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164 ······· APPENDICES Physiotherapy KCE reports vol. 40 Transcutaneous electrical nerve stimulation (TENS) and ultrasounds (US) are the two electrophysiotherapeutic modalities the most frequently used by ambulatory physiotherapists. However, the effectiveness of both TENS and US to treat patients with low back pain has not been demonstrated. Total knee replacement The most common treatment modalities applied by Belgian ambulatory physiotherapists to treat patients with total knee replacement were, from the most prevalent to the least: muscle strengthening, mobilizations, gait rehabilitation, education of the patient, massage, home exercises, and stretching. The following treatment modalities are also frequent but to a lesser extent: contracted-relaxed techniques and cryotherapy. The treatment modalities rarely applied by ambulatory physiotherapists include electrophysiotherapy, manipulations, EMG biofeedback, and hydrotherapy. The treatment modalities and the proportion of physiotherapists in our survey treating at least one patient with total knee replacement are confronted in Table 4.10 with the results of the literature review on evidencebased therapeutic modalities. Only a small number of evidence was available in the literature relative to the physiotherapeutic modalities applied in total knee replacement. Overall, weak evidence was only demonstrated for education of the patient, home exercises, cryotherapy, and electric stimulation, which is the most frequent electrophysiotherapeutic modality used in ambulatory practice. On the contrary, moderate evidence was found for the TENS electrotherapeutic modality which seems ineffective in reducing pain consecutive to total knee replacement. Hemiplegia / Hemiparesis The most common treatment modalities applied by Belgian ambulatory physiotherapists to treat patients with hemiplegia/hemiparesis were, from the most prevalent to the least: mobilizations, gait rehabilitation, muscle strengthening, balance rehabilitation, stretching, education of the patient, and functional rehabilitation (i.e., activities of daily life (ADL)). Numerous specific movement therapies have been developed: Bobath (normal movement approach), Kabat (PNF = proprioceptive neuro factilitation), Johnstone, PeRFTtti, Picard, and Brunnström techniques. Among these specific movement therapies, Bobath and Kabat were the techniques the most applied in Belgian ambulatory physiotherapy.
KCE reports vol. 40 APPENDICES Physiotherapy 165 Table 11 Hemiplegia/hemiparesis: treatment modalities applied by Belgian ambulatory physiotherapists and evidence-based literature Treatment modality Frequency (proportion ± accuracy) Mobilizations 95 ± 3% Gait rehabilitation 83 ± 5% Muscle strengthening 78 ± 5% Balance rehabilitation 76 ± 5% Stretching 70 ± 6% Type of evidence Evidence for (weak to moderate) Evidence for (strong) Evidence for (strong to moderate) Evidence for (moderate) Evidence for (weak) Evidence available in the literature on physiotherapy of hemiplegia/hemiparesis due to stroke Patients with stroke should clearly be mobilized as soon as possible after stroke (moderate evidence). There is weak evidence that mobilizations are useful to treat and prevent shoulder pain in the affected upper limb. Antispastic positioning, range of motion exercises, and stretching performed several times daily are recommended to treat spasticity (experts' consensus). Strong evidence has been found in the literature supporting implementation of gait rehabilitation techniques. Task-specific techniques should be preferred to impairment-focused approaches (weak to strong evidence). There is strong to moderate evidence in favour of strengthening exercises of targeted weakened muscle groups. There is moderate evidence that strengthening exercises improve independence in activities of daily life. Moderate evidence has been found in favour of coordination and balance exercises as they improve level of safety in activities of daily life. Strong evidence exists in favour of task-oriented exercise training to improve balance. Stretching exercises are recommended to improve range of motion and to prevent contractures (low evidence). There is weak evidence that stretching is useful to treat and prevent shoulder pain in the affected upper limb. Antispastic positioning, range of motion exercises, and stretching performed several times daily are recommended to treat spasticity (experts' consensus).
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