PT Critically Appraised Topics
 

Document Type

Critically Appraised Topic

Publication Date

2014

Clinical Scenario

The patient who led me to pursue this question was an 89-year-old female with a right side acute cerebrovascular accident (CVA) leading to significant left side hemiplegia, flat affect, and very poor sitting posture. Unfortunately she has since passed away, but prior to her passing significant medical interventions included custom seating and positioning system, standing and transfer training with two person assist, and static sitting balance training with one person assist. Problems identified were poor sitting balance, poor standing balance, decreased postural control, decreased proprioceptive awareness, decreased sensation, and decreased strength.

For the purposes of my clinical question I want to know what research says about the use of a supportive standing frame on patients with the diagnosis of CVA with significant unilateral hemiparesis or hemiplegia. The patients that are admitted to rehabilitation at skilled nursing facilities for a CVA often display hemiparesis, and are not able to stand without the assistance of two people. For these patients, they often also have a hard time sitting in a wheelchair due to poor sitting posture and inability to detect postural position in relation to midline. When I arrived at the skilled nursing facility there was a supportive standing frame that was gathering dust in the corner of the gym. After large amounts of WD-40 I was able to get it apart and figure out how it worked. I started to use it with my 89-year-old patient, but was wondering why it had gone so unused for so long; was it because nobody knew how to figure out all the levers and pulleys, or because nobody had seen a successful change in their patients with it? This was the inspiration for the critically apprised topic; to figure out why the dust had gathered.

Clinical Question

Does the use of a supportive standing frame in conjunction with traditional physical therapy interventions improve postural control in patients with significant hemiparesis following an acute CVA when compared to traditional physical therapy interventions alone?

Clinical Bottom Line

Based on the outcomes from Bagley et al. and Allison et al., there is fair evidence to suggest that providing supported standing frame treatment in conjunction with traditional physical therapy for patients with acute stroke does not improve outcomes compared to traditional physical therapy alone. Subjects in both studies had poor/very poor trunk control compared to age matched norms on ratings including the Trunk Control Test and the Rivermead Mobility Index, and were receiving sub-acute rehabilitation that required the assistance of 1-2 therapists for standing practice. In both studies there were subjects who were not able to complete the full standing frame protocol due to fatigue. This factor contributed to the high study loss rate (26% and 17%). Allison et al. did not perform a full intention to treat analysis and therefore was at risk for a Type II error revealing no significant difference between groups when one in fact could have existed. Bagley et al. did perform an intention to treat analysis and therefore more weight is placed on the outcomes of this study. Neither study revealed any significant harmful effects from treatment, however there was no evidence that supported the decision for a clinic to purchase a standing frame. If a clinic were to already have one available, it may be beneficial to use in conjunction with traditional acute CVA rehabilitation.

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