing user-informed resources for individuals with foot and ankle pain. 

 

MEASUREMENT PROPERTIES OF THE CPAx 

Australian, Swiss and Chilean researchers conducted a systematic review of 27 studies to examine the clinimetric properties of the Chelsea Critical Care Physical Assessment Tool. Project lead Dr Sabrina Eggmann agreed to answer some questions about the study. 

Your systematic review examined the clinimetric properties of the Chelsea Critical Care Physical Assessment Tool (CPAx). Are there many other tools for assessing physical function and activity for rehabilitation in people who are critically ill? What makes the CPAx different? 

Several tools exist to assess physical function and activity for rehabilitation in people with critical illness – for example, the Physical Function in ICU Test – Scored, the Functional Status Score for the ICU, the Medical Research Council Sum Score and the ICU Mobility Scale. 

However, many of these focus on specific constructs such as mobility or muscle strength in isolation or report on floor and ceiling effects during the ICU stay. 

The CPAx is distinct in that it provides a multidimensional assessment, capturing a range of functional domains including respiratory function, cough, mobility and strength within a single measure. 

It is therefore the only assessment that considers weaning failure, a key aspect of ICU-acquired weakness. 

Scoring can be performed after a standard, evidence-based physiotherapy session, making it quick and easy to evaluate across the trajectory of recovery. 

The CPAx also eases goal setting during rehabilitation. 

Dr Sabrina Eggmann

How many studies and how much data did you find? 

Our review identified 27 articles investigating a total of 2337 patients with critical illness. 

The majority of studies examined more than one of the nine measurement properties as defined by the COnsensusbased Standards for the selection of health Measurement INstruments. 

In total, we found 71 investigations of measurement properties – a substantial body of evidence drawn from across the world, highlighting the generalisability of our results. 

Your review considered many clinimetric properties. Which properties did you find the most evidence for and was it favourable? 

We found high-quality evidence for inter-rater reliability and measurement error, with excellent content validity – supported by high-quality evidence. 

Construct validity was supported by moderate-quality evidence and floor and ceiling effects were minimal. 

Our results therefore support the validity and reliability of the CPAx across the recovery trajectory. 

Which clinimetric properties had limited evidence? 

While intra-rater reliability and responsiveness had adequate pooled results, the graded evidence was considered low quality, indicating the need for further research. 

Similarly, more research is required for specific populations including children and those with neurological impairments. 

What should clinical physiotherapists and researchers each take away from this? 

The CPAx is a feasible, valid and reliable bedside tool. 

Clinicians can use the CPAx with confidence to assess physical function and activity, track recovery, set goals and evaluate rehabilitation outcomes during critical illness – from ICU admission to hospital discharge. 

Further high-quality studies are needed, particularly on responsiveness and in under-represented populations. 

>>>Dr Sabrina Eggmann is a senior clinical academic physiotherapist at the University Hospital of Bern and a postdoctoral researcher at the University Children’s Hospital Zurich, Switzerland. Since 2015, Sabrina has taught postgraduate courses for therapists working in critical care at the Bern University of Applied Sciences. She is also a research affiliate with the Australian and New Zealand Intensive Care Research Centre through Monash University, Melbourne and the chair-elect of the Nurses and Allied Healthcare Professionals Committee of the European Society of Intensive Care Medicine. Sabrina has an interest in early physical rehabilitation, measurement instruments and long-term outcomes. 

OUT-OF-HOURS RESPIRATORY PHYSIOTHERAPY 

A group of UK researchers wrote an editorial exploring the provision of out-of-hours respiratory physiotherapy and implications for both clinicians and patients. First author Samantha Cook answers some questions here. 

Your editorial discusses the complex issue of hospital staff covering out-of-hours respiratory care. What are some of the issues that arise that might impact patients directly? 

Patients who need respiratory physiotherapy out of hours are often clinically complex and require timely intervention for secretion retention, impaired airway clearance, reduced lung volume and/or worsening ventilation. One of the key concerns is that out-of-hours care may not always be delivered by a respiratory specialist. Many physiotherapists on oncall rotas have the technical skills to deliver respiratory interventions but are likely to have less routine exposure to complex respiratory decision-making. Safe and effective care requires advanced clinical reasoning, including knowing when physiotherapy is indicated, when it may be contraindicated and when medical escalation is required. This creates a risk of variation in care, with the broader concern that a patient’s access to specialist respiratory physiotherapy should not depend solely on the time of day or day of the week. 

What about impacts on staff that might indirectly affect patients? 

The current model can and does have a significant impact on staff. Physiotherapists who do not routinely work in respiratory have reported feeling anxious, underprepared and undervalued. The current structure can affect confidence, decision-making and willingness to remain on the rota. Fatigue and workforce sustainability are frequently reported as an issue. On-call work occurs alongside normal daytime roles and call-outs can disrupt sleep, recovery and work-life balance. For respiratory physiotherapists, there may be an additional burden if they are relied on disproportionately to support the rota, provide advice or cover gaps. These pressures can affect morale, retention and sustainability. Over time, this has implications for the workforce and for patients. A sustainable and confident workforce is essential to safe out-ofhours care. 

Samantha Cook

How often are hospital physiotherapists typically expected to work at night on an on-call roster? 

On-call shifts vary between organisations, depending on the size of the hospital, the number of staff on the rota, local service demands and whether the rota covers adults and/or paediatrics. However, in many services, physiotherapists are rostered for an on-call shift approximately every four to six weeks. Although this frequency may appear manageable from a rotaplanning perspective, it creates a specific challenge for skill retention. Emergency respiratory presentations may be infrequent for individual staff members and, as a result, staff may be expected to manage high-risk clinical situations without the regular exposure needed to maintain confidence and advanced clinical reasoning. 

Have any solutions or supports been developed? 

There are examples of local and national support. In the UK, the Chartered Society of Physiotherapy’s on-call hub provides guidance for managers and clinicians on on-call working, including members’ rights, local negotiation, rota arrangements and service redesign. It encourages services to have clear referral pathways, defined service specifications, appropriate staffing models and evidenceinformed approaches to respiratory on-call provision. At a local level, services have introduced approaches such as simulation-based training, competency documents, buddy systems, informal mentorship, on-call support apps and clearer referral criteria. Some organisations have also trialled service redesign, such as extended weekday hours and twilight shifts to reduce overnight demand and improve access to specialist respiratory input. These initiatives are promising but they are not yet consistently implemented or well evaluated. A key issue is that support focuses on helping staff manage within the existing model rather than asking whether the model itself remains the safest and most sustainable way to deliver out-of-hours respiratory care. 

What aspects of this issue need further research and what form(s) should that research take? 

Further research is needed to understand the issue from multiple perspectives. Much of the existing discussion focuses on physiotherapists but we also need to hear from patients, carers, nurses, doctors, critical care outreach teams, service leads and managers. This would help identify what matters most in urgent respiratory care and where current models may be falling short. Ultimately, we need evidence that can inform service redesign rather than relying on local adjustments to manage a national workforce sustainability issue. 

>>>Samantha Cook is an allied health professions researcher and critical care physiotherapist at the Royal Wolverhampton NHS Trust, UK. Her research focuses on out-of-hours respiratory physiotherapy, critical care rehabilitation and workforce sustainability.