suggesting that the environment may not be sufficiently geared to facilitating physical and mental activity or social interaction, and that it may not function as a learning environment71. Other studies suggest that a large percentage of the patient's day is spent in passive pursuits rather than in physical activity. The issue of how much time is spent on physical activity, including practice of motor tasks, and how this time is organized, is therefore a critical one for rehabilitation.
Delivery of physical therapy
Focusing on intensive task-oriented training has required some changes in physical therapy practice, not only in the methods used but also in delivery. Physiotherapists are exploring different ways of organizing delivery to enable the patient to be an active learner. They are examining, for example, the effects of an interactive relationship between patient and therapist, the effects of working in a small group during circuit training, and the effects of sessions where patients work in partnership with each other72.
In an attempt to increase the time spent practicing, several investigators have reported the development of technology to provide computer-aided training, for example, robot-mediated therapy (RMT)73-75. The focus has been on movements of the upper extremity that are challenging, engaging and repetitious. Significantly more improvement in upper limb function has been reported compared with NDT/Bobath therapy of equal intensity and duration74. In addition, the rate of recovery when treatment was delivered with RMT was found to be greater in relation to either no treatment or treatment with sling suspension in a single case study75. The generalizability of RMT and its role in motor learning are yet to be tested.
Intensity of skill practice and exercise
Two aspects of therapy for neural lesions that have received little attention until recently are the intensity of task-oriented training and the extent of cardiovascular stress induced during physical activity. Endurance training, like post-stroke strength training, has long been neglected because of the dogma related to spasticity. It is not only important for patients to practice in order to regain skill in performing actions, but it is also critical that they regain sufficient strength, endurance and fitness to be able to carry out these actions. It is well documented that stroke patients have low physical endurance when discharged from rehabilitation.
Deconditioning can occur within the first six weeks after stroke. In a study that measured exercise capacity in the early post-stroke period, patients performed incremental maximal effort tests on a semi-recumbent cycle ergometer76. Deconditioning may be a consequence of the relatively static nature of typical rehabilitation programs and indicates that intensity of training needs to be addressed specifically and early after an acute brain lesion, in an effort to decrease the deconditioning effects.
Recently, MacKay and Makrides77 investigated the aerobic component of physical therapy and occupational therapy for stroke patients by monitoring heart rate (using heart rate monitors) and therapeutic activities biweekly over a 14-week period. The major finding was that the therapy sessions involved low intensity exercise and activity that did not provide adequate metabolic stress to induce a training effect. Although progressively higher exercise intensities might be expected over time as functional status improves, any increase in HRmean and HRpeak did not reach statistical significance.
The detrimental effect of low exercise capacity and muscle endurance on functional mobility and resistance to fatigue can be compounded by the high metabolic demand of adaptive movements. Stroke patients discharged from rehabilitation showing improvements in gait are not necessarily functional walkers but are often unable to maintain their most efficient walking speed comfortably, thus indicating that the high energy cost of walking and poor endurance further compromise functional performance78,79.
The calculation of walking speed over 10m, a commonly used clinical measure of gait, may overestimate locomotor capacity after stroke. Healthy subjects can walk in excess of their comfortable speed for at least six minutes. Stroke subjects, however, may not be able to maintain their comfortable speed over that time80. This would prevent them from becoming competent community walkers, and may lead to increasing handicap. These results emphasize the need to train endurance and to measure endurance using a test such as the 6-minute walk81.
Improvements in aerobic capacity in chronic stroke have been demonstrated with appropriate training such as bicycle training82, graded treadmill walking83 and combined aerobic and strengthening exercises42. As might be expected, the effects are exercise-specific. Generalization to everyday life, however, is also reflected in the improvements noted in general health and wellbeing. Teixeira-Salmela et al42 assessed their subjects' general level of physical activity in the Human Activity Profile, a survey of 94 activities that are rated according to their required metabolic equivalents. The results indicated that subjects were able to do more household chores and to increase their participation in recreational activities more than before the training program.
CONCLUDING COMMENTS
The regaining of skill in critical tasks requires specific training, with intensive practice of actions in the appropriate contexts. In addition, the individual must be fit enough to perform the tasks of daily life, including taking part in social and recreational activities. Participation in regular exercise and training appears to have significant effects on reducing disability and improving quality of life in older adults and in individuals with disability. The benefits of task-oriented skill training and strength training are also being reported in studies of children with cerebral palsy84,85. Although in these children the primary deficits are neural, adaptive changes in musculoskeletal and cardiorespiratory systems also impose severe limitations on the gaining of functional motor performance86,87. Many of these changes are preventable or reversible88.
Post-discharge services for individuals with chronic disability are, however, poor or non-existent and there are reports of high levels of patient dissatisfaction89 and loss of rehabilitation gains90. The provision of facilities such as strength and fitness centers directed at all age groups and disability levels requires collaboration between public health and community services. Physiotherapists can play a significant role in this collaborative process.
Entry-level physical therapy curricula also have to respond to evidence of the significance of task-oriented training and strength, endurance and fitness training for individuals with acute or chronic disability. Core knowledge should include biomechanics, exercise science and motor learning. The skills required for training individuals with disability, and how to adapt training and exercise to the patient's level of performance, should also form a large part of the education of physical therapy students as well as part of skills upgrading in continuing professional education.
It is a matter of increasing concern that clinical interventions in neurorehabilitation continue to vary widely and depend largely on the preferred approach of the individual therapist5,91, and on the continuing dominance of therapeutic methods developed half a century ago. Lack of both a rational theoretical basis for a treatment method and of any evidence of its effectiveness may be no barrier to its continued use.
To make the change to practice based on evidence and on current theoretical relevance is a large undertaking but already taking place around the world. A start can be made in clinical practice by following prescribed guidelines that are based on available evidence. These are available in texts and in other work cited here. Each physiotherapist needs to accept the responsibility of using evidence-based (or at least scientifically acceptable) methods of intervention and ongoing outcome measurements, including quality-of-life profiles. Patients have the right to be part of an up-to-date neurorehabilitation environment.