STROKE REHABILITATION: OBTAINING, CREATING, USING EVIDENCE

Overview

Goal of rehabilitation after stroke: FUNCTIONAL INDEPENDENCE Best way to get there : PRACTICE and lots of it! But what is the best way to get practice?
How

do we know if it works? We need evidence

http://www.strokemidland.org.nz/about-stroke.php?page=35

Purpose of Innovations

Improve practice
Quality

of practice Quantity of practice

Promote neuroplasticity and recovery

http://www.greatvoice.com/images/practice-1_01.gif

Experience-Dependent Neuroplasticity
Salience
Use

it or lose it Use it and improve it Specificity Repetition Intensity Time Age

Experience-Dependent Neuroplasticity
Salience
Use

it or lose it Use it and improve it Specificity Repetition Intensity Time Age

Innovations in Stroke Rehabilitation

Locomotor Training Vitalstim Upper Extremity Robotics Virtual Rehabilitation Mirror Therapy Constraint-Induced Movement Therapy Bilateral Movement Therapy

Bioness

Amadeo

How do we know what to do?

Be informed Long-term results Lots of patients Randomized, controlled trials Systematic reviews Role of experience and testimonials Collect your own evidence

Obtaining Evidence

Online access
PEDro PubMed

APTA
CPA GoogleScholar

Free access to less recent journals

Journal

of Neurologic Physical Therapy

Open access journals

Open Access Journals

Peer-reviewed
Journal

of Rehabilitation Research & Development Internet Journal of Health Sciences and Practice

Pay to publish
BMC

Public Health Peer-reviewed $1920 (GD$ 384000)

Current evidence UE training

Unilateral Bilateral Constraint-Induced Movement Therapy Systematic Reviews

(Tabak,

Plummer-DAmato, Intl. J. Ther & Rehab, 2010) (van Delden, Peper et al, J. Rehab Medicine, 2012)

Research Review: UE rehab

(Tabak, Plummer-DAmato)

Reviewed 11 studies, with total of 171 participants Overall

Bilateral

exercise appears superior to unilateral

effect, stimulation of interhemispheric connections

exercise
Cross-over

Constraint-induced

movement therapy effective for patients with some active movement in hand and wrist

Research review: UE rehab

(van Delden, Peper et al)

9 studies, with a total of 452 participants

Only

1 study overlapped with previous review

Overall
Bilateral

and unilateral exercise appear equally

effective Consider severity of injury Consider time since stroke

Research review: UE rehab

Salience is important UE rehab that focuses on occupation and important ADLs Importance of function, occupation, vocation

One arm or two?

Evidence unclear Small sample sizes, lack of control groups, lack of randomization Important to continue to collect evidence
UE

/ hand weakness considered most disabling loss by many patients Current programs focusing on bilateral activities seem appropriate Practice is the key

Current evidence Speech-Language Pathology

Brunner, Skeat, Morris, Intl. J. Speech-Language Pathology, 2008 Dysphasia

Best

outcomes occur if dysphasia is treated acutely Expressive or receptive aphasia

Dysphagia

Current evidence Speech-Language Pathology

Clarkson, Br. J. Neurosci Nursing, 2011 Dysphagia interventions: compensation

Positioning

/ posture Bolus modification

Few

studies indicate effectiveness Widely used in US and UK

Sensory

enhancement

Carbonation,

temperature, taste Research inconclusive

Current evidence Speech-Language Pathology

Dysphagia intervention: re-training

Oral-motor

exercises Tongue hold exercises Laryngeal elevation exercises

Botulinum toxin
Limited

research Seems to promote better coordination of swallow

Electrical stimuation
Positive

emerging evidence

Current evidence locomotor training

Robotics Body-weight support Treadmill Over-ground walking Therapist-assisted walking Auditory cues

Research review gait training

Systematic review
Hollands,

Pelton et al, Gait & Posture, 2012

Reviewed 33 studies, average number of participants per study: 17 Auditory / musical cueing provided the most symmetrical gait All interventions helped to improve gait speed
Auditory

cues task-specific practice and exercise functional electrical stimulation, AFO

Stroke Assessment: High tech

Robotics
Assess

upper extremity function

Motor

control, sensory function

Burgar, Lum et al, J Rehab Research & Devel, 2011

Stroke Assessment: Low tech

Berg Balance Scale Tinetti Performance-Oriented Mobility Assessment Dynamic Gait Index Stroke Impact Scale (SIS)
Interdisciplinary

assessment via questionnaire Addresses all areas

Dynamic Gait Index

4-item scale
Originally

8 items

Gait level surfaces Gait with speed changes Gait with vertical head turns Gait with horizontal head turns Sensitive for predicting falls (Score 9 out of 12)
(Marchetti,

Whitney, Phys Ther 2006)

Dynamic Gait Index - example

2. Change in gait speed _____ Grading: Mark the lowest category that applies. (3) Normal: Able to smoothly change walking speed without loss of balance or gait deviation.. (2) Mild Impairment: Is able to change speed but demonstrates mild gait deviations, or not gait deviations but unable to achieve a significant change in velocity, or uses an assistive device. (1)Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, or changes speed but has significant gait deviations, or changes speed but loses balance but is able to recover and continue walking. (0)Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught.

Stroke Impact Scale - 8 domains

Strength (upper and lower extremities) Hand function ADLs and IADLs Mobility Communication Emotion Memory and Thinking Participation/Role function

The Stroke Impact Scale 3.0

Developed to be a comprehensive measure of health outcomes for mild and moderate stroke populations. Incorporates function and health related quality of life (QOL) information into a self-reported questionnaire. Identifies areas that require long-term disability rehabilitation

SIS - Modes of Administration

The SIS can be administered:

person, by trained medical professionals7 By proxy8 By telephone By mail9,10
In

The tests

Stroke Impact Scale 3.0 (Third revision) 59-item questionnaire1,2 Stroke Impact Scale - 16 16-item questionnaire, physical domain only3

Usefulness of results

Rehab professionals can use information from the Stroke Impact Scale to determine in which domains the patients perceives he or she has the most problems. This information may be useful in planning interventions for a specific patient.

Creating Your Own Evidence

Start small
Data

for individual patients Data for groups of patients

Start small
Use

measures that have consensus among staff

SIS

E.g.

Or

consensus within disciplines

Berg,

Tinetti, Dynamic Gait Index, Five Times Sit to Stand, others

Why You Should Create Evidence

Evaluate your patients more objectively Evaluate your interventions more objectively Compare your outcomes to those of others
Clinics,

countries

References, p.1
1. 2. Duncan PW. Stroke Impact Scale version 3.0. 2005. Available at: http://www.chrp.org/pdf/HSR082103_SIS_Handout.pdf Accessed July 2, 2005. US Department of Veteran Affairs Rehabilitation Outcomes Research Center: Stroke Impact Scale. 2005. Available at: http://www.vard.org/rorc/SIS/SIS_Proxy_Database.htm Accessed July 2, July 20, 2005. Department of Veteran Affairs Rehabilitation Outcomes Research Center: Stroke Impact Scale-16. 2003. Available at http://www.vard.org/rorc/SIS/SIS-16.htm Accessed July 13, 2005. National Stroke Association. 2004. Available at http://www.stroke.org Accessed June 23, 2005. US Department of Veteran Affairs Rehabilitation Outcomes Research Center. Helpful links about stroke. Available at http:// www1.va.gov/rorc/helpful_links.cfm Accessed June 23, 2005. Duncan PW, Wallace D, Studenski S, Lai SM, Johnson D. Conceptualization of a new stroke-specific outcome measure: the Stroke Impact Scale. Top Stroke Rehabil. 2001; 8(2): 19-33.

3. 4.
5. 6.

References, p.2
7. 8.
9. 10. 11.

Duncan PW. Wallace D. Lai SM. Johnson D. Embretson S. Laster LJ. The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change. Stroke.1999; 30(10):2131-40. Duncan PW. Lai SM. Tyler D. Perera S. Reker DM. Studenski S. Evaluation of proxy responses to the Stroke Impact Scale. Stroke. 2002; 33(11):2593-2599. Duncan P. Reker D. Kwon S. Lai SM. Studenski S. Perera S. Alfrey C. Marquez J. Measuring stroke impact with the stroke impact scale: telephone versus mail administration in veterans with stroke. Medical Care. 2005; 43(5):507-515. Duncan PW. Reker DM. Horner RD. Samsa GP. Hoenig H. LaClair BJ. Dudley TK. Performance of a mail-administered version of a stroke-specific outcome measure, the Stroke Impact Scale. Clin Rehabil. 2002; 16(5):493-505. Duncan PW. Lai SM. Bode RK. Perera S. DeRosa J. Stroke Impact Scale-16: A brief assessment of physical function. Neurology. 2003; 60(2):291-296.