Benjamin Chitambira1* and David Smithard2
1Richard Stevens Stroke Unit, Physiotherapy Department, East Kent Hospitals University NHS Foundation Trust, UK
2Princess Royal University Hospital, King’s College Hospital NHS Foundation Trust, UK
Received: 02 September, 2015;Accepted: 03 October, 2015; Published: 05 October, 2015
Benjamin Chitambira, Richard Stevens Stroke Unit, Physiotherapy Department, East Kent Hospitals University NHS Foundation Trust, William Harvey Hospital, Kennington Road, Ashford, Kent, UK, TN24 0LZ, Tel: 00441233616242; E-mail:
Chitambira B, Smithard D (2015) Exploring the Extent of Restoration of Voluntary Movements, Function, Quality of Life and Cost of Formal Care in Dense Strokes Treated by the Optokinetic Chart Stimulation Based OKCSIB Protocol: A Prospective Pilot Randomised Case Controlled Study. J Nov Physiother Phys Rehabil 2(2): 051-057. DOI: 10.17352/2455-5487.000025
© 2015 Chitambira B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Optokinetic chart stimulation; Neuro physiotherapy; Neuro rehabilitation; Dense acute stroke; Limb recovery
Background: Stroke remains one of the largest causes of impairment and disability globally. Stroke involves high costs to the health economy.
Objective: To explore the extent of recovery of voluntary movements and function in dense acute strokes treated with the optokinetic chart stimulation based OKCSIB protocol.
Methods: The experimental patient was treated with the OKCSIB protocol. An optokinetic chart was moved in front of the patient for 3 minutes each of lateral, vertical and forwards, twice daily for 5 days a week. The control patient underwent conventional therapy which involved practicing functional task with facilitation of normal movements as per Bobath approach. The main outcome measure was the STREAM upper and lower limb score after 14 weeks.
Results: The experimental patient’s upper limb STREAM scores improved from 0/20 pre-treatment to 18/20 after 14 weeks and 20/20 after 3 months follow up. The control patient’s upper limb STREAM score remained 0/20 pre-treatment, 0/20 after 14 weeks and 0/20 after 3 months follow up. The experimental patient’s lower limb STREAM scores improved from 0/20 pre-treatment to 20/20 after 14 weeks and 20/20 after 3 months follow up. The control patient’s lower limb STREAM score remained 0/20 pre-treatment, 0/20 after 14 weeks and 0/20 after 3 months follow up. The experimental patient’ s function improved from Barthel Index score of 0/20 pre-treatment to 17/20 after 14 weeks and 18/20 after 3 months follow up. The control patient scored 0/20 pre-treatment, 1/20 after 14 weeks and 0/20 after 3 months follow up.
Conclusions: The OKCSIB protocol restored voluntary movements and function when compared to conventional therapy. Fully powered studies are recommended to test the efficacy of the OKCSIB protocol against conventional neuro physiotherapy.
Stroke remains as one of the most devastating of all neurological diseases . It often leads to physical impairment, disability and death . Stroke exerts a huge strain on the health economy when its treatment, rehabilitation, social care and loss of productivity are considered. It costs 8.9 billion pounds in the UK  and 34.3 billion dollars in the US . In stroke patients, functional independence and daily life autonomy are correlated to trunk function, upper limb impairment , arm recovery  and extensor strength in the affected upper limb . A third of stroke patients develop spasticity of the affected upper limb . In sub-acute stroke patients, walking speed is decreased by weakness of the affected lower limb’s anti-gravity extensor muscles such as hip abductors, hip extensors and knee extensors .
A systematic review has shown that the widely used Bobath approach has no evidence for recovery of movements and function in strokes . A recent review has shown that of all conventional neurophysiotherapy approaches, no single conventional neurophysiotherapy approach is superior to any of the other conventional neurophysiotherapy approaches for recovery of function and mobility after stroke . Most conventional neurorehabilitation aims for compensatory function with little time given for upper limb recovery . Even with the move towards repetitive task specific training, it has been shown that people with dense strokes cannot tolerate the high intensities required . This usually involves repeatedly practicing the same functional task for 2 to 4 hours daily at least 5 days a week. Still, upper limbs do not benefit enough to recover movements from upper limb training . Thus it is important to find efficient rehabilitation interventions that improve upper limb and lower limb recovery as well as reduce spasticity in dense acute strokes.
Optokinetic chart stimulation (OKCS) is a novel intervention for neurorehabilitation of completely hemiplegic acute strokes [14-16]. The optokinetic chart is designed on A4 paper and consists of repeated groups of lines with the colours red, orange, yellow, green, blue, indigo and violet. The chart is kept at a distance of 15 to 20 centimeters from the patient’s face and then moved from side to side at approximately one cycle per second for 3 minutes. This is followed by moving the chart up and down for 3 minutes and then forwards and backwards for another 3 minutes. All the patient does is look at the centre of the chart. OKCS is carried out on its own until a patient can stand in parallel bars with the assistance of 2 therapists. At this point sensory interaction for balance (SIB) by standing on balance pads for 3 minutes, is added. This is how the intervention protocol derived the acronym, OKCSIB. It was designed as a further development to the evidence from small trials which showed that optokinetic stimulation had benefits in the treatment of neglect in stroke patients . A novel OKCSIB protocol [15,16], based on OKCS, had its efficacy incrementally assessed through a case series  and then a case control series . The preliminary evidence from these studies warranted further assessment of the benefits of the OKCSIB protocol under randomized controlled trial conditions. The objective of the study is to explore the difference in the extent of restoration of voluntary movements, function, quality of life and weekly cost of formal care between dense acute strokes treated by the OKCSIB protocol and those treated by conventional neurophysiotherapy which involved practicing functional tasks with facilitation of normal movements as per Bobath approach.
Design, setting and ethics
The design was a single blind pilot randomized controlled trial in a combined hyper-acute and rehabilitation stroke unit setting. Ethical approval was given by the London-Surrey Borders Research Ethics Committee. Written informed consent was obtained from each participant. The study’s international trials registry number is ISRCTN35657537.
Potential participants, aged between 75 years and 85 years, and had dense strokes that completely paralysed the affected upper and lower limbs, were recruited into the study. They were recruited if they were able to provide consent. Participants were assigned to either the OKCSIB group or the conventional neurophysiotherapy group by blind remote block randomisation. Table 1 shows the selection criteria for the study.
The experimental intervention was the OKCSIB protocol . The optokinetic chart is designed on A4 paper and consists of repeated groups of lines with the colours red, orange, yellow, green, blue, indigo and violet. The chart was kept at a distance of 15 to 20 centimetres from the patient’s face and then moved from side to side at approximately one cycle per second for 3 minutes. This was followed by moving the chart up and down for 3 minutes and then forwards and backwards for another 3 minutes. All the participant did was look at the centre of the chart. This is done twice daily for 5 days per week. Once a patient could stand with assistance of 2 therapists in parallel bars, sensory interaction for balance (SIB) was added with the participant standing on a balance pad for 3 minutes [14-16]. For the affected upper limb active-assisted anti-gravity extensor exercises were carried out as follows: 5 repetitions for each of shoulder external rotation, shoulder abduction, shoulder ﬂexion and then of a combination of these movements in the proprioceptive neuromuscular facilitation (PNF) pattern of D2F, elbow extension, wrist supination, wrist extension and fingers extension [14,15].
The OKCSIB protocol is progressed by adding backwards and sideways stepping when participants have improved to mobilising in parallel bars with assistance of two therapists . This is to challenge cortico-midbrain locomotors area- lateral vestibulospinal descending motor network  for proximal anti-gravity extensor control. On most days the OKCSIB protocol was carried out by the first author. Conventional activities of daily living that the participant could do as they progressed were added to the OKCSIB protocol. The OKCSIB protocol was carried out daily for 5 days per week for 14 weeks.
The control intervention was carried out and supervised by a conventional physiotherapist trained in the Bobath based normal movement approach. This consisted of facilitation of normal movement patterns and conventional activities of daily living. Both the experimental and control participants received the same occupational therapy concurrently as deemed suitable by their occupational therapists.
The outcome measures were scored by a blinded neurophysiotherapist who carried out the measurements at the participant’s places of residence at the time of measurement. Validated questionnaires were used to measure the outcomes after 14 weeks. The intervention period was 14 weeks. Participants were then followed up to reassess outcomes after 3 months from the 14 weeks. It took 2 hours to complete the questionnaires per each testing session. The primary outcome measure is the Stroke Rehabilitation Assessment of Movement (STREAM) upper and lower limb scores at 14 weeks. STREAM scores after 8 weeks and after 3 months follow up were also used as secondary outcome measures. STREAM is a validated impairment measure  with a maximum score of 20 for each of the affected limbs and a maximum total score of 70 when the mobility subsection is included. Other secondary outcome measures included the Barthel Index  after 8 weeks, 14 weeks and 3 months follow up; the modified Ashworth Scale (MAS)  and the Stroke Specific Quality of Life (SSQOL)  after 14 weeks and 3 months follow up. The Barthel Index is a validated measure of activities of daily living with a maximum score of 20. The MAS and SSQOL are valid measures of spasticity and quality of life respectively with respective maximum scores of 5 and 245. The weekly cost of formal care (WCFC) was also used as a secondary outcome measure after the 3 months follow up. The outcome measurements were carried out by a blinded physiotherapist who did not work in the researcher’s organization.
A total of 216 potential participants were screened for eligibility over a period of 13 months. Figure 1 shows the CONSORT diagram for the study. Only 4 participants were eligible and these were recruited into the study. Out of the 4, one was withdrawn after she was repatriated out of the catchment area and one died from a medical complication unrelated to the study. Two participants completed the study. The experimental participant was a female aged 77 whilst the control participant was a female aged 78. In terms of CT scan reports, the experimental participant had an extensive right fronto-parieto-occipital infarct and the control participant had a left basal ganglia infarct. The experimental participant had unilateral spatial neglect whilst the control participant did not. From those potential participants that had dense weakness, recruitment was limited by the inability to consent and the tightly controlled age range. Figure 1 shows the CONSORT flow chart for the study.