Poor adherence to treatment is commonplace and may adversely affect outcomes, efficiency and healthcare cost. The aim of this systematic review was to identify strategies to improve adherence with musculoskeletal outpatient treatment. Five suitable studies were identified which provided moderate evidence that a motivational cognitive-behavioural programme can improve attendance at exercise-based clinic sessions. There was conflicting evidence that adherence interventions increase shortterm adherence with exercise. There was strong evidence that adherence strategies are not effective at improving long-term adherence with home exercise. Due to the multidimensional nature of non-adherence, the strategies to improve adherence with physiotherapy treatment are likely to be broad in spectrum. Combined interventions may be effective at promoting adherence with clinic appointments and exercise, though further research would be required to confirm this. Further research to increase basic understanding of the factors which act as a barrier to adherence could facilitate development of strategies to overcome non-adherence.
Patients and methods
PATIENTSNinety seven (73%) of the 132 patients who had been in the treatment trial were reassessed close to one year after stroke (mean time since stroke 52 (SD4) weeks; range 39-64). Death or further major strokes were the most common reasons for drop out. There were 48 patients who had received enhanced therapy (22 women, 26 men; 21 left sided weakness, 27 right; mean age 66 (SD1 1) years), and 49 who had received conventional therapy (27 women, 22 men; 23 left sided weakness, 26 right; mean age 69 (SD9) years). As at the earlier assessments, the groups were similar at one year in their functional independence as assessed by the Barthel activities of daily living scale (enhanced therapy group mean 17 (SD3); conventional therapy group mean 17 (SD3)).
ASSESSMENT METHODSThe tests of arm function were the same as reported previously. 1-3 These were (a) Range and strength of active movement (extended motricity index and motor club assessments) (b) motor skills (nine-hole peg test and Frenchay arm test). Also, there was clinical assessment of resistance and pain on passive movement of the arm.
This study showed no significant differences in the rate of improvement after stroke between the two groups. Although EMG biofeedback was used as an adjunct to physiotherapy and represented clinical practice, the results provide little evidence to support the clinical significance of using EMG biofeedback to improve gait in the acute phase after stroke.
Previous comparisons of constructional apraxia after right and left hemisphere damage have not investigated the influence of time since onset. This paper reports some preliminary findings from stroke patients in a physical rehabilitation trial. Fifty-five patients with right hemisphere damage and 65 with left hemisphere damage were assessed on the WAIS-R Block Design test at 1 month and 6 months post stroke. The groups were similar at 1 month but the left hemisphere group showed better average recovery by 6 months. There was great variability in amount of recovery within the left hemisphere group, suggesting individual differences in initial reasons for failing Block Design, and corresponding differences in the recovery process. Compensation by the right hemisphere is discussed as one possible process. Future detailed longitudinal studies may be useful in contrasting the cognitive deficits which underlie constructional apraxia after right-sided and left-sided lesions, and would provide evidence on mechanisms of recovery and adaptation.
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