Implicit Learning in Stroke Study
Research type
Research Study
Full title
A pilot cluster randomised controlled trial, of an implicit learning approach (ILA) versus standard care, on recovery of mobility following stroke.
IRAS ID
250540
Contact name
Louise Johnson
Contact email
Sponsor organisation
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust
Duration of Study in the UK
1 years, 3 months, 29 days
Research summary
Summary of Research
Re-gaining the ability to stand, step and walk are common goals for people with stroke. During rehabilitation, therapists often tell people how to move, e.g. “straighten your knee when you’re standing”, or “lift your foot as you step”. However, these types of specific instructions may not help people to learn new skills. Reducing the number of instructions or using simpler instructions may help people to learn in a more automatic way - e.g. through trial and error. This is called implicit learning.There is very little evidence into implicit learning in stroke. This study will investigate whether patients recover the ability stand, step and walk following stroke better when they are given fewer and simpler instructions.
We will do this using a cluster randomised design. We will invite up to 8 stroke units to take part - half will continue to deliver usual rehabilitation, and half will adopt an Implicit Learning Approach (ILA) for the duration of the trial. Which one of the two approaches the unit delivers will be chosen at random. At the ILA sites, therapists will be trained to deliver rehabilitation using fewer and less complex instructions.
All patients at each unit will receive their rehabilitation using the allocated approach. This helps to ensure that the therapy teams manage to deliver the interventions effectively. We will ask individual patients for permission to complete additional assessments, which form part of the study. Some participants and clinicians will be interviewed at the end of the study, to find out what they thought about the intervention.
This is a pilot study, meaning that we are testing how well this works as a research method. We will not know for certain which approach is best, but it will tell us how we should design a larger trial that will give a clear answer.
Summary of Results
In this study, our aim was to find out whether providing fewer and simpler instructions and feedback during rehabilitation improves movement recovery in people with stroke.
Background:
In the United Kingdom, around 150,000 people suffer a stroke each year. About 80% of these will have weakness on one side of their body. This can vary from a mild loss of muscle strength, to a complete inability to move. This weakness occurs because the damaged part of the brain is no longer able to send strong enough signals to the muscles to make them move. However, with rehabilitation, the brain can remodel so that movement can be recovered. Re-gaining the ability to stand, step and walk are common movement goals for people who have suffered a stroke, and were the focus of this research.
During rehabilitation, therapists often tell people how to move. For example, “straighten your knee when you’re standing”, or “lift your foot as you step”. In sport, these types of instructions don’t seem to help people to learn new skills. Theories suggest that it is better to learn movements through trial and error, rather than by being told exactly what to do. This is because movements such stepping are normally automatic – we don’t think about how to do them. When someone is prompted to think about how they are stepping, the automatic processes that would normally control the movement become disrupted, and they don’t step as well. Therefore, reducing the number of instructions or using simpler instructions can help people to learn faster.
Although the evidence from sport is convincing, this idea has never been properly tested in people with stroke. Before we can do a big study to find an answer, we need to understand the best way to investigate this. This study was the first stage of research to understand whether patients recover the ability stand, step and walk following stroke better when they are given fewer and simpler instructions. This was a pilot study, meaning that we tested how well our research method worked. This means we did not try to find out for certain which approach is best, but we learnt about how we should design a larger trial that will give a clear answer.
Design and Methods
We used a cluster randomised design. Eight stroke units took part in the study. Four continued to deliver usual rehabilitation, without any input from the research team. Four adopted an Implicit Learning Approach (ILA) for the duration of a trial. At the ILA sites, therapists were trained to deliver rehabilitation using fewer and less complex instructions. Which one of the two approaches the unit delivered, was chosen at random.
In a cluster design, all patients at each unit receive their rehabilitation using the allocated approach. This helps to ensure that the therapy teams deliver the interventions effectively. We asked individual patients for permission to complete additional assessments, which formed part of the study. Participants were interviewed at the end of the study, to find out what they thought about the intervention. Ewe also talked to therapists, to find out about their experience of delivering it.
Patient and Public Involvement
Patients worked closely with us to develop the research programme, and were involved throughout as part of our Trial Steering Group. They gave guidance on running the project, and helped us to write information sheets.
Results
We recruited 54 participants to the study – 30 in the control units and 24 in the intervention units. The study overlapped with the COVID-19 pandemic. The restrictions imposed by the pandemic meant that we could not follow up with all patients who enrolled in the trial. Therefore, we were only able to collect follow up measures (at 3 months after stroke) for 41 participants. We found that patients were willing to be part of the study, and that the measures we chose were simple to collect, and were appropriate.
To help us to understand how well physiotherapists delivered the ILA intervention, we video recorded and later analysed treatment sessions. We found that therapists at the intervention sites were able to reduce the amount of communication they gave, but this varied across sessions. On average, therapists gave 6.4 statements per minute control sites, and 4.8 at intervention sites. They also focussed less on body movements, with 75% of instructions on the control group focussed on the body, whereas this was 29% in the intervention group.
Pour interviews with patients found no differences between the intervention and control groups, in terms of their experience of therapy. Changing the way that therapists communicated did not have negative or positive effects. Through our discussions with therapists, we learned that they sometimes found the approach difficulty to deliver, but this improved with time/practice. Different therapists had quite different views about when an ILA might be beneficial, and some were concerned that changing communication practice might have a detrimental effect on their relationship with patients.
Conclusion
It is feasible to change the way in which therapy is delivered, to promote implicit learning. With training, therapists are able to change their communication – but this takes time to embed, and they found it easier in some scenarios than others. Patients did not report and differences in experience of therapy. They were willing to be involved in the study, data collection was successful, and aside from the challenges created through the COVID-19 pandemic, dropout rates were low. The cluster design worked well for this trial.REC name
South Central - Berkshire B Research Ethics Committee
REC reference
18/SC/0582
Date of REC Opinion
3 Dec 2018
REC opinion
Further Information Favourable Opinion